Acute confusional states in elderly cancer patients

Acute Confusional

States in Elderly

Deborah Welch-McCaffrey

R

ECENT nursing literature’ has identified acute confusional states(ACS) in the elderly to be an anticipated event for many older persons during hospitalization.“3 The exact incidence of ACS in the elderly during hospitalization is unknown; however, it has been estimated that approximately 30% to 50% of elderly medicalsurgical patients will experience an ACS.1’4 Richeime? notes that the diagnosis of delirium is madeby consulting psychiatrists in 10% to 13% of elderly medical-surgical patients. Furthermore, he believes the prevalence may be as high as 80% in some subpopulations. Chisholm et al3 studied the prevalence of acute confusion in hospitalized elderly patients and found the averageonset to be 6% days after admission. It is known that the risk of developing cancer increaseswith age. While the incidence of cancer at age 25 is less than one in six hundred, by age 70 the incidence rises to approximately one in ten.6 A hospital admission may well be anticipated for the diagnosis, treatment, and/or managementof cancer in the elderly patient. Lamont et al7 report that the use of acute-carehospitals by the elderly continues to increasein the United States.The average length of stay for the person who is 75 or older is 14 days as compared with nine days for all persons.’ Not only is length of stay increased, but a higher mortality rate has been associatedwith longer hospital stays.’ Since an ACS may be an expected event for elderly cancer patients, nurses caring for these patients must be cognizant of the multiple etiologies and symptoms of ACS and, hence, appropriate nursing interventions for their care.’ From clinical observations, the higher prevalence of impaired mental status distinguishes the elderly cancerpatient from other patients with cancer. Acute confusion, apart from the psychosocial distress of coping with cancer, is the focus of this article since, in most cases, there are no agespecific differences in an older person’s emotional From the Good Samaritan Cancer Center and the Institute of Gerontology, Good Samaritan Medical Center, Phoenix, AZ. Address reprint requests to Deborah Welch-McCaffrey. RN, MSN, Good Samaritan Cancer Center, Phoenix. AZ 85006. 0 1988 by Grune & Stratton, Inc. 0749-2081/88/0403-0006$05006$05.00/O

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and Jan Dodge

responseto a diagnosis of cancer as comparedwith their younger counterparts.lo DEFINITION AND FEATURES OF ACUTE CONFUSIONAL STATES

Confusion is complicated by the absence of a definition that is generally acceptedby the majority. A major problem is the lack of consensuson the terminology. Examples of the various terms used to describe confusion includes reversible dementia, delirium, acute brain failure, pseudosenility, clouded states,and acute brain syndrome. Regardless of terminology used, this altered state involves a constellation of behaviors given the label of confusion becauseit baffles the caregiver. l1 The term acute confusional state in this paper uses the definition by Foreman,’ stating that an ACS in an “organic brain syndrome characterized by transient, global cognitive impairment of abrupt onset and relatively brief duration, accompanied by diurnal fluctuation of simultaneousdisturbances of the sleep-wake cycle, psychomotor behavior, attention, and affect. ’ ’ It is important to distinguish ACS from chronic dementia as defining characteristics are similar in both, ie, impairment of thinking, judgement, and perceptions (Table 1). Although both ACS and chronic dementia are consideredorganic brain syndromes, the two generally differ in onset and reversibility. Dementia, a chronic condition, develops over a period of months to years and involves loss of intellectual function and memory that may interfere with the individual’s ability to carry out daily activities. lP1*-14Generally, the more acute and physically disabling the condition, the more likely the patient will have an ACS rather than dementia. Old age alone does not cause cognitive impairment that inhibits functional abilities of the older person. Common and expected changes include mild recent memory loss and slowed thinking and reaction time.15 Kane et al’* point out that elderly personsare often labeled “senile” or “confused” due to impaired hearing that may lead to misinterpretation of information. Likewise, the older person may not be given sufficient time to respond to a question, and hence, the label senile or confused Seminars in Oncology Nursing, Vol 4, No 3 (August), 1988: pp 208-216

