Nursing care and interventions for clients with chronic confusion (dementia) are crucial in promoting safety, preventing complications, and improving their overall quality of life by providing a supportive and structured environment, implementing cognitive stimulation strategies, and ensuring adequate communication and collaboration with the healthcare team. Use this nursing care plan and management guide to learn about the nursing assessment, nursing diagnosis, and interventions for caring for clients with chronic confusion.
Medical dictionaries define confusion as a state of disturbed consciousness, with disruption of thought and decision-making capacity. Confusion can be classified into two categories: acute confusion also called delirium and chronic confusion also called dementia (major neurocognitive disorder in DSM-5). Acute confusion or delirium often has an abrupt onset, over hours or days, and is associated with an identifiable risk factor or cause. It is mainly characterized by altered awareness, primarily affecting the client’s attention. Chronic confusion, or dementia, in contrast, is a long-term, progressive, and possibly degenerative process and occurs over months or years. Dementia is currently the seventh leading cause of death among all diseases and one of the major causes of disability globally (World Health Organization, 2021). Both categories can befall any age group, gender, or clinical problem.
Chronic confusion is progressive and variable in nature and may usually involve problems with memory recall, problem-solving, language, and attention. Also, there can be difficulties with perception, rationalizing, judgment, abstract thinking, communication, emotional expression, and the performance of routine tasks. Depression, brain infections, tumors, head trauma, multiple sclerosis, abnormalities resulting from hypertension, diabetes, anemia, endocrine disorders, malnutrition, and vascular disorders are examples of illnesses that may be linked with chronic confusion.
With chronic confusion, the client experiences a gradual but progressive decline in cognitive function. Clients also encounter problems in communication, ADLs, and emotional stability. Chronic confusion can have a great impact on family members and family processes as the client needs more direct supervision and care. Nurses need to be knowledgeable regarding the needs of clients experiencing chronic confusion and also learn more about its characteristics, risk factors, causes, and strategies to assist families in dealing with this growing population of clients.
Chronic confusion, often associated with dementia, Alzheimer’s disease, or other cognitive impairments, significantly impacts a client’s ability to perform daily activities and maintain a good quality of life. The development and implementation of a nursing care plan tailored to the specific needs of clients with chronic confusion are essential in ensuring holistic and client-centered care. This nursing care plan will serve as a roadmap for healthcare professionals, guiding them in delivering effective care, managing symptoms, and addressing unique challenges associated with cognitive decline.
The following are the nursing priorities for clients experiencing chronic confusion:
Dementia describes an overall decline in memory and other cognitive skills severe enough to reduce a client’s ability to perform everyday activities. It is characterized by the following:
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with impaired swallowing (dysphagia) based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. However, if you still find value in utilizing nursing diagnosis labels, here are some examples to consider:
The following are the common goals and expected outcomes for clients with chronic confusion or dementia nursing diagnosis that can be used in the nursing care plan:
It is important to perform a careful and thorough assessment to differentiate between acute and chronic confusion. Additionally, nursing interventions are crucial in clients with dementia/chronic confusion as they aim to promote cognitive function, manage symptoms, enhance safety, and provide support and education for clients and their caregivers.
Collect information about client functioning, including social situation, physical condition, and psychological functioning.
Knowing the client’s background can help the nurse identify agenda behavior and use validation therapy, which will guide reminiscence. Obtaining the client’s history from family members is also important. Background information may help the nurse understand the client’s behavior if the client becomes delusional and hallucinates.
Evaluate the level of impairment.
The level of confusion will determine the amount of reorientation and intervention the client will need to evaluate reality accurately. The client may be awake and aware of his or her surroundings. The client’s baseline mental and functional status must be taken upon initial assessment. Then, the acuity of symptoms and the timeline of progression must be established.
Observe for personality, behavior, or mood changes.
If a personality, behavior, or mood change has been observed, an objective assessment of the behavioral and psychological symptoms of dementia (BPSD) with the client and a family member using the short version of the Neuropsychiatric Inventory (NPI-Q), Mild Behavioural Impairment Checklist (MBI-C) or if a mood change has been observed with the Patient Health Questionnaire-9 (PHQ) should be performed.
Review responses to diagnostic examinations (e.g., memory impairments, reality orientation, attention span, calculations).
Once a baseline level is established, a brief cognitive screening assessment may be performed. Using a standard evaluation tool such as the Mini-Mental State Examination (MMSE) can help determine the client’s abilities and assist with planning appropriate nursing interventions. The Confusion Assessment Method (CAM) is a valid and reliable instrument that can help monitor changes in the client’s cognitive function. It includes four main features (acute onset and fluctuating course of symptoms, inattention, disorganized thinking, or altered mentation).
