UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The relationship between acute confusion and select patient characteristics and environmental variables… Kozak, Cindy Joy 1994

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_1995-0053.pdf [ 6.13MB ]
Metadata
JSON: 831-1.0086913.json
JSON-LD: 831-1.0086913-ld.json
RDF/XML (Pretty): 831-1.0086913-rdf.xml
RDF/JSON: 831-1.0086913-rdf.json
Turtle: 831-1.0086913-turtle.txt
N-Triples: 831-1.0086913-rdf-ntriples.txt
Original Record: 831-1.0086913-source.json
Full Text
831-1.0086913-fulltext.txt
Citation
831-1.0086913.ris

Full Text

T H E RELATIONSHIP B E T W E E N A C U T E CONFUSION A N D S E L E C T PATIENT C H A R A C T E R I S T I C S A N D E N V I R O N M E N T A L V A R I A B L E S IN E L D E R L Y PATIENTS A D M I T T E D T O A N A C U T E O R T H O P A E D I C SERVICE By CINDY J O Y K O Z A K B . N . , The University of Manitoba, 1981 A THESIS S U B M I T T E D IN P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F S C I E N C E LN NURSING in T H E F A C U L T Y O F G R A D U A T E STUDIES The School of Nursing We accept this thesis as conforming to the required standard T H E UNIVERSITY O F BRITISH C O L U M B I A December 1994 © Cindy Joy Kozak ,1994 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of NU^SiKi<^ The University of British Columbia Vancouver, Canada Date DtCZmBtR 3 D , iqqy DE-6 (2/88) n Abstract Acute confusion is a common complication of hospitalization in the elderly that contributes to the mortality and morbidity of this patient population. Although elderly individuals admitted to hospital with an orthopaedic condition consistently present with numerous risk factors associated with the development of acute confusion, not all develop the condition. The purpose of this prospective, descriptive, correlational study was to determine if there are specific patient characteristics and environmental variables associated with the development of acute confusion in elderly patients admitted to hospital with an orthopaedic condition, and if these factors could distinguish those elderly patients who become acutely confused from those who do not. Miller's Functional Consequences Theory (1990) provided a framework for examining the etiology of acute confusion in this population. A non-probability convenience sample of 41 subjects participated in the study. Participants received serial assessments of their cognitive status using the Folstein Mini-Mental State Exam (1975), the Clinical Assessment of Confusion - A (revised) (1990), and the Visual Analogue Scale - Confusion (1986). A determination of the occurrence of acute confusion was based on a predetermined change in score on all three assessment tools used. Fourteen (34%) of the participants developed acute confusion during the first week of hospitalization. Factors significantly associated with the development of acute confusion included: admission to a particular ward, a higher emotional stress score, a higher level of dependency prior to admission, a pre-existing cognitive impairment, and a primary diagnosis of fracture. The findings of this preliminary study support a multiple factor etiology for acute confusion within this patient population. Elderly patients admitted to hospital may have common pre-existing psychosocial risk factors that put them at risk for the i n development of acute confusion regardless of their physiologic risk. In addition, the findings suggest that the experience of an unplanned event, such as a hip fracture may be a differentiating characteristic of patients who develop acute confusion within the general orthopaedic patient population. iv TABLE OF CONTENTS Abstract ii Table of Contents iv List of Tables vi Acknowledgment vii Chapter One Introduction 1 Background and Significance of the Problem 1 Problem Statement 2 Purposes 3 Research Questions 3 Definition of Terms 3 Conceptual Framework 4 Assumptions .8 Summary 8 Chapter Two Review of the Literature 10 Introduction 10 The Nature of Acute Confusion 10 Measuring Acute Confusion 15 Identified Factors Associated with the Development of Acute Confusion 17 Summary 26 Chapter Three Method 28 Introduction 28 Design 28 Setting, Sample Selection and Sample Size 29 Data Collection Instruments 32 Procedure 36 Data Analysis 43 Ethical Considerations 44 Summary 46 Chapter Four Presentation of Findings 47 Introduction 47 Demographic and Descriptive Information 47 Study Sample and Nonparticipants 47 Other Characteristics of the Study Sample 51 Age-related changes 52 Psychosocial risk factors 52 Physiological risk factors 54 Comfort and pleasure risk factors 56 V Findings Related to the Research Questions 58 Research question one 58 Research question two 60 Age related changes 61 Psychosocial risk factors 62 Physiological risk factors 64 Comfort and pleasure risk factors 65 Research question three 66 Summary 67 Chapter Five Summary, Conclusions, Limitations and Implications 68 Introduction 68 Study Summary 68 Conclusions 70 Limitations 71 Study Revisions 74 Study Design 74 Data Collection 75 Implications 77 Nursing Research 77 Nursing Practice 78 Nursing Education 79 Summary 80 References 81 Appendix A Concepts in the Functional Consequences Theory 86 Appendix B Risk Factors for the Development of Acute Confusion in the Hospitalized Elderly 88 Appendix C Folstein Mini-Mental State Exam 90 Appendix D Clinical Assessment of Confusion - A (revised) 93 Appendix E Clinical Assessment of Confusion - A 94 Appendix F Visual Analogue Scale - Confusion 95 Appendix G Nursing Ward Introductory Letter and Protocol for Patient Assessment 96 Appendix H Hospital Consent Guidelines 100 Appendix I Letter of Information and Consent to Participate 110 Appendix J Acute Confusion Data Collection Form 112 Appendix K Data Collection Form: Nonparticipants 121 VI List of Tables Table 1 Correlations Among the Four Data Collection Instruments 35 Table 2 Data Collection Variables 43 Table 3 Demographic Characteristics Study Sample and Nonparticipants 48 Table 4 Primary and Secondary Diagnoses: Study Sample and Nonparticipants 51 Table 5 Cognitive Status on Admission 54 Table 6 Types of Non-analgesic Medications Administered During Study Participation 54 Table 7 Patient Characteristics and Environment Variables Present for Study Subjects With and Without Acute Confusion 61 Acknowledgment vu This accomplishment would not have been possible without the assistance and support of a number of individuals. I would like to thank my committee members, Dr. Anna Marie Hughes and Tess Orlando, for their advice, encouragement and guidance throughout the process. I would also like to thank Dr. Joy Johnson for her thoughtful review of the completed project. I would like to thank Chris Bradley for her assistance with data entry and for her support along the way. I would like to acknowledge the orthopaedic nursing staff at the study hospital for their assistance with data collection. I would also like to thank the study's participants who gave freely of their time. Finally, I would like to thank my fiance, Jim for his patience, understanding and encouragement that supported me through to the completion of this project. 1 Chapter One: Introduction The elderly, or those individuals aged 65 and over, accounted for 30.5% of all acute hospital admissions in Canada in 1990 (Statistics Canada, 1992). Although this age group makes up only 11 % of the population, they account for 56% of all hospital days. By the year 2011, it is projected that 15% of the Canadian population will be 65 years or older (Perreault, 1990). As the proportion of elderly in the population increases, the proportion of hospital admissions and hospital days utilized by them is expected to increase by approximately 50% among those aged 65 - 84, and by 120% among those aged 85 and over (Desmeules, Huang & Mao, 1993). Hospitalization holds a number of risks for the elderly person, and often results in complications unrelated to the original reason for admission to hospital. Acute confusion is one complication that is frequently seen in elderly individuals admitted to acute care hospitals. In this first chapter, the incidence of acute confusion in the hospitalized elderly and the significance of acute confusion is discussed. A problem is identified in determining the specific combination of risk factors of acute confusion that would predict the occurrence or non-occurrence of the condition in the elderly orthopaedic population. Specific research questions are formulated and definitions of relevant concepts are provided. Miller's Functional Consequences Theory (1990) is discussed as a framework for examining the etiology of acute confusion in elderly individuals hospitalized with orthopaedic conditions. Finally, several assumptions that have been made in the development of this research are articulated. Background and Significance of the Problem The incidence of acute confusion in the hospitalized elderly has been reported as ranging from 14% to 60% (Foreman, 1991; Inouye, 1991; Millar, 1981; Mullen & Mullen, 1992; Williams et al., 1985). Acute confusion in the elderly has been linked to morbidity, mortality, relatively longer hospitalizations, and greater intensity of requisite nursing care. In addition, there is a greater rate of institutionalization post-2 hospitalization for elderly patients who develop acute confusion while in hospital (Inouye, 1991; Levkoff, Safran, Cleary, Gallop, & Phillips, 1988; Lipowski, 1983; Mullen & Mullen, 1992; Weddington, 1982; Williams, Ward, & Campbell, 1986). Consequently, acute confusion can be linked with higher costs and greater consumption of health care resources. Acute confusion can also affect the independence and quality of life of elderly individuals. The functional status of the individual may be permanently compromised. Problem Statement The occurrence of acute confusion in the hospitalized elderly individual is rarely attributed to a single factor, but is likely the result of an interplay between patient characteristics and environmental variables. A number of risk factors for the development of acute confusion in the hospitalized elderly have been identified, including such things as immobility, age, pre-existing dementia, a diminishing ability to live independently, disruptions in patterns of daily living, sensory impairments, pain and confinement (Wolanin & Phillips, 1981). Knowledge of risk factors associated with acute confusion creates a potential for the prevention or minimization of acute confusion in the elderly hospitalized patient. Nursing interventions implemented for those patients at risk and based on the reduction of the effects of risk factors could lead to improved patient outcomes. Elderly individuals admitted to hospital for orthopaedic conditions consistently present with numerous patient characteristics and environmental variables identified as risk factors for the development of acute confusion. However, from this author's experience, not all of these patients become acutely confused. This observation is substantiated by the research findings, which report a varying incidence of acute confusion among elderly patients admitted for orthopaedic conditions (Williams et al., 1985; Moore & Mulrooney, 1991). Whether there is a specific combination of patient characteristics and environmental variables associated with the development of acute confusion in 3 elderly patients admitted to hospital for orthopaedic conditions that distinguishes those who become acutely confused from those who do not has not been clearly identified. The identification of such risk markers may allow practitioners to differentiate between those who are at risk of becoming acutely confused from those who are not. This differentiation could provide guidance for nursing interventions necessary to minimize this complication and thus to improve patient outcomes. Purposes The purposes of this study are: 1) to identify the incidence of acute confusion in elderly patients admitted to an acute orthopaedic service at one British Columbian Lower Mainland tertiary care hospital, and 2) to develop a risk profile of acute confusion by examining the patient characteristics and environmental variables present for both those individuals who become acutely confused and those who do not at some point during their first week of hospitalization. Research Questions 1) What percentage of patients aged 65 or older, admitted during the study period to the orthopaedic wards at a British Columbian Lower Mainland tertiary care hospital develop acute confusion in the first week of hospitalization? 2) What are the patient characteristics and environmental variables common among those individuals who become acutely confused? 3) What are the patient characteristics and environmental variables that differentiate those individuals who become acutely confused from those who do not? Definition of Terms The following definitions have been used in this study: 1) acute confusion - an abrupt, reversible change in an individual's cognitive abilities and behaviour that fluctuates in severity. 4 2) acute orthopaedic service - acute care tertiary hospital wards wherein personnel care for patients admitted on an elective or emergency basis for orthopaedic injuries or conditions. 3) orthopaedic injury or condition - any problem that affects the function of the skeletal system, its articulations and associated structures (Miller & Keane, 1978). 4) elderly patient - any individual 65 years of age or older, who is admitted to hospital. 5) risk factors - specific patient characteristics and environmental variables that may be used to identify those individuals with a high probability of developing a particular condition. 5) patient characteristics - distinctive age-related changes and risk factors, in particular, psychosocial, physiological, and comfort and pleasure factors that can be used to describe and differentiate an individual or group of individuals from another. 6) environmental variables - risk factors external to an individual that can affect their functional ability. 7) risk profile - a compilation of specific patient characteristics and environmental variables that could differentiate those individuals who will develop a particular condition from those who will not. Conceptual Framework An assessment of functional ability is used frequently in the area of gerontology to identify the effects of normal aging changes, illness or injury on individuals, to assess their well being, and to provide a framework for the planning of care (Sehy & Williams, 1991). It focuses on those acts individuals can and cannot do, and considers both physical and psychosocial functioning. It is a realistic approach to the assessment of ability in the elderly, because illness frequently is defined by this population as the restriction of activity, the inability to complete activities of daily living, or the presence of discomfort, rather than the presence or absence of pathology (Sehy & Williams, 5 1991). Miller's (1990) Functional Consequences Theory builds on the notion of functional ability in the elderly, particularly in relation to nursing care. Miller's (1990) Functional Consequences Theory focuses on the nursing care needs that are unique to older individuals. She proposes that the ability of older adults to maintain their maximal level of self care is affected by the interaction of normal age-related changes and additional risk factors they may encounter. Age-related changes are defined as "inevitable, progressive and irreversible changes that occur during later adulthood and are independent of extrinsic or pathological conditions" (Miller, 1990, p. 55). These changes are viewed as factors that increase the vulnerability of older individuals to the negative impact of risk factors. Risk factors are defined by Miller as those "conditions that increase the vulnerability of older people to negative functional consequences" (p. 55). She further characterizes risk factors to include the effects of disease, medications and life-style, the availability of support systems, psychosocial circumstances, the environment, and attitudes, including the attitudes of care givers. A complete list of the definitions of the concepts included in Miller's theory appear in Appendix A . Functional consequences can be positive or negative. Miller (1990) states that positive functional consequences are usually the result of "automatic actions or purposeful interventions" (p. 55). For example, use of anti-inflammatory medications to control arthritic joint pain and the organization of rest periods between times of exercise are purposeful interventions that would allow an elderly individual to maintain a desired level of activity. This would be a positive functional consequence. A n example of a negative functional consequence is the development of constipation following a hip fracture. This occurrence often is the result of age-related changes in the digestive system, and risk factors such as limited mobility, analgesic use, and a change or reduction in fluid and nutritional intake. The role of the nurse within the Functional Consequences Theory is twofold: it includes the identification and support 6 of factors that result in positive consequences, as well as the identification of factors that will result in negative consequences, with intervention to inhibit or eliminate these factors. The ultimate goal of all interventions is to enable older individuals to function at their highest level, despite the presence of age-related changes and risk factors. Miller (1990) states that the interaction of age-related changes and risk factors is the crucial aspect that distinguishes the care of older adults from the care of other populations. This distinction provides direction for nursing care so that interventions for older adults are planned to compensate for their age-related changes, to support their existing positive functional consequences, and to modify or eliminate their risk factors. The utility of this theory in examining the incidence of acute confusion in the elderly is that it encompasses a multifactorial approach to understanding the etiology of acute confusion. Patient assessment within Miller's framework includes the identification of potential age-related changes and risk factors that may contribute to the negative outcome of acute confusion. Foreman (1986) and Lipowski (1983) both have presented comprehensive reviews of the multiple factors that can contribute to the development of acute confusion. These factors have been organized by this author within the Functional Consequences Theory framework and are outlined in Appendix B. Age-related changes in the elderly that place individuals at risk for acute confusion include a diminished ability of the brain to adapt to metabolic disturbances, a lowered resistance and ability of the body to cope with stress related to changes in the hypothalamus, a reduced ability to regulate body temperature, and a reduction in cerebral blood flow and glucose metabolism. In addition, the elderly frequently have sensory and perceptual deficits such as impaired vision and hearing (Lipowski, 1983). The identified risk factors for acute confusion are considered in one of three categories: psychosocial functioning, physiological functioning, and factors influencing comfort and pleasure. Emotional stress, depression, anxiety, grief, dementia, 7 social supports, and an unfamiliar environment are examples of psychosocial factors that can contribute to the development of acute confusion. Included with the psychosocial risk factors are the methods of care delivery in use on nursing units, the characteristics of the hospital environment, and caregivers' characteristics, such as then-knowledge of caring for the elderly individual in acute care and their knowledge of acute confusion. A multitude of physiological factors have been identified as contributing to acute confusion. These include nutritional deficits, cardiovascular abnormalities, cerebral disease, endocrine disturbances, temperature regulation, pulmonary abnormalities, infective processes, metabolic disturbances, drug intoxications and immobility (Foreman, 1986). Some of these factors may also be categorized as age-related changes. The comfort and pleasure factors include pain, fatigue or sleep deprivation, hypo- or hyperthermia, sensory deprivation or environmental