CONFUSION

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Table 1. Clinical Characteristic

of Acute

Confusional

States

and Cortical

Dementia ACS

Insidious Months to years None (until late) Normal

Speech Mental status Attention Memory Language

Normal, Amnesia Aphasia

Perception

Hallucinations

Mood/affect

Disinterested

of systems

from

Involvement

Cummings

Sudden Hours to days Postural Slurred

distractable

(late)

and/or disinhibited of extraneural

JL, Benson

organ systems

slow DJ: Dementia:

tremor,

Pronounced A Clinical

is employed.13 Goldberg16 also noted that in its less severeform, delirium may be misdiagnosedas behavioral problems since many patients mask confusion by being quiet or appearingdepressedor anxious. Symptoms of acute confusion are identified in Table 2. ” In an ACS, a clouded mental state may be the presenting feature as thinking becomes disordered,15,‘7 with the awarenessof time being forgotten first, followed by place and recognition. ‘* Impairment of abstract thinking may be obvious as the patient appearsperplexed or missesthe meaning of what the nurse is asking or telling. Impaired memory is evidenced by the patient’s inability to recall recent events or register new information. l4 Remote (long-term) memory may be intact but used at inappropriate times. l1 As the thought process becomes increasingly disorganized, the patient’s speech may become more fragmented and incoherent, with reiterations and intermingling of themes that are incomprehensible.12,i7 Mood is variable and may alternate from profound depressionand withdrawal to irritability and extreme anxiety.5,19Along with mood, psychomotor activity may fluctuate. There are three variants of the clinical presentation of acute confusion:1”7 (1) hypokinetic, characterized by decreasedpsychomotor activity, somnolence, apathy, arousal and excitability; (2) hyperactive, characterizedby increased arousal of the autonomic system, psy-

myoclonus,

asterixis

Inattention, fluctuating arousal, variably alert Impaired by poor attention Normal or mild anomia: misnaming may be prominent; dysgraphia often prominent Visual, auditory, and/or tactile hallucinations may be florid. Fear and suspiciousness may often be prominent. History of systemic illness or toxic exposure

not prominent

usually absent Normal or mildly

EEG Reproduced sion).

Characteristics

Conical Dementia

History Onset Duration Motor signs

Review

209

Approach,

Stoneham

diffuse

slowing

MA, Butterworth,

1983 (with

permis-

chomotor hyperactivity, marked excitability, tendency towards hallucinations and delusions; and (3) mixed, characterizedby a fluctuating state between the extremes of the two variants. Visual illusions are more common than hallucinations. With sensorylossesand decreasedstimulation, especially at night, the elderly patient may misinterpret people, actions, or objects. The confused individual (particularly with a hearing loss) may experience transitory delusional beliefs, eg, the food is poisoned, or “I’m being experimented on. r914,l’ A disturbance in the sleep-wakecycle is often a frustrating problem for nursing staff. While somnolence occurs during the day, the individual may becomehyperalert and agitated at night. 1~17719 This sleeplessstate is often referred to as Sundowner’s Syndrome. Confusion after dark is thought to be causedby difficulty in adjustment to darknessand decreasedsensorystimuli, particularly in those patients with a loss of vision and/or hearing.17 A fast-pacedclinical setting may create anxiety and tension which may heighten the confusion and insomnia. ‘* ETIOLOGY

The causes of ACS are numerous and can be divided into physiological, psychological, and environmental disturbances.’ It is imperative that the numerous etiologies of acute confusion be identi-

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Table 2. Core Symptoms

of Acute Confusion

Decreased capacity to attend to environmental stimuli Transient shifts of attention Easily distracted by irrelevant stimuli Senses uneasy equilibrium with environment Impaired attentional ability Disorientation to time Occasional disorientation to place, person Memory alterations Deficits in registration, retention, recall Immediate memory more impaired than remote memory Perceptual disturbances Misperceptions, illusions, or hallucinations Above symptoms more prevalent when falling asleep or awakening Symptoms more marked at night Thought-process impairment Halting or incoherent speech Limited ability to reason or problem-solve Fragmented and unpredictable behavior Profound disturbances in the sleep/wake cycle Variable psychomotor activity Restlessness, agitation Quiet, withdrawn, even stuporous Data from Zisook