Review the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for the criteria of delirium and dementia.
The DSM-5 requires the following criteria for delirium:
The following criteria for dementia include the following:
Examine the ability to receive and send effective communications.
Ability/readiness to reply to verbal directions/limits may vary with the degree of orientation. The client may present changes in behavior, such as getting lost in familiar neighborhoods, social withdrawal, difficulty in performing tasks, or difficulty in communication. The client may report a different awareness of deficits than their caregivers.
Observe decline and variations in personal hygiene or behavior.
In addition to the cognitive decline, there is also a decline in the client’s ability to function and perform everyday tasks, such as grooming and hygiene. This information assists in promoting a particular program for grooming and hygiene activities. Dementia is a progressive disorder, therefore the client does not have insight into their deficits.
Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior.
Clients with chronic confusion may have depressive symptoms. Especially among older adults, the prevailing depressive symptoms could be considered modifiers of cognitive performance; however, they could also be indicators or early clinical signs and symptoms of dementia or Alzheimer’s disease (Cantón-Habas et al., 2020).
Assess for sundown syndrome.
This phenomenon associated with confusion happens in the late afternoon. The client displays increasing restlessness, agitation, and confusion. Sundowning may be a manifestation of sleep disorders, hunger, thirst, or unmet toileting needs. Another recent account highlights the dysregulation of circadian biology and changes in circadian rhythm related to reduced light as the cause. Inappropriate ambient light and subsequent dysregulated circadian rhythms may become a plausible cause for sundowning (Guu et al., 2022).
Determine the client’s anxiety level in connection with the situation. Observe behavior that may be suggestive of a potential for violence.
Confusion, disorientation, suspiciousness, impaired judgment, and loss of social inhibitions may result in socially inappropriate/harmful behaviors to self or others. The client may have poor impulse behavior control. Clients are often calm during the morning, later experiencing increasing periods of irritation during the afternoon or evening hours. The client may also still wake up at night with an incidence involving profound anxiety, fear, or panic (Theofanidis et al., 2021).
Involve the family members or caregivers in assessing the client’s cognitive decline.
To obtain information in addition to that provided by psychometric screening tools, or if the client is unable to answer the questions on the screening tools, having a family member or the caregiver complete a questionnaire for identifying cognitive and/or functional change, such as the Ascertain Dementia 8 (AD-8) questionnaire or the Informant Questionnaire on cognitive decline in the Elderly (IQCODE) is recommended (Ismail et al., 2020).
Assess the client’s ability to perform activities of daily living (ADLs) and instrumental ADLs (IADLs).
Aside from cognitive decline, there must also be a decline in the client’s ability to function and perform everyday tasks. The everyday function of a client is often evaluated in terms of the ability to perform IADLs, such as managing finances or medications, or, if more severe, ADLs. Functional assessment can be done with validated and more familiar tools including the Disability Assessment in Dementia (DAD), Functional Assessment Staging Scale (FAST), Functional Activities Questionnaire (FAQ), or the Barthel Index Score.
Review the results of the client’s diagnostic and imaging examinations.
Laboratory tests to check all clients during the evaluation of dementia include complete blood count, urinalysis, metabolic panel, vitamin B12, folic acid, thyroid function tests, and serological tests for syphilis and HIV. It may also be imperative to assess erythrocyte sedimentation rate, lumbar puncture, heavy metal screen, ceruloplasmin levels, Lyme disease titer, or serum protein electrophoresis. Brain imaging is sometimes ordered, especially if the age of onset is early, atypical or rapidly progressing symptoms are present, or there is diagnostic uncertainty. A brain MRI without contrast is often the initial test ordered (Emmady et al., 2022).
Observe the client’s gait and gait speed.
There is strong evidence that slower gait speed is associated with dementia, according to population studies. When gait speed (cut-off gait speed below 0.8m/s) is coupled with cognitive impairment, whether subjective or objective, the risk is higher. It is recommended to test gait speed in clinics for those clients with cognitive complaints or impairments if time or resources are available. Instruct the client to walk at a comfortable pace and have them perform three repetitions, then calculate the average time (distance/time = gait speed).
Assess for hearing impairment and the use of hearing aids.
