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PRINCIPLE 4: Management of older people with confusion

NSW hospitals will have programs in place for older people with confusion that align with these principles. The implementation will be in partnership with the older person, their carer and family.

Management strategies

Management of the older person with confusion

Adapted from AHMAC, 2011.

Strategies to manage confusion should be multimodal and include:

  • Consult the carer about their role in the care plan and provide appropriate information (i.e. delirium brochure, dementia fact sheets) and training. Refer to formal services as needed.
  • Ensure that the carer’s needs are assessed and supported.
  • Be flexible with visiting hours for carers and family members and consider a family roster.
  • Ensure there is thorough documentation and that a handover of behaviour takes place between each shift.
  • Ensure glasses and hearing aids are clean and working.
  • Inadequate pain relief can precipitate confusion. Pain should be assessed, monitored and appropriate pain relief administered.
  • Opiates can precipitate confusion, they should be used as clinically appropriate and the individual closely monitored.
 
  • Antipsychotics are not effective in the treatment of confusion. Non pharmacological strategies are more effective.
  • Antipsychotic medications can be useful for severe behavioural disturbance. They should be used under medical supervision and reviewed.
  • Physical restraints should be avoided and psychotropic medications should be limited and closely monitored.
  • Consider if the older person is at risk of falls.
  • Provide success based therapeutic activities based on the individual’s likes (music, hobbies, reading games) to reduce boredom and frustration, enhance quality of life and cognition (2). Diversional therapy such as use of rummage boxes are useful for promoting such activities.

Management of the older person with confusion

  • Provide information on confusion, dementia and delirium as appropriate including training for the carer on how to support the older person.
  • Provide information on services such as support groups, respite services and other carer support services.
  • Provide information in appropriate language, use translators. Be aware of cultural differences.
  • Consider lighting levels and music.
 
  • Supportive care environments are important. Consider natural lighting during day and a quiet environment with lights turned down at night.
  • Involve carers and family in reorientation and reminiscence strategies such as the use of clocks and family photos.  
  • Introduce a “Get to know you” system
  • Create a quiet environment with reduced activity/ stimulation and soft lighting at night (to assist with reorientation).
  • Tailor care to the needs of the individual, modify activity and adapt according to need as well as likes and dislikes (“Get to know you” program in place such as Sunflower, Top5 or Patient profile).
  • Provide timely interventions.
  • Closely monitor bowels and use strategies to prevent constipation, manage any signs of constipation early.
  • Refer to medical staff and relevant nurse with expertise in aged health e.g. Clinical Nurse Consultant/ Nurse Practitioner if available.
  • High observation areas can be used to further assess the individual, minimise harm and provide therapeutic care.
  • Encourage oral fluids.
  • Assist with meals as required, including the setting up of meals and opening any packages.
  • Assist with ordering meals by assisting with filling in order forms.

References

  1. Australian Government Department of Health and Ageing. Delirium Care Pathways. Commonwealth of Australia 2011
  2. NSW Ministry of Health, Royal Australian and New Zealand College of Psychiatrists. Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD). A handbook of NSW clinicians. NSW Ministry of health and the Royal Australian and New Zealand College of Psychiatrists 2013.
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