S and Braff D.”

fied since intervention planning is based on the outcome of this assessment. Zisook and Braff17statethat personsover age60 are at greater risk for developing ACS, as the senescent brain is more vulnerable to disturbances that affect its function. Therefore, even small disturbances may lead to cognitive impairment. Generally, the causes of ACS during hospitalization are multivariate in nature, ie, emotional stress brought on by hospitalization and an unfamiliar environment, medications, fluid and electrolyte imbalance, fever, fear, and uncertainty. ‘J*-~~J’-~~ Psychogenetic theories explaining the mechanism of acute confusion include the following:1’17 (1) Acute confusion develops as a result of generalized cerebral insufficiency. (2) Neurochemical mechanisms become altered, and the imbalance of the cholinergic and adrenergic mechanism underlie acute confusion. (3) Acute stressmediated by abnormally high circulating corticosteroids or by increasedvulnerability of the hypothalamus to their effects. Physiological

Causes

Wolanin” believes that confusion can be predicted in any problem that interferes with oxygen-

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ation of the brain cells, interruptions of the constant need of glucose for metabolism, or alteration of neural function by chemical means. Therefore, virtually any disease,trauma, toxin, drug, or stress can causeACS becausethese biochemical, physiological, or structural insults can interfere with cognitive function. 15,17Even urinary retention and fecal impaction may cause or contribute to ACS, especially in the patient with communication problems.10*12Physiological causesof acute confusion in the older cancer patient include hypoxia and its related effects, specific tumors, and drugs. Hypoxia. Hypoxia is a major systemic problem with an acute onset and a reversible confusional state. Anemic, hystotoxic, and ischemic hypoxia along with hypoxemia can precipitate acute confusion. l1 Anemic hypoxia causedby altered oxygen transport due to a decreasedred blood cell count and hemoglobin is often causedby hemorrhage or any acute blood loss, anemia of chronic disease,treatment or disease-relatedhemolysis, overuse of aspirin, or it is a postoperative complication. The older cancer patient with acute leukemia or treatment-relatedbone marrow depression,or who is in the postoperativerecovery phase, is at risk for the clinical appearanceof hypoxia-related confusion. Hystotoxic anemia is associatedwith conditions that prevent cells from metabolizing oxygen. Examples include fever, dehydration, and accompanying electrolyte imbalances(ie, hypokalemia, hyponatremia, hypocalcemia or hypercalcemia, uremia). Cancer-relatedrisk factors for hystotoxic anemiawith resultant confusion in the older person include treatment with hyperthermia or diuretics, extreme nauseaand vomiting leading to dehydration, and electrolyte imbalances that accompany cancer and its treatment. Hypoxemia that results when gas exchange is compromised may occur with primary and metastatic lung cancer and when pulmonary lymphangitic spreadis a problem. Ischemic hypoxia, a result of obstructed cerebral blood flow may present with hypotension associatedwith interleukin therapy, septic shock, brain involvement by tumor causing increased intracranial pressure, and superior vena cava syndrome. Tumors. Holland*’ stated that the presenceof an acute mental disturbance or suddenpersonality change in a previously emotionally healthy indi-