A cross-sectional study of 6451 individuals designed to be representative of the US population, with a mean age of 59.4 years, found a decrease in cognition with every 10 decibels reduction in hearing, which continued to below the clinical threshold so that subclinical levels of hearing impairment were significantly related to lower cognition. Hearing aid use was the largest factor protecting from a decline in cognition. Hearing loss might result in cognitive decline through reduced cognitive stimulation.
Chronic confusion is progressive and variable and involves problems with memory recall, language, attention, and problem-solving capabilities with reduced comprehension, judgment, abstract thinking, reasoning, communication, emotional expression, and performance of routine tasks. Nursing interventions need to be modified over time because the client’s cognitive function may continue to deteriorate.
Avoid exposing the client to unusual situations and people as much as possible. Maintain continuity of caregivers. Maintain routines of care through established mealtimes, bathing, and sleeping schedules. Send a familiar person with a client when the client goes for diagnostic testing or into unfamiliar environments.
Situational anxiety associated with environmental, interpersonal, or structural change can intensify into disturbed behavior. Clients diagnosed with dementia often experience memory disorders that make it difficult to operate in an unfamiliar or shifting environment.
Promote reality-oriented relationships and environment (e.g., display clocks, calendars, personal items, seasonal decorations).
Orientation to one’s environment increases one’s ability to trust others. Assisting the client to orient to the current environment, to people around them, and regular time frames, such as mealtime, will lead to less confusion.
Encourage the client to check the calendar and clock often to orient himself or herself.
Familiar personal possessions increase the client’s comfort level. Place large calendars and clocks in the client’s field of view. The client must be oriented according to the current level of their mental state and potential.
Talk to the client using simple, concrete nouns in positive terms.
This method can reduce anxiety. Saying “stay sitting on the chair” is more positive than saying “Don’t get up.” Impaired communication due to confusion, altered memory, or diminished judgment can be tackled by simple and pragmatic procedures such as speaking slowly and softly and using short, simple words and phrases.
Allow family members to orient the client about current news and family events.
A confused client may need help understanding what is happening. Increased orientation promotes a greater degree of safety for the client. When talking to the client, they should also be reminded of the day of the week or the time of the year.
Avoid challenging illogical thinking.
This can threaten the client and result in a defensive reaction. Acknowledging feelings and reinforcing reality may be more appropriate if the client becomes delusional or illogical. Challenging the core of the delusion should be avoided to prevent agitating the client.
Approach the client with a caring, friendly, and accepting attitude and talk calmly and slowly.
Clients can sense feelings of compassion. A calm, slow manner projects a feeling of comfort to the client. The nurse should also always start an intervention by introducing themselves and addressing the client by name.
Allow the client to reminisce, existing in his or her reality if not detrimental to the client’s well-being.
Depending on the cause, long-term memory is usually retained longer than short-term memory. This approach can be enjoyable for the client. Reminiscence therapy is a strengths-based approach that can provide person-centered care as it draws upon memories from people’s lives, memories that are considered to be often preserved in dementia (Macleod et al., 2020).
Present one simple direction at a time and repeat as necessary.
People with chronic confusion need time to understand and interpret directions. The nurse must focus on one piece of information at a time and briefly review what has already been discussed with the client. This helps reinforce the original message accordingly.
Suggest supplementary therapies to decrease cognitive decline.
Supplementary therapies, such as meditation, massage, or gymnastics, may help reduce stress, which is associated with exacerbation of memory loss.
Encourage the client to keep a diary, if possible.
Advise the client to use a diary where they could write down lists of tasks that need to be done or ask a third party to remind them of their appointments or other obligations. Written or oral reminders can be of great help to the client whose memory is dysfunctional.
Schedule the client for cognitive stimulation appointments as ordered.
Clients with mild to moderate symptoms may benefit from partaking in structured group cognitive stimulation approaches. These groups involve engagement with activities and materials that provide and provoke some degree of cognitive improvement, within a social context.
Present reality carefully and gently.
When an acute state of confusion has set in or during the later stages of Alzheimer disease when the memory has severely deteriorated, the client may plea to see their deceased loved ones. This unrealistic request can be carefully avoided by not ‘revealing the truth’ but by simply responding with, “I’m sorry, she’s not here, but I am. You are safe and I’m going to be with you all evening”. This can be followed by distractions, such as, “Can you please help me tidy this table?”
Administer medications as prescribed.
Medications that may help delay the progression of cognitive decline include the following:
Early in the disease, nursing care focuses on assisting the client make small and useful adjustments to their environment. Recognizing which intervention might be the most appropriate for each client requires a broad knowledge of suitable strategies available and an understanding of the level of decline in each situation.
Break down self-care tasks into simple steps.