monotony, sensory overload, and a lack of meaningful routines. The development of acute confusion in the hospitalized elderly is rarely attributed to any one of the above factors alone. Rather, it is the interplay between age-related changes and the risk factors of psychosocial functioning, physiological functioning, and comfort and pleasure factors that result in acute confusion in this patient population. This complex interplay makes it difficult for nurses to predict which patients will develop this condition, and to intervene to prevent the development of acute confusion. However, as Neelon (1990) states,"... the ability to identify potential risk factors and understand etiologic mechanisms is important for identifying the high risk patients and developing effective intervention strategies" (p. 583). The use of the Functional Consequences Theory provides a framework to identify specific risk factors associated with those elderly patients hospitalized with an orthopaedic condition who develop acute confusion and provides guidance for the development of a risk profile that may allow for the differentiation of those individuals who will develop acute confusion from those who will not. 8 Assumptions There are two assumptions that have been made at the outset of this study. It is assumed that changes in the cognitive status of an individual are measurable over time. It is also assumed that early detection of those individuals at risk for developing acute confusion would permit early nursing intervention to minimize the effect of this condition on patient outcomes. Summary Acute confusion is a common complication in the hospitalized elderly that has significant impact on the use of health care resources and the independence, functional status, and well being of individuals. A number of risk factors associated with the development of acute confusion have been identified in the literature. Although an elderly individual hospitalized with an orthopaedic condition frequently has a great number of these factors present, not every individual develops acute confusion. Clearer identification of the specific combination of patient characteristics and environmental variables that are common in the development of acute confusion in the elderly population hospitalized with orthopaedic conditions would permit early identification and implementation of nursing interventions designed to minimize the impact of this condition on patient outcomes. This first chapter has presented the purpose of this study and the research questions that were examined. The Functional Consequences Theory (Miller, 1990) provides the conceptual framework for examining the risk factors for acute confusion in elderly individuals hospitalized with orthopaedic conditions. This report is comprised of five chapters. Chapter Two provides a review of the literature relating to the concept of acute confusion and results in a conceptual definition. Literature that identifies risk factors associated with the development of acute confusional states in the elderly hospitalized population in general and the elderly orthopaedic population in particular is reviewed and critiqued. The research methodology is described in Chapter Three. Chapter Four presents the findings of the 9 study. Chapter Five presents an overview of the study, conclusions, limitations, study design revisions, and implications for nursing research, practice, and education. 10 Chapter Two: Review of Literature Introduction Although acute confusion has received increasing attention in recent literature, there continues to be discrepancies in the definition of this concept. The purpose of this chapter is to review the research and non-research reports regarding acute confusion to: (a) establish what is known about the nature of acute confusion, (b) discuss mental status testing in acutely confused elders, (c) identify the factors that have been associated with the development of acute confusion in the hospitalized elderly, and (d) identify gaps in the literature in relation to the identification of specific factors associated with the development of acute confusion in the elderly individual hospitalized with an orthopaedic condition. The literature review substantiates a need for clearer identification of specific factors associated with the occurrence or non-occurrence of acute confusion in the elderly orthopaedic population. The Nature of Acute Confusion Acute confusion is a multidimensional concept. It is referred to in the literature by a variety of terms including acute dementia, delirium, acute brain syndrome, and acute transient cognitive disorder (Gillick, Serrell, & Gillick, 1982; Lipowski, 1983; Williams et al., 1979). A review of the literature reveals both a cognitive and a behavioural component to the conceptualization of acute confusion. It is considered an abrupt, temporary change in central nervous system functioning accompanied by a range of inappropriate behaviours. The definition of delirium provided in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) is most frequently cited as a definition for acute confusion. It characterizes the syndrome as a rapid onset of "reduced ability to maintain attention to external stimuli,. . . disorganized thinking,.. . reduced level of consciousness, sensory misperceptions, disturbances of the sleep-wake cycle and level of psychomotor activity, disorientation, and memory impairment" (p. 100). Lipowski (1987) describes the clinical 11 features of acute confusion in each of these areas. He states that the main cognitive functions of perception, thinking and memory are all affected. Sensory stimuli are misinterpreted, there is a decreased ability to use abstract concepts and solve problems, thinking is disorganized, and registration, retention and recall are impaired. Behavioural manifestations include a disturbance in attention. The individual is distractible, and can be either hypo- or hyperalert. This attention disturbance fluctuates during the day. The sleep-wake cycle is often reversed, with drowsiness during the day, and wakefulness and agitation at night. The individual's behaviour can vary from lethargy and slowed response to hyperactivity. Lipowski noted the transient nature of acute confusion, and the importance of prompt treatment for reversal of the condition. Untreated acute confusion has a high risk for patient injury, and is associated with a high mortality rate (Lipowski, 1987). Further examination of the clinical features of acute confusion has added to our knowledge of this condition. A pattern of cognitive and behavioural changes indicative of acute confusion is beginning to emerge. This focus on clinical features began with a grounded theory study by Wolanin (1977) that examined the terms nurses and physicians used to describe behaviours in patients in a long term care facility who were perceived to be confused. Two categories of confused behaviour were identified: cognitive inaccessibility and social inaccessibility. Wolanin included in her description of cognitive inaccessibility those behaviours indicating difficulty with intellectual functioning, such as diminished alertness, interest, thought quality, idea association and memory. Social inaccessibility included behaviours that interfered with cooperation with others such as restlessness, agitation, noisiness, combativeness, and hostility. The utility of these descriptors and their correlation with tests of cognitive function in patients with acute confusion have not been explored further. More specific categories of cognitive and behavioural changes have evolved as various clinical assessment tools for acute confusion have been developed. This has 12 assisted in the incorporation of the clinical features of acute confusion into the definition of the concept, and provided a complementary assessment modality to mental status testing when identifying acute confusion in the clinical setting. The contribution of specific studies to the definition of acute confusion is described below. Williams and colleagues (1979) were among the first to develop categories of clinical observations of patient behaviours that were indicative of acute confusion. This occurred as part of a larger study examining the relationship between select nursing activities and the incidence of acute confusion in elderly patients hospitalized with a hip fracture. In their study, 91 elderly patients with hip fracture and no history of chronic confusion were surveyed in their first five days of hospitalization. Cognitive assessment included tests of memory, orientation and ability to follow instructions. Types of patient behaviours that were considered not appropriate to the situation or unusual for the patient were gathered through patient observation and nurses' verbal reports when interviewed by the researcher. Four categories of behaviour were identified: (a) verbal or nonverbal manifestations of disorientation to time, place, or persons in the environment, (b) inappropriate communication or communication unusual for the person such as nonsensical speech, calling out, yelling, swearing, or unusual silence, (c) inappropriate behaviour such as attempting to get out of bed, pulling at tubes, dressings, or picking at bedclothes, and (d) illusions or hallucinations. There was a negative correlation between individual cognitive assessment scores, and the number of behaviours indicative of confusion. As cognitive scores declined, the number of confused behaviours increased. The validity of using the above categories in identifying those patients who are acutely confused from those who are not acutely confused was demonstrated in a subsequent study. Williams, Ward and Campbell (1988) assessed elderly individuals hospitalized with a hip fracture and no previous history of mental impairment with both a mental status questionnaire and a Confusion Rating Scale developed from the above categories. They reported a "78-79% rate of 13 agreement between results on the Confusion Rating Scale and mental status scores" (p. 28). The development of this scale provided clearer identification and categorization of the observable clinical behaviours associated with acute confusion. It also provided a quantitative measurement for the behavioural component of acute confusion. The clinical presentation of acute confusion was more closely examined in a study conducted by Patricia Vermeersch (1990). A list of 141 observable patient behaviours indicative of confusion was taken from the literature and rated in order of importance by medical-surgical nurses from a variety of acute care settings. Factor analysis was used to identify five main dimensions of confusion, including cognition, general behaviour, motor activity, orientation, and psychotic/neurotic behaviours. Twenty-five behaviours were represented by these categories. The validity of these descriptors in providing a clinical definition of acute confusion was established through their concurrent use with the Visual Analogue Scale for Confusion (VAS-C). Vermeesch's initial review of the literature provided support for the conceptualization of acute confusion as a multidimensional concept and provided content validity for the instrument. It also emphasized that the nursing diagnosis of this condition is based on the observation of multiple patient behaviours. The outcome of this study was the development of the Clinical Assessment of Confusion - A (CAC-A) instrument, an instrument that measures confusion as diagnosed by nurses from their observations of the behaviour of hospitalized adults. In the process of validating the CAC-A, Vermeesch found that nurses conceptualize acute confusion as both a dichotomous condition, and one that occurs on a continuum. That is, patients were initially identified as either confused, or not confused. When the patient was identified as confused, the occurrence of confusion could be further characterized on a continuum of intermittent to constant. Confusion had the qualities of duration and severity, and there appeared to be a "critical level of confusion at which the nurse moves from monitoring of 14 confused behaviour to intervening to control or end the confused behaviour" (p. 131). Vermeesch noted the subjective nature of confusion, and concluded that it was the change in the pattern of behaviours or cognition scores that should alert nurses to the development of acute confusion rather than the actual score or number of behaviours. Foreman (1991), attempted to clarify the pattern of cognitive deficits and psychomotor behaviours in acute confusion. The cognitive status of 238 elderly hospitalized medical patients was assessed using mental status testing (the Mini-Mental State Examination, Folstein, Folstein & McHugh, 1975), a behavioural assessment tool (The Clinical Assessment of Confusion-B, Vermeersch, 1988, cited in Foreman, 1991), and a visual analogue scale for confusion (VAS-C, Nagley, 1986). One hundred and thirteen (47.5%) subjects were diagnosed with acute confusion. The items on the assessment tools were examined using exploratory factor analysis. Five factors, namely cognition, orientation, perception, motor behaviour, and higher integrative functions, were found to account for 29.8% of the variance. Although the multiple cognitive and behavioural dimensions of acute confusion were supported by these findings, the five factors represented a small portion of the variance. On stepwise discriminant function analysis, nine items from the two assessment tools were identified as diagnostic of acute confusion. Those items included: (a) the inability of the individual to spell WORLD backwards, (b) the inability to speak clearly or comprehensibly, (c) difficulty performing serial 7's, (d) difficulty drawing a pentagon, (e) the inability to name three objects, (f) minor forgetfulness, (g) calling people from the past, (h) pleasant and cooperative general behaviour, and (i) the ability to perform some activities of daily living. The discriminant equation correctly classified 90.34% of the subjects as acutely confused or not confused; sensitivity of the equation was 80.5%/specificity was 99.2% (Foreman, 1991). Orientation and motor activity, elements frequently used by nurses to diagnose confusion, were not included in the statistical model as features that would be diagnostic of an acute confusional state. As these dimensions that are conventionally 15 used by nurses to identify acute confusion represented a small portion of the variance in the study, Foreman determined that other fundamental aspects of this condition remained unidentified and hence unmeasured. He concluded that "we know more about what an acute confusional state is not, than about what it is" (p. 12). Although the literature to date on the correct operational definition of acute confusion has been equivocal, certain consistent elements of the concept can be extracted. Acute confusion is an abrupt change in an individual's cognitive abilities and behaviour. It is first evidenced as part of a dichotomous condition, that when present, can be evaluated on a continuum of occurrence from intermittent to constant. Cognitive changes in acute confusion include changes in perception, thinking, memory and orientation, including registration, retention, and recall. Behavioural changes can be divided into the following categories: general behaviour, alertness, motor activity and behaviour indicative of perceptual changes. Behaviours indicative of confusion are generally considered by the health care team as inappropriate, disruptive and potentially endangering to the patient. They can include such behaviours as pulling at lines and tubes, attempting to get up unassisted when it is unsafe, and a reversal of the sleep-wake cycle. Acute confusion is a reversible condition that has the qualities of duration and severity. When using a specific assessment tool for acute confusion, it is the change in score on assessment that is indicative of acute confusion, rather than a single numerical score. Measuring Acute Confusion The majority of studies examining acute confusion in the hospitalized elderly have relied on discrete scores on a mental status questionnaire to determine cognitive abilities of individuals. Individuals are considered to be confused if their scores fall under a pre-determined cutoff. The advantage of standardized measurement through the use of mental status questionnaires is widely recognized. However, it is important to consider the limitations of this assessment modality. 16 Numerous mental status questionnaires are available for patient assessment and individual tools will not be discussed here. However, each tool measures varying components of mental status, and the length of time required to complete each tool varies greatly. Elderly individuals can become fatigued during lengthy assessments, resulting in poor scoring and false positive results. Also, all tools utilize an interview format and elderly individuals with hearing deficits or visual difficulties can be disadvantaged. A major criticism of mental status questionnaires is that individual scores only indicate the presence or absence of mental impairment at a given point in time, and do not differentiate among various causes of impairment. For example, individuals with mild dementia, depression, or acute confusion can all score below the "normal" cut off on a mental status questionnaire. In addition, these questionnaires only evaluate the cognitive aspects of acute confusion, disregarding the behavioural component. These limitations make it difficult to compare studies that have used discrete scores on different mental status questionnaires as indicative of acute confusion. Researchers reviewing the utility of mental status questionnaires in assessing for acute confusion consistently identify that there is no one tool that could be used as the single measure for diagnosis of this condition (Foreman & Grabowski, 1992; McDougall, 1990; Williams et al., 1988; Yazdanfar, 1990). All mental status tools disregard the behavioural component of acute confusion. Nursing historically has relied on observable clinical indicators to diagnose acute confusion, rather than formal mental status assessments. Several recent studies have explored the clinical features of acute confusion in an attempt to develop more objective and consistent descriptors of behaviours indicative of this condition. As a result of these studies, a number of behavioural assessment tools have been developed (Neelon, Champagne, McConnell, Carlson, & Funk, 1992; Vermeersch, 1990; Williams, Campbell, Raynor, Mlynarczyk, & Ward, 1985). These tools address some of the 17 limitations of mental status questionnaires because assessment is based on clinical observation, rather than the individual's ability to respond to questions. The effect of sensory impairments or individual fatigue are hence minimized. Items on the tools have been chosen for their ability to differentiate behaviour indicative of acute confusion. Although a behavioural tool provides a systematic assessment of this aspect of acute confusion, the use of a behavioural tool alone does not provide an indication of an individual's level of cognitive functioning. In order to ensure that assessment for acute confusion is comprehensive, as Foreman and Grabowski (1992) recommend, both a tool measuring cognitive aspects and a tool measuring behavioural aspects of the condition should be used. Identified Factors Associated with the Development of Acute Confusion Although there are numerous studies that have estimated the incidence of acute confusion in the hospitalized elderly, a limited number of studies identified patient characteristics or environmental variables associated with the development of this condition. Further, the majority of studies published examined acute confusion in elderly individuals admitted for general medical problems. Seymour, Henschke, Cape and Campbell (1980) conducted a prospective study of the incidence and etiology of acute confusion in 70 elderly patients admitted on an emergency basis to acute medical wards A diagnosis of acute confusion was determined on the basis of the patient's history and discrete score on a 10-item mental status questionnaire. Sixteen percent of the patients were classified as acutely confused, which was correlated with dehydration and constipation. It