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PATIENTS

vidual who has cancer is most likely secondaryto cerebral dysfunction related to cancer or its treatment. When the cancer is the causative agent, either the primary canceror a metastaticprocessmay be the precipitator of confusion. Carcinoid tumors are the most common endocrine malignancy to cause psychiatric symptomatology. *’ Although depression is the most common psychiatric manifestation of carcinoid tumors, anxiety and confusion may be seen.Adrenal insufficiency as a result of lung and breast metastasescan also be linked with acute confusion, although this is a rare entity.22 Subtle change in mental status is a general manifestation of increased intracranial pressure resulting from brain metastases.23Complaints of sleeping more than usual, difficulty concentrating, irritability, forgetfulness, and memory loss are often noted by the family. This symptomatology may precipitate acute confusion. Prefrontal lesions in the cerebrum may causepersonality changes, memory loss, impaired judgement, and emotional lability.23 Again, these symptoms may be correlatesof acute confusion. Meningeal carcinomatosis, characterizedby diffuse multifocal seeding of the leptomeningescovering the surface of the brain and spinal cord, may result in altered mentation and memory 10~s.~~ Personality changes may be subtle without blatant confusion at initial presentation. Drugs. Drugs are a major causeof both acute and chronic impairment of cognitive function since older personsmay have altered changesin absorption, distribution, metabolism, and excretion of medications.12,13915Y17,19,25 Thus, the elderly experience more frequent drug-drug and drug-disease iatrogenic reactions than do younger patients.l5 The first sign of an adversedrug reaction is often a change in mental function; therefore, medications should be suspectedwhen impaired cognition is encountered.‘5,25Polytherapy, particularly with psychoactive drugs having strong anticholinergic properties, is probably the greatestprecipitator of acute confusion in the older patient. Both prescribed and over-the-counter medications with anticholinergic properties should be considered (Table 3). Petersen and Popkin reported that the problems of assessingpsychiatric symptomatology associatedwith cancerchemotherapyinclude the fol-

Table 3. Drugs That May Cause or Contribute to Confusion Analgesics Codeine Demerol Darvon Morphine lndocin Talwin Antihistamines Benadryl Atarax Antihypertensives Aldomet Catopres Hydralazine lnderal Reserpine Antimicrobials Gentamicin lsoniazid Antiparkinsonians Bromocriptine Sinemet Symmetrel Cardiovascular Atropine Digitalis Diuretics Lidocaine

Data from

Kane R, Ouslander

Hypoglycemics Insulin Sulfonylureas Psychotropic drugs Antianxiety Benzodiazepines Valium Ativan Xanax Antidepressants Lithium Tricyclics Antipsychotics Haldol Mellaril Thorazine Sedative-hypnotics Chloral hydrate Dalmane Halcion Other Tagamet Steroids Over-the-Counter Excedrin PM Compoz Sominex Dristan Benadryl J, and ltamar

A.12

lowing: (1) use of multiple drugs in treatment protocols; (2) metabolic effects causedby disease and its treatment; (3) direct/indirect effects of the malignancy on the central nervous system; and (4) inclusion of corticosteroids in treatment protocols. Severalchemotherapydrugs have neurotoxic effects whose manifestations include componentsof confusion. High-dose cytosine arabinoside can cross the blood-brain barrier and cause short-term memory deficits. 27 Hexamethylmelamine causes confusion, depression, and hallucinations in 20% of patients, with symptomsbeginning several days to weeks after the onset of chemotherapy.26There is no documented dosagenor time relationship to the incidence of this problem with hexamethylmelamine, and recovery takes days to weeks after withdrawal from therapy. It is also unclear whether the behavioral symptomsrepresenta manifestation of an underlying organic syndrome or an affective disturbance.26Confusion associatedwith intrathecal methotrexate and cranial irradiation is one component of a cluster of symptoms associated

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with multifocal leukoencephalopathy. A side effect of L-asparaginase includes confusion as a component of CNS dysfunction occurring in 21% to 60% of patients receiving the drug.26Other chemotherapy drugs known to cause mental status changesin the form of confusion include dacarbazine (in only 5% of patients), velban (in 60mg/kg are associatedwith this problem.26 Psychological Causes The causativeeffects of emotional stressprecipitated by physical illness and hospitalization of the elderly patient can not be overstated. In older adults sensory changes, particularly visual and hearing loss and inexperience with hospitalization, create additional stress. Losses may include not only a decline in physical health, but also loss of loved ones, income, jobs, and a feeling of uselessness.28 Depressionis common in the elderly and may be present in at least 10% of this population at any given time.29 Depression may present clinical features similar to ACS, since cognitive impairment may be evident.29 It is important to determine whether depression is a primary or secondarydisorder. Malignancies are often cited as one of the best-known triggers for depression.15,29 Anxiety is a common complaint of the elderly and may manifest itself in a somatic form with motor restlessness,autonomic signs, agitation, and insomnia.3oShaw and Opit31 found that up to one third of elderly patients hospitalized for medical illness received benzodiazepines (antianxiety drugs) to reduce anxiety symptoms. Environmental Causes Rapid or frequent changes in the elderly patient’s environment may precipitate ACS since familiar objects and surroundings and orienting cues may be absent.12,18The emotional stressof being away from familiar surroundings, fear of invasive procedures, and having multiple caregivers compound the stressof hospitalization for the elderly. Disturbances in the sleep-wake cycle and the hyperkinetic statemay result in sleeplessnessand further precipitate confusion. 10*12Y17 ASSESSMENT