Confused clients are incapable of following complicated instructions; breaking down an activity into simple steps makes completing the activity more achievable. Executive function and memory have been shown to have specific relationships to functional limitations. Individuals with marked executive dysfunction are likely to have significant difficulty carrying out such complex tasks as managing a complicated medication regimen, preparing a meal involving multiple ingredients and steps, or balancing a checkbook (Cipriani et al., 2020).
Promote participation in resocialization groups.
This promotes a sense of responsibility and independence. Social contact enhances cognitive reserve or encourages beneficial behaviors, although isolation might also occur as part of the dementia prodrome (Livingston et al., 2020).
Provide repetitive hand activities.
Involving the client in safe, repetitive activities occupies the client’s mind and hands. The activities may reduce agitation and provide a release of energy (e.g., folding and refolding towels and washcloths). Activity-based strategies have been developed to prevent the onset of physical agitation. The application of combined stimuli (tasks, reading, work-related, manipulation) is more effective than a single activity (Carrarini et al., 2021).
Give finger food if the client has difficulty using eating utensils or if unable to sit to eat.
Feeding oneself is a complicated task and may prove challenging for someone with chronic confusion. Clients diagnosed with dementia may experience problems with dexterity or hand-eye coordination and therefore may struggle to use cutlery to cut up foods or transfer foods to their mouth. Food items such as sandwiches, fish fingers, sausages, cheese cubes, vegetable sticks with dips, biscuits, or sliced fruits may be appealing to clients with dexterity problems.
Provide structured activities and retain daily habits.
The nurse must try to maintain daily habits as consistently as possible. Providing the client with a strictly structured day creates a sense of reassurance and reduces stress.
Plan rest periods and consistent sleep schedules.
Planning of set rest periods during the day is recommended as fatigue contributes to stress and rest reduces this level. Provide the client with quiet activities, such as listening to music in the afternoon or early at night to help reduce the sundowning effect.
Encourage the client to make decisions as much as possible.
To provide the client with a sense of hope, the nurse should encourage them to make as many decisions as possible. This level of involvement gives a sense of some control.
Provide information about cognitive programs.
Cognitive programs seek to prevent the reduction of executive functions and other aspects of working memory that are damaged during the aging process. According to the results, cognitive interventions had two outcomes: improving independence in IADLs and ADLs. The Self-Management Program (SMP) strengthened older adult’s independence in IADLs by improving internal locus of control, participation, problem-solving, and self-determination skills (Motamed-Jahromi & Kaveh, 2020).
Encourage the client to engage in physical activities or exercise regularly.
Results of a study show that the outcome of physical intervention was the improvement of independence in ADLs. the “three-step workout for life program” and “water exercise training program” focused on physical activity and improving familiar and simple activities for promoting the older adult’s independence in ADLs. Physical exercise is an efficient and cost-effective way to prevent the loss of the older adult’s functional ability.
The promotion of safety is an important part of the holistic care for these vulnerable clients. If the client is to be cared for at home, care for their safety and consideration of whether the caregiver is capable of meeting the client’s needs should be emphasized.
Place forms of identification on the client.
Clients with chronic confusion may wander and become lost; identification bracelets increase client safety. The client should not be left unsupervised ideally, and if they get lost, forms of identification, including identification bracelets, clothing labels, and tracking devices, can help them get home or be found quickly (Wang et al., 2022).
Keep the environment quiet and nonstimulating. Reduce sights and sounds with a high potential for misinterpretation such as buzzers, alarms, and overhead paging systems.
Sensory overload can result in agitated behavior in a client with chronic confusion. Misinterpreting the environment can also contribute to agitation. Images on walls may be threatening to the client. Confounding environmental stimuli must be kept to a minimum; reducing the volume of noise, speaking quietly and softly, and not giving the impression of being in a hurry.
Ensure that the client is in a safe environment by eliminating possible hazards such as pointed objects and harmful liquids.
Clients with chronic confusion lose the ability to make good judgments and can easily harm themselves or others. The removal of potentially hazardous objects, such as knives, liquids, drugs, or chemicals, from the client’s environment may need to be done and monitored.
Let the client eat in a peaceful environment with fewer people.
The noise and confusion in a large dining room can be overwhelming for a confused client and result in agitated behavior. Early removal from stressful situations such as noisy activities involving large groups of people will alleviate stress levels. Conditions characterized by a variety of stimuli, such as talking while music is on, may increase anxiety and cause irritation.
Play soothing music or white noise in the background during group activities.