is not known what other factors were examined in determining the etiology of acute confusion in the sample. Rockwood (1989) examined the incidence of acute confusion in 80 individuals over the age of 65 who were admitted to general medical services in two acute care hospitals. Admissions were based on both an emergent and an elective basis. Acute 18 confusion was defined using the American Psychiatric Association (1980) criteria, and was identified by the investigator's clinical observations of the patients. Twenty five percent of patients became acutely confused following hospitalization, which correlated with increasing age, chronic cognitive deficits, increased dependence immediately prior to hospitalization, and greater severity of illness. Although a mental status questionnaire was used in the study, it is unclear if the mental status scores were actually used in the diagnosis of acute confusion. Chisholm, Deniston, Igrisan and Barbus (1982) examined the prevalence of acute confusion in patients over the age of 60 years admitted to medical surgical wards during two study periods. Individuals were considered confused based on their discrete scores on a mental status questionnaire and staff nurses' ratings of the presence of confusion. A daily confusion prevalence rate of 5.5% was reported. The investigators contributed this low prevalence rate to the nursing care delivery system in use in the hospital, the physical layout of the units, and the hospital philosophy of individualized care. It is not known if patients were comparable in their physiological risk of the development of acute confusion. Factors associated with the development of acute confusion, here called delirium, were the focus of a study by Levkoff and associates (1988). A group of 117 patients with a discharge diagnosis of delirium were identified from the total number of medical and surgical patients aged 60 or older who were discharged from the hospital over a two year period. A retrospective review of this group of patients' charts identified four factors that distinguished 80% of all cases of delirium: (a) a urinary tract infection at any time during the hospital stay, (b) no urinary tract infection but low serum albumin levels on admission, (c) neither of these two, but an elevated white blood cell count on admission, and (d) none of the previous risk factors, but the presence of proteinuria on admission Only physiological risk factors were included in the study. The prevalence of delirium as a discharge diagnosis in the total patient population was 0.7%. A 19 discrepancy between the actual incidence of acute confusion (delirium) and the recorded incidence has been documented in other studies (Lucas & Folstein, 1980; Palmateer & McCartney, 1985), and may be a threat to the validity of the findings of Levkoff et al. It is possible that the use of chart data alone does not allow for the correct identification of significant factors in the development of acute confusion. Schor et al. (1992) examined risk factors for acute confusion (here called delirium) in 325 medical or surgical patients aged 65 years or older. A diagnosis of delirium was based on the presence of clinical criteria for delirium outlined in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (American Psychiatric Association, 1987). Twenty-eight percent of patients developed delirium, which was associated with prior cognitive impairment, advanced age, and the presence of a fracture. Risk factors considered in the study included the presence of age-related changes, psychosocial, physiological, and comfort and pleasure risk factors. A strength of this study is the inclusion of individuals in the sample with a pre-existing cognitive impairment. One study was found that defined acute confusion based as a change in score on both a mental status test and a behavioural tool. Lusis, Hydo, and Clark (1993) examined common characteristics of patients who became acutely confused following admission to a medical nursing unit. Individuals over the age of 65 years were screened on admission with the Short Portable Mental Status Questionnaire(SPMSQ), and included in the study if they were cognitively intact (score of 0-2 errors). These individuals were then monitored for the first four days of hospitalization for changes in their cognitive status. Daily assessments included completion of the SPMSQ, the Clinical Assessment of Mental Status (CAMS), a visual analogue scale for confusion, and the observation of a number of psychosocial and physiological factors. Patients were considered acutely confused if they developed a change in mental status indicated by more than two errors on the SPMSQ and movement on the CAMS toward 20 the "mentally confused" end of the scale. Ninety-three individuals were included in the study and only one individual (1.1%) became acutely confused. Factors associated with the development of acute confusion in this individual were greater age, poorer functional scores, and elevated liver function values. Characteristics associated with non-confused individuals included an average age of 75.5 years, higher levels of independence, good sensory status, and higher education. The generalization of the results of this study is limited by the extremely low incidence of acute confusion. In addition, the authors identified that the exclusion of individuals with cognitive impairment from the sample may have biased the study and limited the identification of factors associated with the development of acute confusion. The above studies provide support for the presence of contributing risk factors for the development of acute confusion. However, no conclusive identification of a risk profile of contributory patient characteristics or environmental variables is identified. The studies focused on different, distinct patient groups, which makes it difficult to compare and contrast the results of one study to another's. The majority of studies defined acute confusion based on a discrete score on a variety of mental status tests; a behavioural component was only included in two of the definitions. All cases of acute confusion may not have been identified with the assessment method employed. Investigators focused on either psychosocial or physiological factors that contribute to the development of acute confusion to the exclusion of other factors or the interplay of factors. Other factors significant to the development of acute confusion were frequently not included in data collection. Application of the above findings to the elderly patient admitted to hospital with an orthopaedic condition is difficult. Yet, patients admitted with orthopaedic conditions frequently have several identified risk factors for the development of acute confusion, including being elderly and having restricted or limited mobility, pre-existing cognitive impairments, pain and sensory 21 deprivation, and having been relocated. Patient characteristics and environmental variables pertinent to this population may not be present in other patient populations. Four studies were found that examined the incidence of acute confusion in elderly patients admitted for orthopaedic conditions. One of these studies utilized a sample composed of patients admitted with hip fractures, or admitted for elective total joint arthroplasty. The remaining three studies focused solely on elderly individuals admitted with hip fractures. The clinical characteristics of patients with hip fracture who develop acute confusion were the focus of a study by O'Brien, Grisso, Maislin, Chiu and Evans (1993). Their sample of 101 women was drawn from a larger case control study of hip fractures. Criteria for inclusion in the study included normal cognitive function as assessed with a mental status questionnaire. Patients were considered confused based on a discrete score on the same mental status questionnaire administered six days following admission to hospital, and were categorized as having severe, moderate, or mild to no confusion based on their scores. Demographic and clinical characteristic data were obtained from a retrospective chart review. Information was gathered on physiological factors, age-related changes and limited psychosocial factors. Higher degrees of confusion were associated with greater age at admission, elementary school education or less, a pre-existing diagnosis of psychiatric illness, urinary incontinence prior to hospital admission, and a greater number of medical complications during hospitalization. This study provides a beginning composite picture of the factors associated with acute confusion in the elderly orthopaedic population. Many of the factors identified are in agreement with those identified in the general population. However, these findings must be interpreted with caution. The sample consisted only of women with a specific orthopaedic condition, and excluded individuals with profound cognitive impairment. The sample may not have been representative of the entire orthopaedic population at risk for the development of acute confusion. 22 Williams et al. (1979) examined the relationship of nursing activities and patient, surgical and environmental variables in the development of acute confusion in 91 elderly patients with hip fractures who had no history of chronic confusion. A diagnosis of acute confusion was based on behavioural observation and discrete scores on a mental status questionnaire administered on the first, third and fifth postoperative days. Data were examined for each day of testing using multiple regression analysis. The most consistent predictors of postoperative confusion were the presence of confusion on admission to the hospital or confusion during the preoperative period. As in the study of O'Brien et al. (1993), lesser degrees of confusion were associated with freedom from urinary problems. In addition, greater post-operative mobility and the use of timepieces and television were associated with improved mental clarity. Williams and colleagues described the composite high risk patient in this study as "the very aged person who had been on tranquilizers, was male, had urinary problems, and was more immobilized than patients with similar injury and surgery" (p. 35). This study added to the knowledge of concurrent factors associated with acute confusion in the elderly orthopaedic population, and supported the notion of multiple factor involvement. As in the previous study, a limitation to these findings is the use of a sample with a single orthopaedic condition, and the exclusion of patients with a history of chronic confusion from the sample. In a subsequent study, Williams et al. (1985) described two models for predicting acute confusion in elderly patients admitted with a hip fracture. Prospective data were gathered on 170 patients over the age of 60, who had no previous history of mental impairment. A diagnosis of acute confusion was based on a discrete score on a mental status questionnaire as well as a behavioural score. Subjects were assessed daily for the first five post-operative days. Slightly over half of the subjects (51.5%) developed confusion during the five day period. The first model identified pre-hospitalization characteristics that predisposed an individual for the development of acute confusion. 23 This model was based on the summed confusion scores for the five days. Increased age, three or more errors on mental status testing, and limited pre-injury levels of activity were significant predictors on admission for the development of acute confusion. Daily confusion scores were used in the development of the second model, which identified risk factors for acute confusion associated with treatment and hospitalization. Predictors of confusion, in this instance, included increased age, lowered mental status scores on admission, the confusion scores from the previous day, and urine elimination problems. In comparing the factors in this study with Miller's (1990) categories in the Functional Consequences Theory, consideration was given to psychosocial, physiological, and comfort risk factors and limited age-related changes in the data analysis. A number of factors have been consistently identified as being associated with acute confusion in the elderly patient hospitalized with a hip fracture. These include increasing age, the presence of confusion on admission, and urinary problems in the post-operative period. Although these findings support multiple factor causation for acute confusion, they must be interpreted with caution when considering the population of patients admitted with orthopaedic conditions. It is unclear if urinary problems are a causative factor for acute confusion, or a consequence of the condition. The designation of acute confusion based only on a discrete score on differing mental status questionnaires and the limitation of the study samples to individuals with no known previous history of mental impairment limits the applicability of the results. In addition, the use of a sample of patients with a single diagnosis prohibits generalization of the results to all elderly patients with orthopaedic conditions. Only one study was found that examined acute confusion in a more generalized orthopaedic patient population. Moore and Mulrooney (1991) evaluated the effectiveness of nursing interventions in preventing acute confusion among 50 elderly patients admitted to hospital for hip fractures or total joint arthroplasties. Patients were 24 assigned to either a control or an experimental group. Specific nursing interventions to orient patients to the environment were administered to those individuals in the experimental group from admission until the fifth post-operative day. Acute confusion was operationally defined as "inappropriate communication,... inappropriate behaviour, . . . hallucinations and disorientation" (p. 14). A Behaviour-Communication checklist for confusion adapted by the authors from the work of Williams et al. (1979), was used to evaluate patients each shift. In addition, the Folstein Mini-Mental State Exam and two subtests of the Weschler Memory Scale were administered to the patients prior to, and several days after, surgery. Patients were considered confused based on a discrete score on these testing modalities. There was no significant difference in the development of confusion between the two groups of patients. A small unspecified number of patients became confused during the study. On examination of the data, the investigators found that patients with fractures had a higher incidence of confusion than patients admitted for elective surgery. Those patients with fractures had a higher incidence of urinary problems, received more analgesia prior to surgery, received less analgesia after surgery, and had a shorter length of time in surgery than patients having elective surgery. The investigators identified that conclusions could not be drawn from these findings because the background data for patients with fractures was incomplete, but suggested that there may be factors related to unplanned hospitalization that are specific to the development of acute confusion in this population. Patients undergoing unplanned surgical procedures, particularly for repair of hip fractures, have also been identified in a separate study as having a higher incidence of acute confusion. Bowman (1992) investigated the relationship between anxiety, unplanned surgical events, and the development of acute confusion, referred to in her study as transient postoperative delirium. Delirium was operationally defined as a score of less than 23 on the Folstein Mini-Mental State Exam or reports of behaviours 25 indicative of delirium observed by staff nurses. Twenty-two subjects were randomly selected from a population of patients over the age of 60 admitted to hospital for scheduled non-emergent surgery. A comparison group was also selected consisting of 22 individuals admitted with traumatic events requiring surgical intervention. All subjects had "no validated history of dementia or chronic mental impairment" (p. 26). Thirty-two percent of the unplanned surgery group developed delirium, compared to 5% of the planned surgery group. Three variables differed significantly between the two groups, including patients' history of alcohol consumption, history of depression, and the type of surgical procedure performed. Seventy-five percent of the subjects in the unplanned surgery group underwent orthopaedic procedures. It is unknown what percentage of subjects in the planned surgery group also had orthopaedic procedures performed. The majority of studies utilizing an orthopaedic patient population have focused on individuals hospitalized with hip fractures. There is a relatively higher reported incidence of acute confusion in this patient population. The occurrence of acute confusion has been associated with increasing age, pre-existing confusion, and urinary difficulties. Moore and Mulrooney's (1991) findings suggest that the experience of a hip fracture itself may be characteristic of patients developing acute confusion. Bowman's findings (1992) provide support for this idea. However, no studies have been reported that examine the incidence of acute confusion in elderly individuals admitted to an orthopaedic service in general. Characteristics important in the development of this condition may be unidentified in the non-hip fractured orthopaedic population. Examination of the incidence of acute confusion in the general orthopaedic population and identification of a broad range of both psychosocial and physiological factors associated with acute confusion in this patient population are needed to fill this gap. 26 Summary The literature examining the nature of acute confusion and factors associated with the development of this condition has been reviewed in this chapter. Although this literature is inconclusive, a conceptual definition of acute confusion has been formulated that focuses on acute confusion as an abrupt, reversible change in an individual's cognitive abilities and behaviour as a result of an interplay of age-related changes and risk factors. The constraints of mental status questionnaires in assessing acute confusion have been identified. Limitations that were identified in the literature to date include: varying definitions of acute confusion, the use of a discrete score on differing mental status questionnaires, the use of distinct patient populations, and a focus on single categories of factors that are associated with acute confusion. Few studies have examined factors associated with acute confusion in the general elderly orthopaedic patient population. It remains unclear what specific patient characteristics and environmental variables are associated with the development of acute confusion in elderly patients hospitalized with orthopaedic conditions. The significance of acute confusion in the use of health care resources has been discussed earlier. Individuals who become acutely confused require relatively more intensive nursing care, and are at higher risk for injury. In addition, the functional status of confused individuals may be permanently compromised. Early identification of those individuals at risk for the development of acute confusion can assist with focusing nursing care resources in the prevention or early treatment of this condition. Clear identification of the specific patient characteristics and environmental variables associated with the development of acute confusion in the elderly hospitalized orthopaedic population may assist in maximizing the use of health care resources by early identification and prompt intervention for patients with this condition. 27 Chapter Three describes the method used to conduct this study in an attempt to further explore the specific factors associated with acute confusion in elderly patients admitted to a general orthopaedic service. 28 Chapter Three: Method Introduction The incidence of acute confusion in the elderly individual hospitalized with an orthopaedic condition varies even though these individuals consistently present with numerous risk factors associated with acute confusion. A review of relevant research identifies the many risk factors common among elderly hospitalized patients who develop acute confusion. However, not all elderly patients admitted with an orthopaedic condition, and who present with these risk factors develop acute confusion. Therefore, the questions for this study were: 1) What percentage of patients aged 65 or older, admitted during the study period to the orthopaedic wards at a British Columbian Lower Mainland tertiary care hospital, develop acute confusion in the first week of hospitalization? 