Since the onset and course of ACS is variable, nurses are in a strategic position to observe fluc-

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tuations in cognitive function. Selbst13stressesthat history is the most important diagnostic tool. Kane et all2 suggestthree questions that may be helpful in accurately identifying ACS: (1) Has the onset of abnormalities been sudden(eg, hours to days)? (2) Are there physical factors that may be contributing to these abnormalities (eg, acute illness, medications, sensory deprivation)? (3) Are there psychological factors that may be contributing to impaired cognitive function (eg, anxiety, grief, depression, psychosis)? Documentation of the patient’s preadmission or baseline mental status is imperative. If the patient presentswith ACS, this information should be obtained from a family member or friend.1*12*13Becausefluctuations in cognitive function, attention, and the sleep-wakecycle may occur, careful documentation of the changesthat occur over time is critical to further evaluate ACS.17’2 A standardizedmental status questionnaire may be used as a screening tool. If a standardizedtool is not used, Zisook and Braff” suggesttesting of the following areas:(1) Orientation. Ask, “Where are you? What is the date, year?” (2) Recent memory. Ask the patient to repeat three unrelated items, eg, hat, tree, car, and then recall theseitems after three minutes. (3) Ability to perform cognitive tasks. Ask the patient to perform simple calculations, spell a word backwards, interpret proverbs. Similar information may be obtained by simply observing and interacting with the elderly patient. For example, is the patient alert, agitated, distracted, or somnolent? Does the patient respond appropriately to questions asked? Is the patient able to follow simple commands?Does the patient have any bizarre or paranoid ideas? Does the patient seem to be aware of current events? Once again, documentation and communication of abnormal findings needto be reported throughout the hospital stay. Medical work-up for ACS v dementia will generally include a complete blood count, ESR, glucose, BUN and creatinine, electrolytes, liver and thyroid function studies, vitamin B,, and folate levels, VDRL, and/or serum drug levels. Other studies may include arterial blood gases, chest x-ray, CT scan of the head, ECG, and urinalysis.11,12,17Knowledge of the abnormal findings will be important for nurses to recognize as the potential physiological causesof ACS are considered.

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Our predictive capabilities are extremely important acknowledging that if we can predict confusional states we can prevent them. l1 The cancerrelated etiologic variables that may help identify patients at risk are listed in Table 4. Certainly, the greater the given number of potential etiologies, the greater is the likelihood of acute confusion. Examples of older patients with cancerhaving significant risk for an ACS are: (1) the older patient with acute leukemia and hypokalemia from Cushing’s syndrome, who is septic and in reverse isolation, or (2) the elderly man with metastaticprostate cancer who is anemic from extensive bone metastases, who displays acute postoperative symptoms from a hip-pinning procedure following a fall, and who is receiving regular narcotics to treat both acute and chronic etiologies of pain. In looking for early signs of confusion, suspicion should intensify whenever the elderly person presents with a recent change in alertness, mood, awareness,thought process, or behavior. Because of the variability of symptoms, observersmay see strikingly divergent symptoms. The night staff should be particularly proficient at assessingthe early signs of acute confusion. The family may comment that “He’s just not himself,” citing subtle personality changes that may be a prelude to more pronounced changesin mental status.24 Specific answers about cognitive abilities should be solicited from the family: Is the confusion new or is it a gradual worsening of an Table 4. Potential Cancer-Related Acute Confusion

