| ~~~~~~~Fatures _

Martha Keniston Laurence

Dealing with Confusion in the Elderly
SUMMARY
Elderly patients with established brain
failure present the family doctor with
problems of longterm management for
which there are, at best, limited
pharmacologic solutions. An organized
plan of management developed jointly with
the significant other(s) will help achieve
treatment objectives. By assessing the
patient's physical and mental function, it is
possible to work out appropriate changes in
the living environment and behavioral
interventions which will help retard
deterioration, maintain and conserve
function and reduce the confusion and
distress felt by all parties. Though initially it
may be more time consuming for the doctor
to take on this leadership and coordination,
the recurrent and frustrating crises over the
long haul may well be reduced. Certainly
patient care will be improved. (Can Fam
Physician 1981; 27:1565-1568).
SOMMAIRE
Les patients ages, affectes par une insuffisance
cerebrale, donnent au medecin de famille des
problemes a long terme pour lesquels il existe, au
mieux, des solutions pharmacologiques limitees. Un
plan de traitement bien organise permettra
d'atteindre les objectifs. En evaluant les fonctions
physiques et mentales du patient, il est possible
d'apporter des changements appropries dans son
milieu de vie et dans son comportement, lesquels
aideront 'a retarder la det6rioration, A maintenir les
fonctions et a reduire la confusion et la detresse
ressenties par toutes les parties. Bien qu'au debut
cela puisse representer un plus gros investissement
de temps pour le medecin qui se charge de la
direction et de la coordination, 'a la longue, cela peut
bien vouloir dire une diminution des crises qui sont
toujours frustrantes. Le patient s'en portera
surement mieux.

Dr. Laurence is a psychologist,
educator and gerontologist; an
associate professor in the
Department of Family Medicine at
Dalliousie University and consultant
in geriatrics in the Department of
Medicine at Camp Hill Hospital,
Halifax, NS. Reprint requests to:
Dr. Laurence, Department of
Family Medicine, 5599 Fenwick
Street, Halifax, NS. B3H 1R2.
"I used to be a TGIF man. I never
thought I'd ever see the day, but I have
become a TGIM man-I can't wait till
Monday mornings so I can escape to
work."
CAN. FAM. PHYSICIAN Vol. 27: OCTOBER 1991
HIS REMARK came from the ex-
asperated husband of a woman
with a moderate degree of impairment
due to Alzheimer's disease. She is un-
able to go shopping but she gives him
hell when he buys other than Delmonte
canned vegetables. She gets up and
dresses herself each day; some days
she has dinner prepared when he re-
turns home from work. He says she
seems to need to "blow up" at him
every two or three days. He has
learned that if he wants to get it over
with early in the day, he wakes her up
before he goes to work in the morning.
Otherwise she "lets him have it"
when he gets home in the afternoon
because he went to work in the mom-
ing without saying goodbye to her. He
can do nothing right, there is "no
pleasing her", she won't leave the
house socially and doesn't want him
to, he finds himself drinking more and
has begun taking weekends off. He
feels guilty, angry, inadequate and
fearful-he is about to retire.
"I quit my job as a nurse at the local
hospital so I could stay home and take
care of my father-in-law. We feel
strongly that we don't want to put him
in a nursing home. But we don't know
what to do with him either."
This came from the prime care pro-
vider to a grandfather who has severe
1565
dementia and who is being cared for
by his family. He has good days and
bad days. His behavior is unpredict-
able. At times he becomes belligerent
and resists getting dressed in the morn-
ing or eating his meals. Some days he
recognizes his family and some days
he doesn't. Sometimes he is continent
and other times he isn't. He gets con-
fused and can't find the bathroom-
and then gets agitated when they try to
help or remind him. A lot of the time
he is very pleasant, affable and partic-
ularly good with the grandchildren
with whom he laughs and talks. His
son expresses near disbelief that this is
the same man who has been his father,
a pillar of the local community in
which he owned and operated a store.
They are bewildered, sad, frustrated
and angry.
The Family Doctor's
Perspective
You listen, you can empathize with
the expressed frustration, the pain.
You know this patient, the situation.
You have 15 people sitting outside in
the waiting room. You're running be-
hind now. Do you prescribe something
for the 'significant others' in these sit-
uations? Do you try something else for
the patient? You've read that pheno-
thiazines are in; you've read that
they're out. The reviews on hydrogen-
ated ergot alkaloids (Hydergine) are
controversial and certainly inconclu-
sive. Where do you begin? What do
you do?
The Patient's Perspective
The patients have been living with
the development of their condition for
some time. To separate the actual
amount of organic deterioration from
the emotional and psychological
aspects is almost impossible, because
the emotional reaction has an effect on
overall performance. Quite possibly
the patient had experienced memory
deterioration for some years before
Alzheimer's disease was diagnosed
and also experienced the resulting fear
and anxiety over that loss.