2) What are the patient characteristics and environmental variables common among those individuals who become acutely confused? 3) What are the patient characteristics and environmental variables that differentiate those individuals who become acutely confused from those who do not? The Functional Consequences Theory provided a framework for organizing the data collection and guiding the data analysis. This chapter outlines the research method used to examine these questions. Sample inclusion criteria are delineated and the procedure and methods of data analysis are discussed. The assessment tools used in the study are presented and the ethical considerations outlined. Design A prospective, descriptive, correlational design was chosen to examine the research questions. This design is most appropriate for the research questions, because it is the relationship between select variables and the occurrence of acute confusion that is being explored (Lobiondo-Wood & Haber, 1990). None of these variables can 29 be manipulated, and subjects cannot be randomly assigned to confused and not confused groups; thus precluding the use of an experimental design. In addition, little is known about the relationship between the occurrence or non-occurrence of acute confusion and the presence of specific patient characteristics and environmental variables. Setting, Sample Selection and Sample Size A non-probability convenience sample was selected from all elderly patients directly admitted to two orthopaedic wards at a tertiary care hospital in the British Columbian Lower Mainland. The study period of approximately ten weeks occurred from May 1994 to August 1994. The two wards had 31 and 50 beds respectively, and were located on different floors in the same building. An all-RN staff provides care on both wards within a delivery system of total patient care. Total patient care in this hospital refers to a method of nursing care delivery in which the RN assigned to a patient for a particular shift is responsible for all aspects of patient care, including follow up of individual patient problems with other members of the multidisciplinary team, during that shift (Hegyvary, 1977). Potential subjects for the study were identified through discussion with the Managers of the orthopaedic wards or their delegates and a review of the daily admissions lists for the orthopaedic service. The following criteria were used for subject selection. Patients were: 1) admitted to one of two orthopaedic wards within the previous 24 hours, 2) aged 65 years or older, 3) initially admitted directly to the orthopaedic service. If patients were initially admitted "off service" or to another hospital, transfer from another ward or acute care hospital to the orthopaedic ward occurred in less than 24 hours following their initial injury, 4) admitted to hospital for reasons other than terminal or palliative care, 30 5) anticipated to have a hospital stay of greater than 72 hours and no transfers to other hospital wards were planned for the first seven days of the hospital stay, 6) conscious on admission, 7) able to communicate (speak/write) in English, and 8) not intoxicated on admission. Patients developing delirium tremens during their hospital stay were also excluded from the study because confusion related to delirium tremens was not the focus of this study. During the course of the study, it was found that some patients were not appropriate to approach for participation due to their unstable medical conditions. Hence, an additional criterion was added dictating that the patient's initial medical condition was stable enough to tolerate repeated participation in the mental status assessment. A major purpose of this study was to determine the incidence of acute confusion, rather than the presence or magnitude of the effect of an intervention. Because this is considered survey research, the required sample size was primarily determined by evaluating the precision of the incidence estimates that would be considered acceptable (Rea & Parker, 1992). The sample size was calculated in the following manner: 1. The confidence level or risk of error the investigator was willing to accept in the study was chosen. Considering the time and resource constraints of a graduate thesis and the consequences of drawing incorrect conclusions with regard to the occurrence of acute confusion, a 95% confidence level was chosen. 2. The confidence interval or range of error that would be acceptable in the results was then determined. In this study, the investigator, in consultation with a statistician, determined that a 10% range of error in the identified incidence of acute confusion would be acceptable. 31 3. The sample size was then calculated. Using the method appropriate for variables expressed in terms of proportions, sample size is approximately equal to the square of the reciprocal of the confidence interval (Rea & Parker, 1992). For this study, the required sample size would be equal to (1/.10)2 , or 100 individuals. In addition, a sample size of 100 would permit the detailed analysis described in the "Data Analysis" section. One hundred subjects would be needed to compare the various subgroups of interest. During the study period, approximately 103 individuals aged 65 years or older, were admitted to the orthopaedic wards at the target hospital. However, of this group, 56 patients were ineligible, or chose not to participate in the study. Seven of these 56 patients are of special note as the very criteria that excluded them could have placed them at risk for the development of acute confusion: five patients were unable to speak English and two patients were intoxicated with alcohol on admission. Patients admitted on an emergent basis who met the study criteria were often identified within the first 24 hours of hospitalization. However, these patients were frequently taken to surgery prior to meeting with the investigator, and were unable to give informed consent to participate in the study within 24 hours of their admission to hospital. Five patients of the 56 patients lost to the study were lost for this reason. Seventeen of the patients who chose not to participate agreed to provide demographic information to allow for the assessment of the representativeness of the study sample, which is discussed in Chapter Four. Forty-seven individuals (46%) met the study criteria and were willing to participate in the study. Six of these individuals were lost to the study as they elected to withdraw prior to completion of the required assessments, leaving a total of 41 subjects. Given this sample size, a 95% confidence interval of +/- 16% would be expected in the reported incidence of acute confusion. This sample is considerably smaller than the initial sample proposed for the study. Summer bed closures in the orthopaedic department limited the total population from 32 which to draw a sample. As stated earlier, only 40% of the population met the study criteria, were willing to participate, and completed the study, rather than the anticipated 75%. A decision to terminate data collection was influenced by the high acuity on the nursing wards that persisted during the last two weeks of data collection. Such high acuity made it difficult for the nursing staff to assist with the data collection. Taking these factors into consideration, as well as the time constraints of a graduate thesis, and following consultation with the thesis committee, data collection was stopped at the ten-week period. Given the small sample size, the findings of this study will be examined as a preliminary or pilot study. Data Collection Instruments The Folstein Mini-Mental State Exam (MMSE) (Folstein, et al., 1975) (see Appendix C) is an eleven question assessment of the cognitive aspects of mental functioning including orientation, registration, attention and calculation, recall and language. The exam takes approximately 15-20 minutes to complete. Scores on the questions are weighted and the maximum total score is 30. A score of 24 is considered the cutoff for determining cognitive impairment. This quantitative estimation of cognitive abilities has been shown to be useful for serial documentation of cognitive changes. The MMSE has been used widely in the health care field. Reliability and validity of the MMSE have been reported in a number of sources (Foreman, 1987; Nelson, Fogel & Faust, 1986; Folstein et al., 1975). Test-retest reliability has been reported to range from .83 to .98 (Folstein et al., 1975). Foreman (1987) provided the most comprehensive report of reliability and validity. Internal consistency was reported to be .96. Criterion related validity was determined by correlating scores on the MMSE, the Short Portable Mental Status Questionnaire (SPMSQ), and the Cognitive Capacity Screening Exam (CCSE) with the clinical diagnosis of cognitive impairment. Spearman correlation coefficients for criterion-related validity were .78. Sensitivity, specificity, and predictive values for global cognitive impairment were estimated in a 33 population of elderly, hospitalized medical-surgical patients. The sensitivity rate was .82, specificity was .80, and predictive values of positive and negative tests were .80 and .82, respectively. Pearson product moment correlation coefficients between the MMSE and the Short Portable Mental Status Questionnaire and the Cognitive Capacity Screening Exam were .83 and .88 respectively, providing evidence of the concurrent validity of the MMSE. The reliability of the instrument when used in serial administration was not reported. The Clinical Assessment of Confusion-A, revised, (CAC-A (revised)) (see Appendix D) is an adaptation of a behavioural scale developed by Patricia Vermeesch (1990) to measure acute confusion in hospitalized adults. It is completed in consultation with the nursing staff, and consists of a list of 25 behaviours considered indicative of acute confusion. In the original tool (CAC-A) (see Appendix E), items receive a weighted score based on their presence or absence. For the purposes of this study, the scoring system was revised (with the author's permission) to allow for measurement of the qualities of duration and severity. The maximum possible score on the original tool is 77. Vermeesch suggests the following interpretation of CAC-A scores: a score of 2 to 8 indicates possible confusion, a score of 9 to 14 indicates mild confusion, a score of 15 to 24 indicates moderate confusion, and a score greater than 28 indicates severe confusion. An interpretation for scores between 25 and 27 is not provided. These ranges were derived from concurrent measurements of acute confusion with the CAC-A and the Visual Analogue Scale - Confusion (VAS-C), a visual analogue scale that measures the degree of acute confusion as perceived by nursing staff developed by Nagley (1986). The validity of the original CAC-A has been assessed in conjunction with the VAS-C. In comparison to the VAS-C, the CAC-A was found to correctly classify 69% of assessed patients. Sensitivity and specificity of the CAC-A are reported as 65% and 79%, respectively. Interrater reliability of the original CAC-A was examined using 34 Pearson's product moment correlation with a reported score of .88 (Vermeesch, 1990). Foreman (1989) reported a test-retest reliability of .85, an internal consistency rate of .80, and interrater agreement of .79 for the CAC-A. The tool correlates strongly with the MMSE and VAS-C (Foreman, 1989). The Visual Analogue Scale for Confusion (VAS-C) (see Appendix F) is a visual analogue scale developed by Nagley (1986) that is used to measure the degree of acute confusion as perceived by the nursing staff. It consists of a 10 centimetre line anchored at the left with "no confusion" and at the right with "severe confusion". The nurse is asked to place a slash on the line indicating his or her perception of the degree of acute confusion present. The measured distance in centimetres from the left end of the scale is used as the score for the VAS-C. Scores on the VAS-C correlate strongly with the MMSE and CAC-A (.83 and .82, respectively) (Foreman, 1989). Concurrent validity of the VAS-C has been demonstrated by a moderate correlation with the Short Portable Mental Status Questionnaire (r = .63) and interrater reliability has been reported as .98 (Nagley, 1986). Assessment of the concurrent validity for the CAC-A and the sensitivity of the revised scoring system for the CAC-A were determined in the current study from 148 different assessments of 41 patients. Concurrent validity was determined by comparing CAC-A scores with scores on both the MMSE and VAS-C using Pearson's Product Moment Correlation. The CAC-A (revised) scores were also correlated with scores on both the MMSE and VAS-C. The correlation scores for the two scoring systems were then compared to determine the sensitivity of the revised scoring system. Intercorrelations among the scores obtained with the four assessment tools are in Table 1. In interpreting the correlation table it is important to remember that the MMSE measures changes in mental status, the CAC-A, CAC-A (revised) and VAS-C measure changes in behaviour. The scoring on the two categories of tools have an inverse relationship. That is, an individual with acute confusion would have a relatively lower 35 score on the MMSE and relatively higher scores on the CAC-A, CAC-A (revised) and VAS-C. Similar to Foreman's (1989) findings, there is a strong correlation between the CAC-A and the MMSE and VAS-C. There was also a strong correlation between the revised form of the CAC-A and these two assessment tools. This suggests that both the CAC-A and the CAC-A (revised) are valid measures of both changes in mental status and changes in behaviour indicative of acute confusion. The low correlation between the VAS-C and the MMSE supports the idea that the VAS-C and MMSE are measuring different concepts. The very high correlation of the original CAC-A with the CAC-A (revised), and the similar correlations of both forms of the CAC-A with the VAS-C suggests that the revised scoring system did not change the validity of the CAC-A. However, the lower correlation of the CAC-A (revised) with the MMSE suggests that the revised scoring system is more sensitive to behavioural changes than the original tool. Table 1. Correlations Among the Four Data Collection Instruments (n = 148) Assessment MMSE CAC-A CAC-A VAS-C Tools (revised) MMSE 1.00 -.83** -.74* -.48* CAC-A 1.00 .98** .83** CAC-A(revised) 1.00 .85** VAS-C " 1.00 *p < .01 **p < .0001 For the purpose of this study, acute confusion was operationally defined as an abrupt, reversible change in cognitive abilities and behaviour. These tools were chosen for their ability to capture the elements of acute confusion as defined earlier. Serial assessments using the MMSE, CAC-A (revised) and VAS-C were made. The CAC-A 36 (original) was completed by the investigator based on patients' assessments with the CAC-A (revised). Patients were considered to be acutely confused if there was a combination of: (a) a decrease in their MMSE score of four points or greater from their initial score, (b) an increase in their CAC-A (revised) score of five points or more from the initial score, and (c) an increase in their VAS-C score of greater than .5 cm. from their initial score. The change in score on each assessment tool that was used to determine acute confusion was chosen arbitrarily by the investigator, based on scoring for each tool that would move the individual from one category of cognitive status to another. The revised scoring system for the CAC-A was also considered in this determination. The completion of the CAC-A (original) was used for validity assessments only. Scores on the CAC-A (original) were not used in the determination of acute confusion. Procedure Approval for the study was obtained from the University of British Columbia, Clinical Screening Committee for Research and Other Studies Involving Human Subjects and the appropriate research committees at the target hospital. As part of the procedure for obtaining hospital consent to conduct research, this investigator met with the Manager or his or her delegate and the nursing staff of each of the nursing wards prior to commencement of the study to obtain permission to conduct the study. The purpose of the study was outlined and an explanation of Manager and staffs participation in the study was given. A brief written description of the study with the criteria and protocol for patient selection (see Appendix G) and copies of the assessment tools were provided to the two wards. Individual nursing staff participation consisted of assisting with the data collection for study patients whom they were caring for on any particular shift. The nurse assisted the investigator with the completion of the Clinical Assessment of Confusion - A (revised) and Visual Analogue Scale -Confusion for his or her assigned patients. These two tools required approximately five minutes to complete. The availability to assist with the data collection was confirmed 37 verbally with each individual staff nurse prior to the completion of patient assessments. As this investigator is the Manager on one of the wards where the study took place, permission to conduct the study on that ward was sought from the Patient Services Director. During the data collection period, the Manager or delegate on each ward was once again provided with a protocol for patient selection and initial contact (see Appendix G). Patients who were potential subjects for the study were initially identified and approached by the Manager or delegate of the ward. As this investigator is the Manager of one of the nursing wards, a delegate was used for the initial contact with patients on her ward. Patients were given a brief description of the purpose of the study and asked if they were interested in discussing the study further with the investigator. The ability of the patient to give consent was also assessed by the Manager or delegate according to guidelines presently used in the hospital. If the patient met all other study criteria, and was not deemed able to give consent on his or her own behalf, the purpose and description of the study was discussed with the appropriate guardian or responsible person (henceforth referred to as the representative), using the hospital's general consent guidelines (see Appendix H). The investigator visited the wards daily and met with the Manager or delegate to determine if potential participants had been identified in the past 24 hours. The investigator met with these patients or their representatives and explained the study in more detail, as outlined in the section on Human Subjects Considerations. Written consent for participation was obtained (see Appendix I). On obtaining written consent to participate, a baseline assessment of the patient's mental status was conducted by this investigator using the Folstein Mini-Mental State Exam (MMSE). This initial assessment was conducted pre-operatively for 33 patients, and post-operatively for eight patients. The investigator also completed the Clinical Assessment of Confusion-A (revised) (CAC-A (revised)), and Visual Analogue Scale for 38 Confusion (VAS-C) with the nurse admitting the patient or caring for him or her at the time of the initial assessment to establish baseline parameters for behaviour. The CAC-A (original) was completed by the investigator based on the nurse's assessment of the patient using the CAC-A (revised) to permit assessment of the sensitivity of the revised scoring system. Serial mental status and behavioural assessments using the four tools were continued every second day from the initial assessment, occuring on the third, fifth, and seventh days of hospitalization. The assessment was completed at approximately the same time of day; assessments generally took place in the afternoon between 1500 hours and 1900 hours. Patient participation in the study was considered complete once a patient was determined to have acute confusion, on the