Etiologies

of

CCWS3

Infection Metabolic

Trauma Vascular

Tumor latrogenic Chemotherapy

Pneumonia, urinary tract, bacteremia, septicemia, abscess Endocrine and electrolyte imbalances, hypoxia, vitamin deficiency, cachexia, dehydration, hepatic and renal failure Falls, accidents, head injury, surgen/ Hypertension/hypotension, atherosclerosis, superior vena cava syndrome Primary or metastatic brain, carcinoid, adrenal involvement Hepatic, renal or pulmonary toxicity; polytherapy Cis-platinum, hexamethymelamine, L-asparaginase, intrathecal methotrexate, dacarbazine

insidious problem? If it is new with an acute onset, most likely it is reversible once the underlying cause is identified. The work-up to identify the etiology of acute confusion in an elderly person with cancer should proceed with the samevigor as one would employ with a 30-year-old patient. Confusion is not an automatic correlate of being old and having cancer. NURSING MANAGEMENT OF ACUTE CONFUSIONAL STATES

Foreman’ maintains that nursing care of the confused patient should include physiological, psychological, and environmental support. This care should be directed toward preventing or modifying the disorganization, supporting and protecting the patient during abnormal behavior, and reorienting the patient to reality. Wolanin and Phillips” note that nursesare more attunedto both preventing and treating confusion since confusion is rarely an unexpected occurrence and follows an orderly sequence of events. Nursing interventions for the confused patient are listed in Table 5. Physiological Support

Interventions that provide physiological support might include providing adequatefluid and nutritional intake, assuring that elimination needs are met, promoting activity and self-care, providing pain relief, and judicious administration of drugs.2*10Since the confused patient may not recognize the need for fluids, the nurse and/or family member(s) should offer fluids frequently or provide fluids of choice within the patient’s reach. Likewise, food should be provided that is desirable to the patient. Small frequent feedings and the use of finger foods may promote independencein patient feeding and provide adequatecaloric needs. Elimination needs must be anticipated by the nursing staff. Often decreased mobility and the delayed urge to void may lead to urinary incontinence.32Frequently, falls in the acute care setting are due to patients with impaired cognition getting up without help to take care of toileting needs.1o733Getting the patient to the bathroom, commode, or on the bedpan before or after meals and approximately every two to three hours will ensure optimal elimination, promote safety, and minimize episodesof incontinence. Allowing the patient to participate in self-care is an important orienting measure. Other benefits of

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Table 5. Nursing Interventions

for the Confused Patient

Communicate frequently, calling the patient by name and utilizing touch; give simple direct commands; avoid complex questions or explanations. Provide orienting devices such as clock, calendar, personal items and pictures from home. Maximize sensory input and communication by the use of eyeglasses, hearing aid, and dentures. Provide an organized environment avoiding excess noise; a private room is desirable. Maintain adequate fluid intake by offering fluids frequently. Anticipate elimination needs by toileting after meals and every two to three hours. Allow patient to participate in self-care activities, utilizing verbal cueing when necessary. Approach patient in a calm, reassuring manner. Explain to the patient what you are going to do. Ambulate the patient two to three times per day. Encourage patient to eat meals sitting up in a chair. Provide active or passive range of motion every shift for the bedridden patient. Utilize mittens, restraints, and poseys for the protection of the severely agitated patient. Remember the rule of thumb: start low and go slow when pharmacological interventions are chosen for the agitated or delusional patient

self-care include increased activity and range of motion. The confused patient may need direction and verbal cueing to achieve this measure.Ambulating the anxious or agitated patient will not only provide increasedactivity, but may decreasewandering and promote the need for rest periods. Goodel16statesthat pain is the primary problem in 50% to 60% of elderly cancer patients and is best managedwith regularly scheduledadministration of low-dose oral medication. Since pain may contribute to anxiety and confusion, optimal pain control should be achieved. As stated previously, virtually any drug can cause or contribute to confusion.11~12~‘5~‘7 Therefore, it is important to ascertain the patient’s and family’s view regarding the importance of the elder’s mental clarity and acuity since drugs may diminish cognitive function.** Generally, every attempt should be made to avoid or discontinue any medication that may affect the cognitive function of a confused elderly patient.‘* Along with the administration of medications, documentation of any cognitive impairment (particularly after a new drug is started) should be noted. Pharmacologicalinterventions for confusion and agitation should be applied after other measures