Even in the normal course of events,
elderly people tend to commit 'errors
of omission' both in performance on
mental testing and in everyday func-
tion. They tend to compensate for real
or perceived losses by giving up trying
1566
to do things. So we have a continuum
of loss, resulting anxiety and fear,
avoidance of making errors by not try-
ing, and physical and mental inactiv-
ity-which unfortunately increases the
impairment and probably hastens the
process. These patients question their
value, their acceptability to others. In
their confusion and the accumulation
of reduced capacities, they often expe-
rience a personality change and are de-
scribed by their significant others as
'irritable' and having 'outbursts'. The
patient is often aware that this is hap-
pening but is unable to control it,
thereby developing remorse over his
irrational behavior. We end up with a
negative escalating cycle of impaired
function and emotional inability to
cope. An overlay of depression, par-
ticularly in the earlier stages of the de-
velopment of the disease, is not un-
common. When patients most need
reassurance, they are least likely to get
it because their behavior tends to alien-
ate others.
No one is to blame in this cycle. The
situation and the reaction of the vari-
ous parties are in fact normal re-
sponses to abnormal circumstances.
We need an approach to the problem
as a situation or system in which all
variables are at play.
Treatment Objectives
For the family doctor, the signifi-
cant other(s), and sometimes the pa-
tient, the statement of treatment objec-
tives provides a reference point for
determining the course of intervention
and management plan.
TABLE I
Objectives in Treatment
1. Retardation of deterioration
2. Rehabilitation to and
maintenance of maximum
independence of function
3. Optimal quality of life for patient
and significant other(s)
The first objective is to retard the
deterioration in function as much as
possible for as long as possible. The
disease is longterm and progressive,
but with certain kinds of interventions
may be retarded.
Objective number two is for the pa-
tient to achieve and maintain maxi-
mum level of function-physical and
mental. Our efforts are directed toward
independence and mastery of skills for
daily living such as dressing, eating,
and toileting.
Thirdly, our objective is to address
the quality of life for both the patient
and the significant other(s) involved in
the situation. Consideration of the
needs of any one party in the situation
cannot be done in isolation and must
be viewed as part of a unit. To allow
the obligations and frustrations and
tasks of maintaining the elderly parent
in the family cannot be a positive ex-
perience if it ends up wrecking the
lives of the children and grandchil-
dren.
TABLE 2
Steps in Management
1. Diagnosis
2. Review of treatment objectives
3. Joint development of treatment
plan
4. Continuing care and update
plan
Principles of Treatment
"If you don't use it you lose it".
This certainly applies to healthy aging.
It also applies as a principle in the
management of a situation in which
there is permanent impairment. Our
expectations of the patient must be
therapeutically appropriate-they
must stress patients sufficiently so that
they function at their maximum capac-
ity. However, if our expectations are
inappropriate or too stressful, we will
in fact be facilitating increased de-
terioration and breakdown. Our ten-
dency with demented old people is
either to overstress (through too high
expectations and some notion that they
need to be 'stimulated') or to under-
stress by doing everything for them
(out of our own frustration or some
idea of 'good care'). The result in
either case is greater dysfunction.
The key becomes assessment. Only
with an accurate assessment of the ca-
pabilities and functioning levels of the
patient and the significant other(s) can
we design a management plan which
will stress the patient at a therapeutic
level. The patient's physical and men-
tal function must be assessed in the
context of his living situation.
In order to achieve our treatment ob-
jectives (retardation of decline, maxi-
mum independence of function, qual-
ity of life) it is important to find a
management regime which achieves
CAN. FAM. PHYSICIAN Vol. 27: OCTOBER 1981
the balance between too much and too
little.
To Do or Not to Do
1. One of the first areas of manage-
ment planning is reality orientation.
What environmental and behavioral
cues and clues can we provide to help
the patient retain orientation to person,
place and time? One guiding concept
to maintain or preserve orientation is
familiarity of surroundings, artifacts
and people. We are likely to experi-
ence greater success by building on ex-
isting resources than by introducing
new and confusing demands. We can
capitalize on rituals and patterns of be-
havior from the patient's history. To
brighten up the patient's room with
new wallpaper and furnishings may be
all the more confusing. A trip to visit
another relative may make things
worse. What might make us feel better
may not have the same effect on the
person struggling to make sense out of
the world about him.
Helpful environmental orientation
symbols include items such as calen-
dars, clocks, mirrors, pictures, photos.
Repeating one's name regularly to the
patient, calling her or him by name,
saying what place this is, what time of
day, date, season, it is, can be capried
out by the significant other(s).