seventh day of hospitalization, or upon discharge, which ever came first. Seven individuals with severe cognitive impairment were not able to respond to the questions in the MMSE, and thus received an initial score of zero. Only the behavioural assessment tools (CAC-A (revised) and VAS-C) were used for further assessments. These individuals were considered to be acutely confused if there was a combination of: (a) an increase in their CAC-A (revised) score of five points or more from their initial score and (b) an increase in their VAS-C score of greater than .5 cm. from their initial score. During the course of the study, this investigator noted a testing effect during the administration of the serial mental status assessments using the MMSE. The effect observed was that many patients remembered the questions from the mental status assessment after the initial assessment. This investigator was frequently greeted by patients who would provide responses to the orientation portion of the assessment prior to the assessment commencing. In addition, there were many incidents of patients deliberately remembering the words used to assess their memory in the previous assessment rather than the words given for the current assessment. Several patients had 39 developed systems to facilitate their performance on the serial seven's including memorizing the responses, practicing in the intervening days, or using systems of adding and subtracting to arrive at the answers. Eleven patients in total (27%) demonstrated a testing effect with the mental status assessments using the MMSE. The mental status assessment also appeared to cause anxiety for many patients. They were concerned with "doing well" even when reassured that this was not a test. All six patients who chose to withdraw from the study prior to completing the required assessments stated they did not think they would do well on the mental status assessment and thus would prefer not to continue in the study. Six individuals initially assessed with all three instruments met only the behavioural criteria for acute confusion on subsequent assessments. That is, they had an elevation in their CAC-A (revised) scores of five points or more from their initial scores, and an increase in their VAS-C scores of greater than .5 centimetres. However, their MMSE scores did not decrease by four or more points. Clinically, these patients were considered by the nursing staff to be acutely confused. This is supported by an understanding that one of the main characteristics of acute confusion is the fluctuating nature of the condition (Foreman, 1986; Lipowski, 1987). MMSE assessments during the course of an individual's participation in the study would reflect their cognitive status only at a given point in time. In contrast, the nurse's assessment of behaviour utilizing the CAC-A (revised) was based on the nurse's entire experience with that individual. This behavioural assessment would be more sensitive in identifying an individual who was demonstrating the fluctuating nature of acute confusion. For this reason, patients who met only the behavioural criteria for acute confusion were included in the group of patients who developed acute confusion. In addition to the serial assessments outlined earlier, participating patients' records were reviewed to obtain demographic information as well as information on select age-related changes, and psychosocial, physiological, and comfort and pleasure 40 risk factors in accordance with Miller's (1990) Functional Consequences Theory. This information was recorded on a data collection form designed by the investigator (see Appendix J). For the purpose of data collection, age-related changes were recorded as a simple "yes" or "no" indicating the presence or absence of these changes. A large number of individual risk factors for acute confusion were selected from the literature for inclusion in the data collection process. In keeping with Miller's (1990) Functional Consequences Theory framework, these risk factors were grouped under psychosocial, physiological, and comfort and pleasure categories, and were recorded as dichotomous or continuous variables. Chi-square analysis would not be meaningful with this large number of variables, given the anticipated small sample size. A maximum of five variables in each risk factor category could be allowed. In order to meet this criterion, some of the individual risk factors within each category were grouped by the investigator into "like" categories that were then given one score prior to data collection. It was assumed that each risk factor carried a similar weight when developing the risk factor scores. A varying number of scores were developed for each category of risk factor. These scores are briefly explained below. A detailed description of the numerical designation within each score can be found in the Data Collection Form (see Appendix K). Psychosocial risk factor scores: 1. pre-admission independence score: calculated by summing the number of community supports used by the patient prior to admission and a numerical score from 1 to 4 assigned for their self-reported mobility prior to admission. Possible pre-admission independence scores could range from one to nine, with a lower score signifying greater independence. 2. emotional stress score: calculated for each patient based on the sum of four factors that could influence the patient's level of stress: (a) the patient's number of previous 41 hospitalizations, (b) the type of admission, with an elective admission designated " 1" and an emergency admission designated "2" (c) whether the patient underwent a surgical intervention, with "no" designated "1" and "yes" designated "2", and (d) the number of times the patient was transferred from the ward of admission to another area of the hospital during the hospital stay (these transfers could be temporary or permanent). Possible scores could range from four (low emotional stress) to ten (high stress). 3. continuity of care score: the number of nursing shifts for which the patient received care from the time of admission until discharge from the study divided by the number of individual nurses who were assigned to the patient on those shifts. A higher score signifies a greater amount of continuity in care. Physiological risk factor scores: 1. mean daily analgesic dosage in morphine equivalents: the patient record was reviewed for all analgesics the patient received during the time they were enrolled in the study. The analgesic dosages were recorded based on hospital days, and converted to a morphine equivalent using the analgesic equivalency chart available in the study hospital's Parenteral Drug and Therapy Manual. A mean daily dosage of analgesic for each patient was calculated. 2. mobility score: the patient's mobility status for each day enrolled in the study was assigned a numerical value, with higher values indicating decreased mobility. A possible daily score could range from 1 to 7. The final score was the sum of all daily mobility scores for the time period the patient was enrolled in the study, with a possible range of 3 to 49. 3. metabolic risk score: this score was composed of the sum of abnormal laboratory results, abnormal vital signs, and total number of medical complications documented in the patient record for each patient. Possible scores could range from 0 to 104. . 42 Comfort and pleasure risk factors: 1. sleep deprivation score: the patient's sleeping pattern was recorded from the patient record for each day enrolled in the study and converted to a numerical score with "0" designated for no note, "1" for sleep disturbance, and "2" for no sleep. Daily scores were summed to produce an overall score. The possible range of scores was 0 to 14. 2. pain score: calculated based on the patient's daily self report of comfort. The following scoring system was utilized: pain levels greater than that acceptable to the patient were scored "2", pain levels less than or equal to levels acceptable for the patient were scored "1", and a score of "0" was assigned if the patient could not give a self report. The daily assessments for each patient were summed to produce an overall score. The possible range of scores was 0, signifying no information available, to 14. 3. environmental stimulation score: calculated for each patient based on the type of room they occupied, and the total number of roommates present in the room each day. The assumption made was that a ward room with a larger number of roommates would have greater noise and activity, and would provide more environmental stimulation. This information was gathered through observations made by the researcher and a review of ward occupancy lists. Possible scores ranged from 3 to 28, with a higher score signifying increased environmental stimulation. Thus, although data were collected on each separate variable, actual data analysis for the study was based on the list of variables shown in Table 2. 4 3 Table 2. Data Collection Variables Demographics Age Gender Education Level Pre-admission level of independence Social Supports Risk Factors Psychosocial Ward of Admission Pre-admission Independence Score Emotional Stress Score Continuity of Care Score Comfort and Pleasure Sleep Deprivation Score Pain Score Age-related changes Impaired Vision Impaired Hearing Physiological Primary Diagnosis Secondary Diagnosis Number of Non-analgesic Medications in Hospital Mean Daily Analgesic Dosage Mobility Score Metabolic Risk Score Environmental Stimulation Score Demographic and diagnostic data were requested from those patients who did not wish to participate in the study to determine if the sample obtained was representative of elderly patients admitted to the orthopaedic service. Information obtained included the patient's age, gender, living situation prior to admission, admitting diagnosis, secondary diagnoses and type of admission. The data collection form for nonparticipants can be found in Appendix K. All data were coded, entered into a computer file and analyzed using SPSS-X 3.0. The data were summarized with descriptive statistics. Interval level demographic variables were summarized with measures of central tendency, including the mean, median, and standard deviation. The incidence of acute confusion is reported as a percentage of the sample. Further data analysis was guided by the research questions, the measurement level of the data, and the sample size. The majority of the data were at the nominal or ordinal level. Chi-square techniques were used to identify relationships Data Analysis 44 between the occurrence or non-occurrence of acute confusion and various patient characteristics and environmental variables. For variables with a large range of frequencies, and a normal distribution of results, unpaired t-tests were used to detect differences between mean scores for patients with acute confusion and those who did not develop acute confusion Ethical Considerations Protection of the human rights of the participants was ensured throughout the study by adherence to standard procedures regarding research with human subjects. The investigator met with potential subjects, identified and previously approached by the Manager or delegate, and provided them with details of the study, including the amount of time they could expect to dedicate to the study, any potential risks, and a description of the methods used to ensure the confidentiality of their participation. The majority of patients approached to participate did not have any problems giving informed consent on their own behalf. There were some patients that met the inclusion criteria but who had some degree of cognitive impairment on admission that interfered with their ability to give informed consent. These patients were routinely identified on admission through information forwarded from their care facility or from direct information from a family member or caregiver. They consequently were known to the Manager or delegate. As these patients met all other inclusion criteria, informed consent was sought from a representative, using the policy for obtaining consent for care utilized by the hospital (see Appendix H). The representative was initially approached by the Manager or delegate. If the representative was interested in the patient participating in the study, the investigator then met with them. The study was explained as above and written or telephone consent was obtained. A verbal and written description of the purpose of the study (see Appendix I) and an explanation of their participation was given to the patients or their representatives, including an estimate of the time involved for participation. An 45 opportunity was provided to answer any questions they had. The patients or representatives were made aware that participation was voluntary and would in no way affect their medical or nursing care. They were able to withdraw from the study at any time should they no longer wish to participate. Written consent to participate was obtained from all participants (see Appendix I). Ongoing consent to participate was verbally confirmed with each patient prior to subsequent mental status assessments. Individuals who decided not to participate, or who withdrew prior to completing the required assessments, were asked for permission to record information on their age, sex, living situation prior to admission, admitting diagnosis, secondary diagnoses, and type of admission to allow for comparison to the study population. The study was conducted in the patients' rooms on the orthopaedic wards. The only individual involved in conducting the study was the investigator, who is a graduate student with the University of British Columbia, School of Nursing. Participation in the study involved approximately 15 minutes of the patient's time on four separate occasions to complete a mental status assessment, or a total of approximately one hour. Patient participation in the study was considered complete once a patient was determined to have acute confusion, on the seventh day of hospitalization, or upon discharge, which ever came first. There were no anticipated risks to participation in this study. The identification of acute confusion by the investigator was reported to nursing personnel. Although there were no immediate benefits to individuals as a result of their participation, identification of acute confusion may have resulted in earlier intervention to treat the condition. It was anticipated that individuals would not experience any discomfort or incapacity as a result of responding to the questionnaire. There was no monetary compensation offered for participation in the study. Confidentiality was maintained throughout the recording and reporting phases of the study. Each participant was identified only by a code number that appeared on 46 all data forms. Only the researcher knew the identity of the participants, and only her supervisory committee, data entry clerk and statistical consultant had access to the coded study data. Patient records were accessed through the appropriate hospital personnel. Patient record reviews took place in a private office on the nursing wards or in the confidential record review room in the Health Records Department of the hospital. All data are stored in a locked file until such time as all scholarly work with the data is completed. Secondary analysis may be completed subject to approval by the appropriate ethical review committee. A summary of the data may be used in presentations and publications. Individuals will not be identifiable from data presentations or publications. There were no provisions for sharing of the study findings with the participants. Summary In this chapter, the method used to investigate the research questions has been described. Sample selection and sample size have been outlined, and the data collection procedure explained. Instruments used in the assessment of acute confusion have been described and their psychometric properties discussed. Methods of data analysis have been described. Finally, ethical considerations for this study have been discussed. 47 Chapter Four: Presentation and Discussion of Findings Introduction As the sample size obtained during data collection was much smaller than anticipated, the findings of this study have been treated as those of a preliminary study. The findings are presented in two sections. The first section describes the sample of patients based on demographic variables and descriptive information and compares the sample to the group of individuals who chose not to participate in the study. Age-related changes and risk factors for acute confusion descriptive of the sample are then presented. The second section describes and discusses the study findings relative to the research questions that are applicable given the small sample size. More recent literature is incorporated into the discussion of the findings. Demographic and Descriptive Information Study Sample and Nonparticipants Twenty-seven of the 41 subjects (65.9%) were admitted to Ward A and 14 subjects (34.1%) to Ward B. The subjects' ages ranged from 65 to 102 years. The majority of the sample (78%) was female. Information on educational status was missing for 34% of the sample (n = 14). The remaining 63 percent of the sample (n = 27) had completed Grade 6 or higher, with 24.4% (n = 10) having an education beyond Grade 12. The majority of patients (75.6%) were living independently prior to hospitalization, with 34% (n = 14) living alone, and 39% (n = 16) living with a spouse or other adult. Seventy-three percent of the sample (n = 30) described themselves as limited in their mobility prior to hospitalization. Further information on the age of the sample, as well as frequencies and percentages for the study sample characteristics can be found in Table 3. 