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fail. The drugs commonly chosen to treat confusion are short-acting benzodiazepines and antipsychotics.‘*J’,~~ Antipsychotic agents such ashaloperidol are effective in controlling the physical agitation that accompaniesconfusion as a result of impaired cerebral cortical functioning.35 Initial control of physical agitation accompanying confusion can be managedin the following ways: (1) Dosagesshould start low and gradually be increasedwith a maximum dose of 6 mg/d. (2) Administer 1 to 5mg haloperidol intramuscularly, or elixir every 30 minutes, until agitated behavior is controlled. (3) Once control is achieved, the total dose required to control symptoms should be distributed over 24 hours to prevent re-emergenceof symptoms. Therapy with haloperidol should be viewed as a short-term measure to ameliorate symptom distressuntil the underlying medical etiology is identified. Symptoms are usually controlled in one to five doses. For less agitated forms of confusion such as mild sundowning, 0.5 mg haloperidol administered twice a day is often effective. For acute postoperativeconfusion, 0.5 mg haloperidol hourly for six doses works we11.35 Psychological Support

Psychological support is necessary to prevent decrementsin the ego support systemof the elderly patient.* Care should be taken to maintain a calm and tolerant manner, and the use of therapeutic touch may serve as a calming effect and be much more useful than medications.’ 8 New information should be provided slowly to the patient. Reassurance of the patient’s own safety is especially important for the patient who is anxious, frightened, or delusional. l9 A simple reassurance such as “You are safe, I’m with you now,” and “I won’t let any harm come to you” may be helpful. Acute confusional states are often upsetting to family members. Nurses can provide information and education to family and friends regarding confusion and how to best interact with their lovedone. Encouragefamily membersto talk to the patient about concrete things and to avoid asking the patient to rememberdetails of the present illness. l9 Encourage family members to bring in personal items from home that hold special meaning for the patient. Reinforcement of the patient’s occupation, family status, and special interests will serve as internal reference points for the patient. This pro-

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motes internal reorientation that supports the patient’s self-esteemwhile removing the focus from the present situation. l9 Environmental Support Environmental support measuresshould be directed at providing a safe and organized environment and enhancing communication. In order to ensurethe patient’s ability to perceive the environment correctly, eyeglasses, hearing aids, and dentures should be used when appropriate. Face-to-face contact is essential for good communication. Once the nursing staff knows how the patient wishes to be addressed,use that name constantly. Use short, simple statements, and avoid the use of complex explanations or questions. Devices such as a clock or watch (preferably from home), a calendar (day-by-day v monthly) and a schedule that mimics the patient’s daily routine at home are useful measuresfor reality orientation. Television viewing (eg, newscasts,which promote reorientation) may be useful, but watch for discomfort and overstimulation. Primary nursing care also promotes continuity and consistency. Safety issues are of paramount importance for the confusedpatient. Side rails should be raised for confused patients. Restraints should be reservedas

the last resort since they rarely deter the disturbing behavior and can create more fear and discomfort for the patient.2~‘0~18~19 A posey, particularly a vest with closure in the back, allows freedom of movement of arms.‘J Mittens or elbow restraints should be tried before wrist restraints in the patient pulling at intravenous lines, tubes, dressings, etc.” Extended visiting hours should be allowed for family membersto stay with the patient so that physical an&or pharmacological restraints may be avoided. CONCLUSION

Confusion is a complex symptom of physiological, psychological, and environmental disturbances that interfere with brain function.5 As nurses deliver planned and predictive care in a structured and calm manner, elderly cancer patients can be supportedthrough the resolution of an acute confusional state. Nursing research has only begun to study the phenomenaof ACS. 1Y3310Y36 More data is needed regarding the effects of specific nursing interventions on preventing and/or minimizing ACS in the elderly patient. Since confusion is primarily a problem of the elderly and cancer is primarily a diseaseof aging, oncology nurses must be proficient in dealing with this clinical problem.

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