Music intervention, especially when employed in groups, can significantly reduce agitation in cognitively impaired clients. Passive listening to music has been associated with behavioral improvement and reduction of aggressiveness and agitation. Some studies have explored the effectiveness of white noise in preventing the sundowning syndrome, or the use of personalized music, via headphones, upon daily hygiene care or walking, reporting that these approaches can improve agitated behavior.
Provide a pill container for medication management.
Recommendation of the use of a pill container with the days and times of intake recorded helps the client manage their medications safely. This is a good way to ensure that the client takes their medications regularly.
Adapt the client’s environment accordingly.
Keeping the environment dark during the night and bright during the day, hanging oversized clocks, and eliminating unnecessary night-time awakenings decrease the number and mean duration of wandering and excessive wandering at night.
Eliminate environmental stressors as necessary.
Providing a safe environment for the client could promote safe walking. Environmental stressors, such as being cold at night, and changes in daily routines and furniture, should be minimized. Tripping hazards should be removed to reduce the risk of falls, such as throw rugs, extension cords, excessive clutter, and electric cords or wires.
Ensure that the client is wearing appropriate clothes and shoes.
It is necessary to provide suitable shoes and clothes, as well as a secure place to wander and exercise, such as a lounge or garden.
Provide environmental cues within the client’s environment or inside the facility.
For clients with spatial disorientation, environmental cues to reduce the risk of loss and assist them in wayfinding may be effective, such as printed or graphic signage, personal items such as photographs, and posters and murals on walls. Wayfinding clues should be straightforward and the amount of irrelevant information should be minimized.
Explore the possibilities of modern technology associated with preventing the risk of getting lost when wandering.
High-tech strategies may be used to reduce attempts of a client at wandering or getting lost. Monitoring systems, such as warning bells and devices above doors, tracking the client’s position, and sending signals with bells or buzzers when a door is opened can be employed.
Caregiver burden is a major determinant of hospital admissions and nursing home placement. It should be regularly assessed in the follow-up of clients with dementia. It is important that caregivers have access to support and services tailored to their needs so that they may effectively respond to, and manage, the physical, mental, and social demands of their caregiving role.
Communicate with family members or significant others regarding the progression of the problem, prognosis, and other concerns.
These determine areas of physical care in which the client needs support. These areas include nutrition, elimination, sleep, rest, exercise, bathing, grooming, and dressing. The client may have the ability and minimal motivation, or motivation and minimal ability. When the client is discharged from hospital care (if admitted), the nurse should continue with the client’s and family’s education about the disorder while suggesting and activating available support systems.
Help the family and significant others in developing coping strategies. Determine family members’ resources and their availability and eagerness to participate in meeting the client’s needs.
The family members need to let the client do all that he or she can do. This approach will maximize the client’s level of functioning. The proposed interventions should be appropriate to the circumstances of the client, family, and its economic potential. Maintaining an environment that is as less restrictive as possible, but promoting client safety is the primary objective.
Refer the family to social services or other supportive services.
This helps assist with meeting the demands of caregiving for older clients. The nurse should reassure the family that should the situation become too burdensome, there are other services available that can be mobilized. Examples include short respite either at the client’s home or some short-stay care facility whereby the carer will be ‘temporarily replaced’. If necessary, a referral to an appropriate long-term care service, including specialized nursing services, can be suggested.
Encourage the family to use support groups or other service programs.
Community resources provide support, assist with problem-solving, and reduce the demands associated with caregiving. Mutual support groups and discussions with people who have similar problems can help address the stress felt by the caregiver.
Validate the family member’s feelings about the impact of the client’s behavior on the family lifestyle.
Validation lets the client understand that the nurse has heard and realizes what was said, and it improves the nurse-client relationship. Although the clinical focus is on the client, the nurse should also treat the caregivers almost as an extended client as they too may suffer high levels of stress or neglect their well-being while looking after the client.
Encourage the family to include the client in family activities when desirable.
These steps help the client maintain dignity and lead to familiar socialization of the client. The nurse may need to support positive family ties and enhance communication between family members, by promoting mutual respect between them. Strong family relationships and friendships can make life meaningful and help balance the burden of the disease.
Provide educational materials about dementia for the caregivers and refer them to public awareness programs.
Public awareness and education campaigns, co-designed with caregivers, are promising approaches for addressing stigma and enhancing the recognition of the carer’s role by employers and society. Global movements, such as the “Embracing Carers” campaign, have also begun to emerge to promote greater visibility and awareness of carer challenges.
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Here are some references and sources you can use to further your research about the management and care of patients with chronic confusion:
Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession.