48 Table 3. Demographic Characteristics: Study Sample and Nonparticipants Characteristic Study Sample (n = 41) Nonparticipants (n=17) Age M = 77.4 SD=8.5 M = 76.5 SD=7.0 Frequency Percentage Frequency Percentage Gender: 1. Male 2. Female 9 32 22.0 78.0 9 8 52.9 47.1 Pre-hospital mobility level: 1. physically active 2. moderately active 3. hmited 7 4 30 17.1 9.8 73.2 1 8 8 5.9 47.1 47.1 Education level: 1. < Grade 6 2. Grade 6-12 3. > Grade 12 4. not available 1 16 10 14 2.4 39.0 24.4 34.1 0 3 3 11 0.0 17.6 17.6 64.7 Level of independence prior to admission: 1. independent living 2. community care facility: personal care 3. community care facility: intermediate care level 1-3 4. extended care 31 1 9 0 75.6 2.4 22.0 0.0 14 0 3 0 82.4 0.0 17.6 0.0 With whom was patient residing: 1. alone 2. spouse/other adult 3. children 4. not applicable (facility) 14 16 1 10 34.0 39.0 2.4 24.4 6 8 0 3 35.3 47.1 0.0 17.6 Demographic information was collected on 11 patients who chose not to participate in the study and six patients who withdrew prior to completion of the required assessments for a total of 17 patients. The age range of the nonparticipants was 65 - 90 years, which is comparable to the study sample. In contrast to the study sample, which had a majority of female patients, there was a relatively equal distribution 49 of male and female patients in the group of nonparticipants. In order to determine if the gender distribution of the sample was representative of the target population, statistics on the gender distribution for patients aged 65 years or older, admitted to Canadian hospitals for musculoskeletal surgery, were examined. Females accounted for 67% of hospital admissions for musculoskeletal surgery for this age group (Statistics Canada, 1994). This distribution is similar to the gender distribution in the study sample. Thus, it was assumed that the study sample was representative of the population in regard to gender distribution. Characteristics of the group of nonparticipants related to education, level of independence and social support are comparable to the study sample. Information on education level was not available for 64.7% of the nonparticipants (n = 11). The remaining 35.3% of the group (n = 6) had completed Grade 6 or higher, with 17.6% (n = 3) completing higher than Grade 12. The large majority of the nonparticipants (82.4%) were living independently prior to hospitalization, with 35.3% living alone (n = 6) and 47.1% (n = 8) living with a spouse or other adult. Forty-seven percent of the group (n = 8) described themselves as limited in their mobility prior to admission, in contrast to 73% of the study sample who described themselves as having limited mobility. All participants had some previous hospital experience, with half the sample having between one and five previous hospitalizations, and half of the sample having more than five previous hospitalizations. There was also a relatively equal representation of patients admitted on an elective or emergent basis. Twenty-three patients were electively admitted (56%), while 18 (44%) were admitted on an emergent basis. All nonparticipants had some previous hospital experience, with 24% reporting more than five previous hospitalizations. For the current hospitalization, 35.3% of the group were elective admissions and 64.7% were emergency admissions. This is the 50 exact opposite of the distribution for type of admission in the study sample. This difference in type of admission may partially explain the differences in pre-admission mobility between the two groups. The study sample had a higher proportion of elective admissions, most of whom were hospitalized for joint replacements. A main indication for joint replacement surgery is limited mobility. In contrast, the nonparticipants were mostly admitted on an emergent basis, enjoying a fairly mobile life prior to a critical incident that brought them to hospital. The distribution of primary diagnoses for both the study sample and the group of nonparticipants can be found in Table 4. The majority of patients in the sample had between one and five secondary diagnoses, with only one patient having more than five secondary diagnoses. Cardiovascular disease was the most frequent secondary diagnosis, with 24 patients (58.5%) having this secondary diagnosis. Seven patients (10.1%) had a diagnosis of dementia. The distribution of secondary diagnoses within the group of nonparticipants was similar to that of the study sample. The majority of patients in the group of nonparticipants also had between one and five secondary diagnoses (94.1%, n = 16). Cardiovascular disease was also the most frequent secondary diagnosis for this group of patients, with 10 individuals (58.8%) having this diagnosis. Dementia was not present in the group of nonparticipants. Characteristics of both groups with regard to secondary diagnoses can also be found in Table 4. The study sample and group of nonparticipants are comparable on the majority of demographic characteristics. However, there are some differences in terms of their gender, their type of admission, their pre-admission mobility levels, and a secondary diagnosis of dementia. The study sample had fewer men, had a smaller proportion of emergency admissions, described themselves as less mobile than nonparticipants, and did not have a history of dementia. All of these characteristics, namely, male sex, emergency admission, decreased mobility, and pre-existing cognitive impairment have 51 Table 4 Primary and Secondary Diagnoses: Study Sample and Nonparticipants Characteristic Study Sample (n = 41) Nonparticipants (n=17) Frequency Percentage Frequency Percentage Primary diagnosis Hip fracture3 15 36.6 6 35.3 Lower extremity 1 2.4 1 5.9 fracturea 16 39.0 23.5 t t CI Total hip replacement 4 Total knee replacement Multiple traumaa 3 0 6 7.3 0.0 14.6 2 2 2 11.8 11.8 11.8 Other b Total 41 100.0 17 100.0 Secondary diagnosis None 4 9.8 0 0.0 Dementia 7 17.1 0 0.0 Cardiovascular disease 24 58.5 10 58.8 Cerebral disease 3 7.3 2 11.8 Endocrine disease 8 19.5 3 17.6 Pulmonary disease 4 9.8 4 23.5 Depression 3 7.3 0 0.0 Other 16 39.0 5 29.4 Note. The percentages for secondary diagnosis total greater that 100 as individuals could have more than one secondary diagnosis. aEmergency admission. D A mixture of emergency and elective admissions not specified in previous categories been identified in other studies as having a relationship to the development of acute confusion (Bowman, 1992; Schor et al., 1992; Williams et al., 1979; Williams et al., 1985;). The study sample may be biased in relation to the distribution of these three characteristics. Study results should be considered with this limitation in mind. Other Characteristics of the Study Sample Information was collected for the study sample on the presence of age-related changes in vision and hearing, and other risk factors for acute confusion. Select characteristics are presented here to provide a more indepth description of the study sample. This information has been organized using Miller's (1990) Functional 52 Consequences Theory. Information on the presence of age-related changes will be discussed, as well as those risk factors used in subsequent data analysis. The risk factors have been organized under the categories of psychosocial, physiological, and comfort and pleasure factors. Age-related Changes Thirty-nine patients (95.1%) had impairments in either vision or hearing on admission. Of those patients, 20 (51.2%) reported some degree of hearing deficit and 36 (92%) reported some degree of vision impairment. The degree to which corrective aids for vision or hearing were available or used was not determined. Psychosocial risk factors Information on the particular ward to which the patients were admitted was recorded to allow for analysis of possible differences in the incidence of acute confusion. As reported earlier, 27 patients (65.9%) were admitted to Ward A and 14 patients (34.1%) to Ward B. A pre-admission independence score was calculated for each patient based on the number of community supports used by the patients prior to admission and their self-reported mobility prior to admission. Possible pre-admission independence scores could range from one to nine, with a lower score signifying greater independence. Actual scores for the study sample ranged from one to seven (X = 4.2, SD = 2.0). Although the majority of participants described themselves as limited in their mobility, the pre-admission independence score suggests that such decreased mobility did not have a major effect on the participants ability to participate in their activities of daily living. An emotional stress score was calculated for the patients based on four factors that could influence their level of stress: (a) the number of previous hospitalizations, (b) the type of admission, (c) whether they underwent a surgical intervention and (d) the number of times they were transferred from the ward of admission to another area of the hospital during the current hospital stay (such transfers could be temporary 53 or permanent). Possible emotional stress scores could range from four (low emotional stress) to ten (high stress). Overall, the sample had a high level of emotional stress, with scores ranging from seven to ten (M = 8.0, SD = .74). The majority of patients had support systems present while in hospital, with 93% of patients (n = 38) receiving visits from immediate family, friends, or other relatives. Continuity of care for each patient was calculated by summing the total number of shifts that care was received by the patient and dividing this number by the number of individual nurses caring for the patient during those shifts. Actual scores ranged from 1.0 to 2.7, with a higher score signifying greater continuity (M = 1-5, SD = 3.2). The average score of 1.5 suggests that, in general, patients had a different nurse providing care every one and a half shifts. This low continuity score is surprising given that total patient care is the care delivery method on both wards. In this method of care delivery, nurses usually are caring for a similar group of patients for each set of shifts that they work. This low continuity score may reflect the difficulties inherent in maintaining continuity of care when there are different numbers of caregivers on each shift. Cognitive status was assessed for all patients within 24 hours of admission using the Folstein Mini-Mental State Exam, the Clinical Assessment of Confusion - A (revised) and the Visual Analogue Scale - Confusion. Although, on average, the sample scored high on the initial cognitive assessment, slight behavioural changes indicative of confusion were apparent within the sample. These results may reflect the inclusion of patients in the sample with a previous history of cognitive impairment. These patients did not receive an initial MMSE, but were assessed with the other two tools. Behaviours indicative of acute confusion, such as disorientation could also be present in individuals with a previous cognitive impairment, and are reflected in the group results on both the CAC-A (revised) and VAS-C. The range, mean, and median scores on admission for all assessment tools can be found in Table 5. 54 Table 5 Cognitive Status on Admission Assessment Tool Possible Range Range Mean Median Standard Deviation Folstein MMSE (n = 34) 0-30 13-30 27.1 28 4.0 CAC-A (revised) (n = 41) 0-77 0-39 4.5 0 9.6 VAS-C (n = 41) 0 - 10.0 0-9.0 1.1 0 2.3 Physiological risk factors Eighty-five percent of the sample (n = 35) received between one and three types of nonanalgesic medications during their enrollment in the study. The types of medications received are listed in Table 6. Table 6 Types of Nonanalgesic Medications Administered During Study Participation (n = 35) Type Frequency Percentage Digoxin 5 ^-2 ASA 3 4Q Anticholinergics 2 Jl o Diuretics 11 ^'Q Anxiolytics 18 ~ Antihypertensives 19 NSADOS 2 4.9 Note. NSAIDS refers to Non-steroidal antiinflammatory drugs that were not originally prescribed for their analgesic properties alone. Total count of medications administered exceeds sample size because some subjects received more than one medication. Percentage figures reflect total sample of 41. The high proportion of patients receiving antihypertensives and diuretics is reflective of the number of patients who had a secondary diagnosis of cardiovascular disease. The proportion of patients receiving anxiolytics is perhaps surprising, given the trend toward less frequent use of tranquilizers and sedatives for the hospitalized elderly. In addition, the use of anxiolytics has been correlated with the occurrence of 55 acute confusion in other studies (Williams et al., 1979). This may have been a contributing factor for the development of acute confusion in this study, however this degree of analysis was not possible given the small sample size. Information on reasons for or times of administration of anxiolytics was not documented. All but one patient received analgesic medication during the study. The most frequently administered types of analgesics included morphine, given intravenously or intramuscularly, and acetaminophen with or without codeine. Demerol was the analgesic of choice on three occasions only, suggesting that pain management practices on the orthopaedic service are aligned with current understanding about preferred analgesics for the hospitalized elderly. Morphine was given either intravenously or intramuscularly with similar frequencies. Further data analysis was limited by data organization which identified information by hospital day and did not identify post operative days. This resulted in data that were not comparable across the sample. A mobility score was determined for all patients in the following manner: each day patients were enrolled in the study, they received a numerical value indicating their mobility status. Higher values indicated restricted mobility. The total score was the sum of all daily mobility scores. Possible scores could range from 4 to 54. The actual scores ranged from 15 to 48 (X = 33.3, Median = 35, SD = 8.4). These results suggest that the sample was relatively immobile during their hospitalization, an expected finding given the nature of orthopaedic conditions. Incidents such as hip fractures, conditions such as arthritis, and the experience of musculoskeletal surgery itself limit an individual's ability to mobilize during hospitalization. The degree of mobility for this patient population usually increases over the first week of hospitalization, as an individual recovers from musculoskeletal surgery. A metabolic risk score was composed of the sum of the abnormal laboratory results, abnormal vital signs and total number of medical complications documented in the patient record for each patient. Possible scores ranged from 0 to 104. The actual 56 scores ranged from 0 to 25 (M = 10.7, Median = 10.0, SD = 5.8). The sample in general appears to have had low metabolic risk. However, these results cannot be considered reflective of the actual metabolic risk of the sample. There was a large variation in the actual number and types of laboratory tests ordered for individual patients, as well as inconsistencies in the documentation of results from patient to patient. Actual incidents of abnormal physiological parameters, abnormal vital signs and medical complications may have occurred and not been detected. Comfort and pleasure risk factors A sleep deprivation score was based on the patient's sleeping pattern as recorded in the patient record for each day he or she was enrolled in the study. The sleeping pattern was converted to a numerical score with "0" designated for no note, "1" for sleep disturbance, and "2" for no sleep. The documentation of this information was incomplete, that is, there was no note indicating sleeping pattern, over 50% of the time. This lack of documentation was surprising given that the patient's sleep pattern is recorded by a check mark on an activities of daily living flow sheet at the study hospital, and documentation of sleeping pattern is a hospital standard. This information would be useful to nurses in assessing for acute confusion, as disturbance of the sleep wake cycle is one of the diagnostic signs of the condition (American Psychiatric Association, 1987). A pain score was calculated on the basis of the patient's daily self report of comfort. The following scoring system was utilized: pain levels greater than that acceptable to the patient were scored "2", pain levels less than or equal to levels acceptable for the patient were scored "1", and a score of "0" was assigned if the patient could not give a self report. Overall, patients reported pain levels greater than that acceptable to them 23.7% of the time, with pain management being of most concern on admission, and steadily decreasing each subsequent day. These results were compared to the results of a recent pain audit conducted at the study hospital 57 (P. Porterfield, personal communication, June 6, 1994), which examined 150 medical and surgical patients self-reported comfort levels, using a scale of 1 - 10, to their self-reported pain levels (also measured on a scale of 1 - 10). An arbitrary cut off of two or more points difference between the patient's comfort level and his or her pain level was used to determine patient comfort. Sixty-one percent of the patients reported a pain level two or more points greater than their 'comfort level'. The findings of this current study suggest that orthopaedic patients may experience less pain or better pain management during their hospitalization than other patient populations. However, this finding also suggests that further work is necessary to ensure that all orthopaedic patients receive optimal pain management during their hospitalization. The accepted standard in pain management is that all patients are maintained within their comfort level during hospitalization. An environmental stimulation score was calculated for each patient based on the type of room they occupied, and the total number of roommates present each day. Possible scores ranged from 3 to 28 and the actual scores ranged from 6 to 28 (X = 18.5, Median = 21, SD = 8.6), with the majority of patients experiencing a high amount of environmental stimulation during their hospitalization. In summary, more indepth descriptive information on the study sample has been presented. Although subjects reported limitations in their mobility prior to hospitalization, they remained relatively independent in activities of daily living. During the course of the study, subjects experienced decreases in their mobility levels, high levels of emotional stimulation, low continuity of care, and satisfactory levels of pain management. Inconsistencies in documentation of information in the patients' records, and limitations in the data collection resulted in variables that could not be included in subsequent analyses. 58 Findings Related to the Specific Research Questions The research questions initially posed for the study were examined in light of the small sample size. Research Question #1 What percentage of patients aged 65 or older admitted, during the study period to the orthopaedic wards at a British Columbian Lower Mainland tertiary care hospital, developed acute confusion in the first week of hospitalization? Fourteen (34.1%) of those patients participating in the study developed acute confusion during the first week of hospitalization (95% CI: 19.6%, 48.6%). This number represents both those patients who met the study definitional criteria for acute confusion, and those patients who developed behavioural changes only. The majority of cases of acute confusion (71%, n = 10) were detected by hospital day five. No previous studies were found that examined the incidence of acute confusion in the general orthopaedic population. The reported incidence rate of 34% is lower than that found in previous studies that utilized a population of patients with hip fractures only (O'Brien et al., 1993; Williams et al., 1985;). The incidence rate is comparable to that found in studies utilizing a general medical population that excluded patients with previous cognitive impairment (Foreman, 1989). This study included patients with a previous history of cognitive impairment. It is of interest that the incidence rate of confusion in the study is similar to that reported in the literature for other patient populations that excluded patients with a previous history of cognitive impairment (Foreman, 1989). A relationship has been previously reported between pre-existing cognitive impairment and the development of acute confusion (0"Brien et al., 1993; Rockwood, 1989;). Accordingly, it would be expected that the inclusion of patients with a pre-existing cognitive impairment in this study would have resulted in a higher reported incidence rate of acute confusion. A total of 59 seven patients (17%) in the study sample had a documented history of cognitive impairment. This small number may not have affected the overall incidence rate of acute confusion within the sample. This finding also suggests that a pre-existing cognitive impairment is only one of a combination of variables that are related to the development of acute confusion. Two other studies that included patients with a previous history of cognitive impairment examined the development of acute confusion. Schor et al. (1992) conducted a prospective study to identify risk factors associated with acute confusion (here called delirium) in elderly hospitalized patients. Two hundred and ninety one medical and surgical patients aged 65 years or older were evaluated daily for the occurrence of delirium utilizing DSM-III criteria. Fifty-one percent of the sample had a previous history of cognitive impairment. Ninety-one patients (31.3%) developed acute confusion during their hospital stay. This is comparable to the incidence of 34% found in this study. In the second study, conducted by Inouye, Viscoli, Horwitz, Hurst, and Tinetti, (1993), 107 medical patients were assessed daily for acute confusion (here called delirium) using the Confusion Assessment Method questionnaire. Patients with mild to moderate cognitive impairment on admission were included in the study. The authors reported an incidence rate of acute confusion of 25%, which is lower than the rate found in this study. A number of factors can be identified that would affect the incidence of acute confusion in this study. This sample may not be entirely representative of the general population of elderly patients admitted to hospital with orthopaedic conditions because of the small sample size, the small proportion of the total number of patients admitted to the orthopaedic wards that it represents, and the differing characteristics of the sample when compared to patients who did not participate in the study. The reported incidence of acute confusion could be lower than the actual population incidence. 