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The Confused Patient
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Although the vast majority
of older people show very little or no decrease in cognitive function,
dementing disorders such as Alzheimer's disease do become more common
with age. Thus, as the oldest segments of the population continue
to grow, clinicians can expect to see more and more patients with
these disorders. Also, in later life various illnesses, both physical
and mental, can cause temporary, reversible cognitive impairment.
The diagnosis of Alzheimer's disease remains largely one of exclusion.
The general measures presented
throughout this handbook can aid in working with cognitively impaired
older people and their caregivers. The following suggestions pertain
specifically to the confused patient.
The NIA-funded Alzheimer's
Disease Education and Referral Center (ADEAR) can provide you with
information about Alzheimer's disease. Call or write:
ADEAR
P.O. Box 8250
Silver Spring, MD 20907-8250
1-800-438-4380
(880 instead of 800 if you are calling from outside the US)
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Communicating With the Patient
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When working with a confused
patient:
 Check
for clouded consciousness, delirium, slurred speech, or other signs.
Remember that the patient's behavior could be the result of a stroke.
Remember
to orient the patient. Explain (or re-explain) who you are and what
you will be doing. If possible, meet in surroundings familiar to
the patient. Consider having a family member or other familiar person
present.
Support
and reassure the patient. Acknowledge when responses are correct.
If the patient gropes for a word, gently provide assistance. Make
it clear that the encounter is not a "test," but rather a search
for information to help the patient.
Use
simple, direct wording. Present one question, instruction, or statement
at a time.
If
the patient hears you but does not understand you, rephrase your
statement.
Although
open-ended questions are advisable in most interview situations,
patients with cognitive impairment often have difficulty coping
with them. Consider using a yes-or-no or multiple-choice format.
If
the patient can read, provide instructions in writing.
Have
a staff member call to remind the patient of appointments. Perhaps
advise the patient to bring a family member or caregiver along.
Consider
having someone call the patient to follow up on instructions after
outpatient visits.
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Assessing Mental Status
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Although assessing an older
person's cognitive function is important, formal testing of mental
status tends to be anxiety provoking for the patient. Often, information
about the patient's mental state is revealed during the medical history.
Information also can be gleaned from the patient's behavior on .arrival
in the medical setting, or from interactions with staff by telephone
before the visit. Family members who may contact you in advance of
the visit are also a source of information.
Formal testing of mental
status often is best left until the latter part of the session-either
between the history and the physical examination or after the examination.
The testing may then be presented in the context of concerns the
patient has expressed. ("You mentioned sometimes having trouble
with memory. Let's try to find out more about that.") Providing
support and encouragement during the testing can decrease the stress.
("Some of these questions are hard, so just do the best you can.")
Although there are limitations
to any mental status test-for example, the test can reflect level
of education or the results may appear normal early in the disease-many
clinicians find the Mini-Mental State Examination (Folstein, Folstein,
and McHugh, 1975) helpful. For easy reference, click
here to obtain a downloadable file that contains this test (This
file requires Acrobat Reader. If you don't already have it,
you can download it here).
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Conveying Findings
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Often, assessment of mental
status shows no significant impairment. If a patient has voiced concern
about his or her mental functioning, he or she may continue to worry
unless substantial reassurance is provided. Emphasize that occasional
trouble remembering information such as names is fairly common among
older people and does not mean there is a serious impairment. Encourage
the use of notes or reminders.
When cognitive impairment
is found in an older person, it may reflect a variety of conditions,
many of them reversible. Possibilities to be alert for include stroke,
medication effects, infections, endocrine disorders, dehydration,
subdural hematomas, normal pressure hydrocephalus, residual effects
of anesthesia, and serious depression or other affective disorders.
Since patients or caregivers may assume that the cause is Alzheimer's
disease, you may need to explain the need for a careful history
and physical examination to search for reversible conditions..
If Alzheimer's disease appears
to be present, the question arises of what to tell the patient.
The answer depends on what the patient wants to know and how well
the patient's mind is working. You might consider, "You have a memory
disorder, and I believe it will get worse as time goes on. It's
not your fault. It may not help for you to try harder. You need
to go ahead and make whatever plans are necessary before your memory
gets worse."
Receiving a diagnosis relatively
early, while cognition is still fairly intact, can allow a patient
to make financial plans, prepare advance directives, and express
informed consent for research. Sometimes the patient is relieved
to know the nature of his or her problem. Disadvantages of telling
a patient the diagnosis include potential stigmatization and the
possibility of adverse emotional reactions.
Informing family members
or others that the patient seems to have Alzheimer's disease often
is best done in a family conference or group meeting, which should
be arranged with the consent of the patient. In some situations,
a series of short visits may be more suitable. You should make clear
your ongoing availability for care, information, guidance, and support.
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Working With Caregivers
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When a patient has Alzheimer's
disease or a related disorder, you can help all concerned by working
effectively with caregivers and other members of the family or household.
In addition to the general measures for supporting caregivers, the
following can help.
Explain
that much can be done to improve the patient's quality of life.
Various measures-such as modifications in daily routine, adaptations
of the environment, reassurance, appropriate cues, and medications
for anxiety, depression, or sleep-may help control symptoms.
Let
the caregivers know there is time to adapt. Decline is rarely rapid..
Provide
caregivers with information about the consumer resources and support
services available from:
Alzheimer's Association
919 N. Michigan Avenue, Suite 1000
Chicago, IL 60611
1-800-272-3900
(880 instead of 800 if you are calling from outside the US)
Help
caregivers and others to plan ahead for the possibility of needing
more help at home or having to look into residential care.
Emphasize
the need-and help find ways-for caregivers to get adequate nutrition,
exercise, rest, and stimulation.
Persuade
caregivers to get respite regularly, especially when patients have
required constant attention. ("You need to keep taking a few hours
for yourself so you'll be able to provide care the rest of the time"
or "Wouldn't you want her to take care of herself if your roles
were reversed?")
Listen
to caregivers' concerns and acknowledge their efforts. ("Your mother
may not be able to express her gratitude, but I know what it takes
to keep her looking so good.")
Ask
if the caregiver, who is at considerable risk for stress-related
disorders, is receiving adequate health care.
When
appropriate, recommend a support group, reading materials, or counseling.
Encourage
caregivers and others to maintain their sense of humor and to recognize
the joys remaining in life.
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