TABLE 3
Guidelines for
Developing Treatment Plan
1. Reality orientation
2. Behavioral prescription of
activity
3. Specific compensations for loss
in function
4. Careful communication of
expectations
5. Contingency plans for the
difficult times
6. Reassessment and modification
of treatment plan
The appropriateness hinges on the
assessment. It may be more appro-
priate to ask patients those questions
and get them to answer. Examples of
orientation behaviors that might be ex-
pected of the patient include things
like getting dressed in the daytime and
wearing pajamas at night, routine
meals at predictable and patterned
times, a daily walk, listening to the
one o'clock news after lunch. Ritual
behaviors provide reassurance and se-
CAN. FAM. PHYSICIAN Vol. 27: OCTOBER 1981
curity. They are achieved through the
activity and its meaning to the patient.
Based on your assessment and with
the involvement of the significant
other(s)-sometimes also the pa-
tient-you examine the daily routine
for the patient and work out a plan.
2. Use the medical model to your
advantage: the behavioral prescrip-
tion. Concern is often expressed about
the sedentary life of many old people.
This often leads into a discussion of
the need to 'stimulate' them into activ-
ity, preferably social. Perhaps our first
assignment is to accept that we may be
unable-even if it were a good idea-
to create socially active people out of
those who may never have been and/or
who are now experiencing moderate to
severe dysfunction. It comes back to
assessment of previous activities and
personal preference. You can, how-
ever, determine and prescribe a bottom
line of activity needed to maintain
function. That might include things
like getting up each day, dressing,
walking a certain distance, going to
church on Sundays, making a phone
call to a particular person once a day,
or so many minutes of fresh air a day.
A routine of prescribed physical activ-
ity and fresh air may work more effec-
tively than, or increase the effective-
ness of, sleeping medication.
3. Think compensation. To help the
patient retain maximum independent
function, we need to devise compensa-
tion for the patient's loss of abilities.
Such compensation must be incor-
porated into their daily routines. Com-
pensation for loss of sight is provided
by spectacles, for hearing loss, by a
hearing aide. In fact, patients have
probably been compensating for intel-
lectual deterioration by 'social mask-
ing'-giving an apparently socially
appropriate response in situations
where their lack of mental function
would be obvious. You may pick this
up in the mental status exam.
For persons with mild to moderate,
and often variable, mental impair-
ment, we can work out reminder sys-
tems. Color coding provides specifi-
cally designed visual cues; for
example, red tape on the hot water tap
or stove burners, special identifying
features for the bathroom door or taped
arrows on the floor from the bedroom
to the bathroom. Patients who seem
unable to cope with a full place setting
at the table may be able to manage one
dish, utensil and food item at a time,
without the placemat, napkin, salt and
pepper, other dishes and utensils.
Quite confused old people can
sometimes obey traffic light signals
but not find their way home. Name,
address, phone number and dime (or
two) on the person, even around the
neck, has worked in certain situations.
If they are unable to work the pay
phone, they may be able to ask some-
one for help.
The management of drug adminis-
tration lends itself to the adoption of an
individualized system (unit dosage and
pill boxes with compartments, etc.).
4. How do we communicate our ex-
pectations to the patient? This is best
done slowly, simply, directly, repeti-
tively and consistently, depending on
our assessment of the patient's ability
to understand and to learn.
Visual communication, such as
showing a person how to do things, a
written plan of daily routines, a behav-
ioral prescription, etc., reinforce and
clarify for all parties what everyone is
going to do. At times of emotional dis-
tress our retention of oral messages is
less than perfect.
The message is stronger in more
than one medium. A written plan
worked out with the significant
other(s) also gives them direction in a
situation in which everyone tends to
flounder about, wondering what can
and ought to be done to make things
better.
5. Peak agitation times occur when
the patient becomes particularly agi-
tated, confused and/or obstreperous. It
is in the nature of the illness and prob-
ably in the situation. Certain behaviors
and responses from those around the
patient may either escalate this re-
sponse or calm the patient down.
DO:
Lower voice to soothing (but not con-
descending or cooing) tones.
Walk with the person, perhaps arm in
arm.
Use short direct statements for com-
munication.
Simply listen.
Check for safety and leave person
alone (particularly when faced with a
battle of wills).
Solve problems later.
DON'T:
Try to explain to the patient-this is
not the time to reason or gain under-
standing.
Raise voices, yell or otherwise esca-
late the emotional climate.
1567
Stimulate further by suggestions of
this or that activity, especially if it
presents the patient with decision-
making or choices.
... KE~~~~~~~~~~~~~~~~~~~~~~...........
-

-R- elddor
Engage in battles of will ('Get out of
bed!' 'I will not!').
Particularly in the earlier stages of
the disease, the person is more vari-
able and unpredictable in function and
coping. The report by significant
others that patients have good days and
bad days may indicate that we need to lo r®~~~~~i:~~::i~~.~: -i~::i~ii::::::i:~:i (cefockr)]:i i~ ~ :i~ ~'~ ~ i:~ i~ ~ ~
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1568