60 In addition, the assessment tools used to detect acute confusion may not have detected all incidences of the condition. As discussed earlier, one of the main characteristics of acute confusion is the fluctuating nature of the condition (Foreman, 1986; Lipowski, 1987). MMSE assessments during the course of an individual's participation in the study would reflect his or her cognitive status only at a given point in time. The nurse's assessment of a patient's behaviour, utilizing the CAC-A (revised) and VAS-C, would reflect only that nurse's experience with the patient during his or her shift. Behaviours indicative of confusion may have occurred in the intervening days or shifts between the assessments and would not have been identified because of the measurement interval chosen. This would also result in a reported incidence of acute confusion that is smaller than the true population incidence. Thus, it may be that the incidence rate of acute confusion in the population is higher than that measured. Research Question #2 What are the patient characteristics and environmental variables common among those individuals who become acutely confused? Chi-square techniques were used to examine the relationship between the development of acute confusion and the presence of age-related changes, psychosocial, physiological, and comfort and pleasure risk factors. A significance level of .05 was used. For some factors, chi-square techniques were not appropriate because of the small sample size and wide range of scores. If the variables had normal distributions, unpaired two-tailed t-tests were used to compare group means for the patients who developed acute confusion and the patients who did not. Because of the small sample size, a significance level of .10 was used for these comparisons. Table 7 provides a summary of the variables for study subjects with and without confusion that were used in this analysis. 61 Table 7. Patient Characteristics and Environment Variables Present for Study Subjects With and Without Acute Confusion Variable Acute confusion (n = 14) No Acute Confusion (n = 27) Age-related changes 96.3% 92.9% Psychosocial risk factors Admitted to Ward A 35.7% 81.5% Admitted to Ward B 64.3% (x2-=8.6)*** 18.5% 1 - 3 Support systems 92.9% 92.6% X X Pre-admission independence score 5.2 (t = -2.55) ** 3.7 Emotional stress score 8.4 (X2- = 8.40)** 7.8 Continuity of care score 1.6 1.5 Admission MMSE 24.2 (t = 1.85)* 28.1 Admission CAC-A(revised) 8.5 (t = -1.78)* 2.4 Admission VAS-C 2.8 1.9 Physiological Risk factors (x2--Diagnosis of fracture 78.6% =14.5)**** 18.5% 1-5 Secondary diagnoses 92.9% 85.2% 1-3 non-analgesic 78.6% 80.8% medications Comfort and Pleasure Risk factors Environmental stimulation score X 16.7 X 19.4 *P<.1 **p < .05 ***p < .005 ****p < .001 Age-related changes. No significant relationship was found between the presence of age-related changes in vision and hearing and the development of acute confusion ( y2 = 0.23, p = .63). This finding was not surprising, given that 95.1% of the total sample had age-related changes in either vision or hearing. However, this is in contrast to the findings 62 of other studies (Inouye et al., 1993) in which the presence of age-related changes such as vision impairment was one of the major factors contributing to acute confusion. In this study, only the presence or absence of age-related changes was measured. As noted earlier, the degree of change, or whether eye glasses or hearing aids were consistently used during the study period to correct the effects of age-related changes were not determined. Psychosocial risk factors. The development of acute confusion was related to the ward the patient was admitted to, the pre-admission independence score, the emotional stress score, and the admission MMSE and CAC-A (revised) scores. Patients admitted to Ward B had a significantly higher incidence of acute confusion ( %2 = 8.6, p = .003) than those admitted to Ward A. This difference could be a result of a number of factors including differences in nursing knowledge and attitudes regarding the care of the elderly, or the ward environment. A major difference between the wards is the types of patients admitted to each, with Ward A admitting primarily elective patients, and Ward B admitting primarily emergency patients with fractures or trauma. A significant relationship was found between the development of acute confusion and the pre-admission independence score. Patients who developed acute confusion had a higher level of dependency prior to admission (t = -2.55, d.f. =39, p = .02). This is comparable to the findings of Williams et al. (1985), where decreased mobility pre-hospitalization was found to be predictive of the development of acute confusion. It is also similar Rockwood's (1989) findings, where the occurrence of acute confusion was found to be related to a higher level of dependency measured by the Katz Index of Activities of Daily Living. The emotional stress scores for all patients ranged from 7 to 10, resulting in four variables for inclusion in the chi square analysis. Patients with a higher emotional stress score also had a higher incidence of acute confusion ( %2 = 8.40, d.f. = 3, p_ = .038). 63 There was no significant relationship found between the development of confusion and the total number of hospital supports ( %2 = 0.00, p_ = .98). There was no significant relationship found between the continuity of care score and the development of acute confusion (t = -1.04, d.f. = 18.5, p_ = .31). The group of patients who became acutely confused did have a slightly higher mean continuity of care score than the patients who did not develop confusion, but this was not statistically significant. This finding was surprising, as a higher continuity of care score reflects a fewer number of caregivers over a period of time. It has been suggested in the literature that improved continuity of care is one method of reducing acute confusion (Duckett, 1993; Evans, Kenny & Rizzuto, 1993). This finding, although not significant, may merit further study to determine whether continuity of care affects the development of acute confusion. Initial cognitive status was determined by the patients' scores on the three assessment tools. Mean initial scores on all assessment tools for acute confusion were compared for the two groups of patients using two-tailed t-tests. A significant relationship was found between the development of acute confusion and both the mean initial MMSE score and the mean initial CAC-A (revised) score. Patients who developed acute confusion had a lower mean initial score on the MMSE (t = 1.85, d.f. = 8.85, p = .098) and a higher mean initial score on the CAC-A (revised) (t=-1.78, d.f = 19.35, p = .09). Patients who became acutely confused tended to have higher mean initial scores on the VAS-C than those who were not confused, (t = 1.55, d.f. = 19.86, p = .137). however, this relationship was not statistically significant. In summary, these findings suggest that there is a relationship between the development of acute confusion and a pre-existing cognitive impairment. These findings are comparable to those of other studies that have also found that a previous history of cognitive impairment is predictive of the development of acute confusion (Inouye et al., 1993; Rockwood, 1989; Schoretal., 1992; Williams et al., 1985.) 64 The association between increased emotional stress, dependence, and previous cognitive impairment with the development of acute confusion suggests that a combination of personal factors and environmental conditions may predispose an individual to the development of this condition. Neelon and Champagne (1992) suggested that the presence of personal risk factors, such as dependence and pre-existing cognitive impairments may lower the threshold of vulnerability for elderly individuals and make them more susceptible to the effects of other physiological or environmental stressors. They proposed that a combination of limited personal competency and greater demand or stress from other factors results in the development of acute confusion. The findings in this study suggest that this proposal is worth further explanation. Physiological risk factors. In examining the relationship between acute confusion and the primary diagnosis of the patient, each category of diagnosis was considered initially in the chi-square analysis. A significant relationship was found between a diagnosis of hip fracture and the development of acute confusion (%2 = 15.4, p_ = .004). When the primary diagnoses for all patients were collapsed into just two categories, fractures and joint replacements, and then compared, the significance of this relationship persisted (%2 = 14.5, p < .001). This finding may partially explain the relationship between ward of admission and the development of acute confusion. Ward B admits predominantly patients with fractures, and thus would have a higher proportion of patients developing acute confusion. As previously stated, no prior studies were found that examined the development of acute confusion in the general orthopaedic population. It has been suggested in other studies (Bowman, 1992; Moore and Mulrooney, 1991) that the experience of an unplanned event, such as a hip fracture may be characteristic of elderly patients who develop acute confusion. The occurrence of a fracture has also 65 been identified as a risk factor for the development of acute confusion by Schor et al. (1992). In a prospective study on acute confusion (here called delirium), 291 patients aged 65 years or older were evaluated daily for the development of delirium. Patients were admitted to medical or surgical services at one American hospital. The presence of a fracture on admission was one of four risk factors found to strongly predict the development of delirium. Although limited by the small sample size, the findings of this current study support this suggestion. The number of secondary diagnoses were grouped at the time of data collection into three categories: (a) none, (b) one to five, and (c) greater than five diagnoses. All three variables were included in the chi square analysis. Although individuals in this study who developed acute confusion tended to have a higher number of secondary diagnoses, the relationship was not statistically significant (%2 = 4.06, d.f. = 2, p_ = .13). Similar results were found when comparing the development of acute confusion and the number of prescribed non-analgesic medications taken. Data for this variable were also grouped into three categories: (a) no non-analgesic medications, (b) one to three non-analgesic medications, and (c) more than three non-analgesic medications. Although the group of patients who developed confusion tended to have a greater number of non-analgesic medications administered, the relationship was not statistically significant (%2 = 4.61, d.f. = 2, p = .10). Comfort and pleasure risk factors. Patients with acute confusion tended to have higher environmental stimulation scores than patients who did not develop acute confusion (t = 0.96, d.f. = 39, p_ = .34), however the difference in scores was not statistically significant. Noise and activity associated with a ward environment and a greater number of roommates may contribute to acute confusion. It has been suggested that high levels of environmental stimulation, such as that found in a hospital environment can create a certain level of demand or stress on an individual. This environmental press ultimately affects an individual's behaviour (Lawton, 1982). This association of environmental stimulation with the development of acute confusion could also partially explain the increased incidence of acute confusion on Ward B, which has a smaller number of private rooms than Ward A. In summary, the relationship between the development of acute confusion and various patient characteristics and environmental variables was examined. Age-related changes in vision and hearing were not associated with acute confusion. Psychosocial risk factors significantly associated with the development of acute confusion included admission to Ward B, a higher emotional stress score, a higher level of dependence pre-admission, and some degree of cognitive impairment on admission as indicated by lower initial scores on the MMSE and higher initial scores on the CAC-A (revised). The only physiological risk factor significantly associated with the development of acute confusion was a primary diagnosis of fracture, particularly a diagnosis of hip fracture. There were no comfort and pleasure risk factors that were significantly associated with the development of acute confusion. Research Question #3 What are the patient characteristics and environmental variables that differentiate those individuals who became acutely confused from those who did not? Multivariate logistic regression was initially planned to analyze the results for this question. Although 34% of the sample developed acute confusion, this proportion is only represented by 14 individuals. Appropriate use of regression analysis requires a minimum sample size of fifteen subjects per variable (Woods, 1988). A smaller number of subjects could result in distortion of the results. The small sample size obtained in this study would only allow for univariate analysis, which would not be sufficient to appropriately address this question. 67 Summary Fourteen (34%) of the participants developed acute confusion during the first week of hospitalization. Factors significantly associated with the development of acute confusion included: admission to a particular ward, a higher emotional stress score, a higher level of dependency prior to admission, a pre-existing cognitive impairment, and a primary diagnosis of fracture. The small sample size obtained in the study precluded multivariate analysis. 68 Chapter Five: Summary, Conclusions, Limitations and Implications Introduction This chapter provides a summary of the study and presents conclusions based on the findings. Limitations to the study are reviewed. In approaching this as a preliminary study, an opportunity to critique the study design is provided; revisions to the study design are discussed. Several implications for nursing research, practice, and education are outiined. Study Summary The impetus for this study came from a clinical observation by the investigator that, although elderly individuals admitted to hospital with an orthopaedic condition consistently present with a high number of the risk factors associated with the development of acute confusion, not all of these individuals actually develop the condition. A review of the literature supported the idea that little is known about the specific risk factors associated with the development or lack of development, of acute confusion in the orthopaedic patient population. In addition, these studies that have been completed specifically focus on patients with a diagnosis of hip fracture, rather than with the general orthopaedic population. The specific questions for this study were whether there are specific patient characteristics and environmental variables that are associated with the development of acute confusion in elderly patients admitted to hospital with an orthopaedic condition, and if these factors could distinguish between those elderly patients who became acutely confused and those who did not. Miller's Functional Consequences Theory (1990) provided a framework for examining the etiology of acute confusion in this population. The specific research questions that were addressed were: 1. What percentage of patients aged 65 or older admitted during the study period to the orthopedic wards at a British Columbian Lower Mainland tertiary care hospital developed acute confusion in the first week of hospitalization? 69 2. What are the patient characteristics and environmental variables common among those individuals who become acutely confused? 3. What are the patient characteristics and environmental variables that differentiate those individuals who become acutely confused from those who do not? A prospective, descriptive, correlational design was selected to examine the research questions. A non-probability convenience sample was used. The participants were 41 patients, aged 65 years or older, who were directly admitted to two orthopaedic wards at a tertiary care hospital in the British Columbian Lower Mainland during a ten-week period. Patients with a previous history of cognitive impairment were included in the sample. All patients received an initial baseline assessment of their mental status using the Folstein Mini-Mental State Exam. Baseline parameters for patient behaviour were established through completion of two assessment tools, the Clinical Assessment of Confusion - A (revised), and the Visual Analogue Scale -Confusion. These tools were completed with the assistance of the nurse caring for the patient at the time of the assessment. Serial cognitive status assessments, using the three tools, were completed every second day from the initial assessment for the first week of the patient's hospital stay, until a change in mental status and behaviour was detected, or until discharge, which ever came first. A determination of the occurrence of acute confusion was based on a predetermined change in score on all three assessment tools. Psychometric testing of the CAC-A and CAC-A (revised) indicated that both forms of the tool were valid measures of changes in mental status and changes in behaviour indicative of acute confusion. Correlations of the two forms of the tool also implied that the revised scoring system was more sensitive to behavioural changes indicative of acute confusion than the scoring system of the original tool. 70 Use of the Folstein Mini-Mental State Exam during the course of the study revealed a previously unreported effect of serial testing. Twenty-seven percent of patients enrolled in the study demonstrated this testing effect. In addition, all patients who chose to withdraw from the study did so because of anxiety related to their performance on the MMSE. Fourteen, or 34% of those patients participating in the study developed acute confusion during the first week of hospitalization (95% CI: 19.6%, 48.6%) The majority of cases of acute confusion were detected by the fifth hospital day. Chi-square analyses and two-tailed t-tests were used to identify age-related changes and risk factors associated with the development of acute confusion. No significant relationship was found between the presence of age-related changes in vision and hearing and the development of acute confusion. Psychosocial risk factors associated with the development of acute confusion included admission to Ward B, a higher emotional stress score, a higher level of dependence prior to admission, and a pre-existing cognitive impairment. Only one physiological risk factor was significantly associated with the development of acute confusion. This was a primary diagnosis of fracture, particularly hip fracture. No significant relationship was found between the presence of comfort and pleasure risk factors and the development of acute confusion. Although 34% of the sample developed acute confusion, this proportion is represented by only 14 individuals. This small sample size precluded the use of multivariate analysis. Conclusions Conclusions which can be drawn from the analysis of the study data are: 1. The correlation of both psychosocial factors and physiological factors with the development of acute confusion suggests a multiple factor etiology for this condition within the population of elderly patients hospitalized with an orthopaedic condition. 71 2. The psychosocial risk factors associated with the development of acute confusion in this sample were similar to those identified in other patient populations, suggesting that the population of elderly patients who are admitted to hospital may have common pre-existing psychosocial conditions that put them at risk for the development of acute confusion regardless of their physiological risk. 3. The significant correlation of the diagnosis of a fracture, particularly a hip fracture, with the development of acute confusion supports the idea that the experience of an unplanned event, such as a hip fracture may be characteristic of patients developing acute confusion within the general orthopaedic patient population. 4. The revised scoring system for the CAC-A appears to increase the sensitivity of this tool for detecting changes in behaviour indicative of acute confusion. 5. The utility of the Folstein Mini-Mental State Exam in assessing the cognitive status of elderly hospitalized individuals comes under question because of it's apparent testing effect, as well as the inability to use this tool as a reliable indicator of mental status changes in patients with a previous history of cognitive impairment. Limitations The following limitations have been identified in the study: 1. The small sample size in the study is a major limitation in analyzing the results of the study or generalizing any findings to the population at large. Recognizing this limitation, this has been considered a preliminary study. General trends and relationships can be identified. Some of the factors that were not found to be associated with he development of acute confusion may be risk factors. There may have been insufficient power to detect these factors because of the limited sample size. 2. Key characteristics of the study sample, such as the type of admission, the ratio of male to female participants, and pre-hospital mobility status, were quite different from the group of patients who chose not to participate in the study. The representation of 72 these characteristics suggest that this sample may be biased in favor of a lowered risk for the development of acute confusion. 3. The use of an English-speaking only sample from a tertiary care hospital limits the generalizability of the study findings. In addition, this criterion may have influenced the representativeness of the sample. The inability to communicate in English has an impact on an individual's ability to make sense of his or her environment, and could contribute to the development of acute confusion. This would have also resulted in a lower observed incidence rate of acute confusion than was actually present. 4. The use of a descriptive design precludes the determination of a causal relationship between variables and the development of an acute confusional state. 5. Assessment intervals chosen for the data collection may not have allowed an accurate identification of all incidents of acute confusion. A hallmark of acute confusion is the fluctuating nature of the condition. With patient assessments occurring every second day, behaviours or cognitive changes indicative of confusion may have occurred in intervening days or even hours, and may not have been identified with the chosen timing of the assessments. This would result in a lower observed incidence of acute confusion than was actually present. 6. Patients admitted on an emergency basis frequently could not have their initial assessment completed prior to surgery. Thus, it is unknown to what degree the initial assessment results completed post-operatively were affected by anesthesia, medications in the immediate post-operative period, or the stress of surgery itself. In addition, some of these patients may have been admitted with acute confusion secondary to factors such as a long period of time between a fall and being found, or abnormal physiological parameters. Baseline assessment results for this group of patients could be lower than the patient's actual pre-operative or pre-hospitalization status. Subsequent changes in assessment scores may not have been large enough to meet the study criteria for the 73 detection of acute confusion. This would have also resulted in a lower observed incidence rate of acute confusion for the sample. 7. The use of the Folstein Mini-Mental State Exam to detect mental status changes in the participants may have also biased the findings. A large proportion of the sample (27%) demonstrated a testing effect with the serial assessments using the Folstein Mini-Mental State Exam. This included remembering the actual questions on the assessment, practicing the item on serial seven's, and remembering the words from previous assessments. This may have resulted in a lower observed incidence rate of acute confusion than was present. Patients who did not have a sufficient change in their MMSE scores, but who met the criteria for the change in behavioural assessment scores were included in the group of patients who defined as acutely confused. This would minimize the testing effect bias. In addition to the testing effect, the anxiety associated with their perceived performance on the MMSE resulted in six patients withdrawing from the study. This may have resulted in a lower observed incidence rate of acute confusion. 8. Although all individuals will have had some degree of age-related changes that can contribute to the development of acute confusion, the presence of deficits in vision and hearing were the only age-related changes specifically measured. The degree of change and whether these deficits were corrected through the consistent use of eye glasses or hearing aids during hospitalization were not measured, limiting the ability to correlate the presence of age-related changes with the occurrence of acute confusion. 9. Data collection methods for a number of the aggregate scores resulted in data that were not comparable across the entire sample of patients. This limited the ability to identify correlations between the occurrence of acute confusion and some physiological risk factors as well as the comfort and pleasure risk factors. 74 Study revisions Based on the findings of this preliminary study, a number of recommendations can be made for revisions to the study design and data collection procedures. Study design During the course of the study, two main factors affected the ability of the investigator to complete the initial assessments within the first 24 hours of the patient's admission. The first was the patient's general medical condition. Study criteria were revised so that patients were eligible for inclusion only if their medical condition was stable enough to allow repeated participation in cognitive assessments. The second factor was the availability of patients who were admitted on an emergency basis and taken to surgery within the first 24 hours of admission. These patients either were not available to the investigator within the first 24 hours, or were too drowsy to be able to consent to participate in the study. This affected the number of patients enrolled in the study, and may have affected the initial assessment scores for those patients who were able to provide consent following surgery. With a significant correlation between acute confusion and admission on an emergent basis, it would be important to maximize the participation of this group of patients in future studies. This could be achieved by having an individual "on call" who could respond to the emergency department or to the ward to obtain consent from patients admitted on an emergent basis and to complete the initial assessments prior to the patient proceeding to surgery. The assessment intervals chosen in this study may have resulted in a lower observed incidence rate of acute confusion than was actually present because of the fluctuating nature of acute confusion. To minimize this limitation, serial assessments with the CAC-A (revised) and VAS-C could be completed by the nursing staff at the end of each care shift. The investigator could review these assessments every twenty-four hours. If a change in behaviour was detected, the patient would then be assessed with the MMSE to detect any concurrent changes in mental status. 75 Continued use of the MMSE for the assessment of mental status is controversial because of the observed testing effects as well as patients' anxiety associated with their performance on the assessment. If the MMSE is used, testing effects could be minimized by presenting the questions within the assessment in a different order with each subsequent assessment. Testing effects found with the assessment question on serial seven's could be reduced by having the patient commence counting backward from a different number on each subsequent assessment. The perceived anxiety that patients experienced as a result of assessments with the MMSE cannot be negated. Alternative methods of identifying changes in mental status indicative of acute confusion that do not involve a "testing" atmosphere should be examined. Alternative assessment tools that were not considered well enough developed for this study and would be worth consideration include the Confusion Assessment Method (Inouye et al., 1990), and the Delirium Symptom Interview (Albert at al, 1992). Both of these tools are based on the criteria for the diagnosis of acute confusion (referred to as delirium) in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), and rely on observations by the clinician of behaviours indicative of acute confusion. Foreman (1993) reports that both tools can be used with patients who cannot communicate or do not speak English, and have minimal response burden for the patient. Data collection. A number of the variables used in data collection were inadequate or not meaningful for data analysis. These included information on age-related changes and many of the aggregate scores developed by the investigator. Each of these will be considered here. The presence or absence of age-related changes in vision and hearing was the only information recorded in this preliminary study. The degree of change, or whether aids were consistently used during the study period to correct the effects of age-related 76 changes is not known. The lack of this information limited the ability to correlate the presence of age-related changes with the occurrence of acute confusion. Information regarding consistent use of eye glasses or hearing aids to correct age-related changes in vision and hearing could be collected on a daily basis by the investigator through patient and nurse interviews. This would provide more indepth information on these variables. A number of the aggregate scores developed by the investigator were not meaningful for data analysis. These included the total analgesic score, the mobility score, the metabolic risk score, the sleep deprivation score, and the pain score. These scores were not comparable across patients for two reasons. The first was the varying length of time each patient was enrolled in the study. Information was collected on patients who developed acute confusion only until the time that the condition was detected. Patients who did not develop acute confusion had information gathered for seven days. Information for the aggregate scores could be gathered for the entire seven days for all patients, regardless of the detection of acute confusion, so that scores would be more comparable. Data forms should be organized to allow identification of information by hospital day and by post-operative day, as well as before and after the development of acute confusion to allow for more indepth analysis. Inconsistent documentation by health care professionals, or inconsistent ordering of laboratory tests and procedures, was the second factor that affected the usefulness of aggregate scores, in particular, the sleep deprivation scores and metabolic risk scores. These inconsistencies are not controllable by the investigator. Alternative methods of collecting information on these risk factors should be considered. Patients' sleeping patterns could be monitored with patients' self-reports, and validated with their hospital record. An alternative would be to include an assessment of the patient's sleeping pattern on an assessment form the nurse completes at the end of each care shift. A standardized illness severity score similar to the Apache II (Knaus, Draper, 77 Wagner & Zimmerman, 1985) that incorporates routine physiologic measurements, age and previous health status could be used as an alternative indicator of metabolic risk. Documentation of the amount of analgesics administered to each patient that was comparable across the sample proved to be more difficult than anticipated. Individual variations in the perception of pain, as well as the use and effect of analgesics resulted in information that was not comparable across a group of patients. A total dose of analgesic that is considered high for one individual, may be inadequate for the pain management of another. Information on the amount of analgesic administered each time should be included in data collection so that an assessment can be made of the appropriateness of the types of analgesics, dosages, and intervals of administration of these medications. However, a detailed assessment of the patient's daily comfort level or satisfaction with pain management may be more useful information to include for analysis of risk factors associated with the development of acute confusion. Implications Recognizing the previously mentioned limitations, the results of this study may have implications for nursing research, nursing practice and nursing education. Nursing Research A number of the findings in this study provide direction for further research. The small sample size and the limitations in the study design limit the generalizability of the results of this study, however the study could be replicated, incorporating the suggestions for design changes. A larger sample should be obtained to allow for verification of the findings and to provide more information about some of the results that were discrepant from the literature. The use of a larger sample would also allow for more detailed analysis to identify which patient characteristics and environmental variables present within the population 78 of elderly patients hospitalized with orthopaedic conditions differentiate those individuals who become acutely confused from those who do not. Further research could clarify if there are risk factors for the development of acute confusion that are common across the population of hospitalized elderly, regardless of medical diagnosis. The serial use of the MMSE for mental status assessments in this study revealed a testing effect with this assessment tool. Further research could examine the extent of this testing effect and determine the validity of the MMSE when used in serial assessments over a short interval of time. The experience of participating in a MMSE also appeared to be stressful for some patients. A qualitative study could more closely examine this experience for elderly patients and determine the utility of the MMSE when considered in combination with the patient's perceived discomfort in participating in the assessment. Finally, the revised scoring system for the CAC-A appears to have increased the sensitivity of this tool in detecting behavioural changes indicative of the development of acute confusion. Further use of the CAC-A (revised) in conjunction with other validated assessment tools would establish concurrent validity for the revised form of the tool. Nursing Practice Should the findings of this preliminary study be validated by other studies, the following recommendations can be made for nursing practice: 1. Initial assessments of elderly patients admitted to hospital should include an assessment of the presence of those risk factors identified with the development of acute confusion. This should include an initial assessment of patients' cognitive abilities, their pre-hospital level of independence, the type of hospital admission, whether elective or emergent, and patients' level of emotional stress associated with 79 hospitalization. Such assessment would assist in the early identification of individuals at risk for the development of acute confusion. 2. Ongoing assessments should be developed and incorporated into practice for those patients identified to be at high risk of developing acute confusion. These assessments should utilize behavioural assessment tools that are simple to complete and that can be done repetitively, without bias. This would allow for early detection of the development of this condition and would provide the opportunity for early intervention, with a possibility of reducing the mortality and morbidity associated with acute confusion. 3. Consistent documentation of factors that are diagnostic of acute confusion, or known to be associated with the development of the condition, such as patients' sleeping patterns, is important. Consistent documentation and evaluation of these factors could also lead to the early identification of acute confusion, as well as guide interventions for the management of patients with this condition. Nursing Education The results of this study have implications for nursing education at all levels, including basic nursing programs, certification courses for gerontological nursing, and workshops relating to the nursing care of the elderly client. Comprehensive nursing education regarding acute confusion in the hospitalized elderly should include information regarding: (a) the risk factors associated with the development of the condition, (b) ongoing assessment techniques with valid and reliable tools that assist in the early detection of the condition, (c) cognitive and behavioural changes indicative of acute confusion, and (d) suggestions for interventions to minimize and possibly prevent the consequences of this condition. 80 Summary The impetus for this study was a clinical observation by the investigator that, although elderly individuals admitted to hospital with an orthopaedic condition consistently present with a high number of the risk factors associated with the development of acute confusion, not all of these individuals actually develop the condition. This preliminary study suggests that the orthopaedic patient population has psychosocial conditions similar to other elderly patient populations that put them at risk for the development of acute confusion. In addition, the diagnosis of a fracture, particularly a hip fracture, may be characteristic of patients with orthopaedic conditions that develop acute confusion. Further research, incorporating the suggestions for study design and data collection from this study, will further develop our knowledge of acute confusion in this patient population, and may lead to improved patient outcomes as well as improved use of health care resources. 81 References Albert, M., Levkoff, S., Reilly, C, Liptzin, B., Pugrim, D., Cleary, P., Evans, D., & Rowe, J. (1992). The Delirium Symptom Interview: An interview for the detection of delirium symptoms in hospitalized patients. Journal of Geriatric Psychiatry and Neurology. 5. 14-21. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington; DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.). Washington; DC. Author. Bowman, A.M. (1992). The relationship of anxiety to development of postoperative delirium. Journal of Gerontological Nursing. 18(1). 24-30. Chisholm, S.E., Deniston, O.L., Igrisan, R.M., & Barbus, A. (1982). Prevalence of confusion in elderly hospitalized patients. Journal of Gerontological Nursing. 8(2), 87-96. Desmeules, M., Huang, J., & Mao, Y. (1993). Projections of deaths and hospitalizations among elderly Canadians. Chronic Diseases in Canada. 14. 145. Duckett, S. (1993). Managing the sundowning patient. Journal of Rehabilitation. 59(1), 24-29. Evans, C , Kenny, P., & Rizzuto, C. (1993). Caring for the confused geriatric surgical patient. Geriatric Nursing. 14. 237-241. Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-mental state - A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 12,189-198. Foreman, M.D. (1986). Acute confusional states in hospitalized elderly: A research dilemma. Nursing Research. 35, 34-38. Foreman, M.D. (1987). Reliability and validity of mental status questionnaires in elderly hospitalized patients. Nursing Research. 36. 216-220. Foreman, M.D. (1989). Confusion in the hospitalized elderly: Incidence, onset, and associated factors. Research in Nursing and Health. 12. 21-29. Foreman, M.D. (1991). The cognitive and behavioural nature of acute confusional states. Scholarly Inquiry for Nursing Practice: An International Journal. 5(1). 3-16. Foreman, M.D. (1993). Acute confusion in the elderly. Annual Review of Nursing Research. H , 3-30. 82 Foreman, M.D., & Grabowski, R. (1992). Diagnostic dilemma: Cognitive impairment in the elderly. Journal of Gerontological Nursing. 18(9). 5-12. Gillick, M. R., Serrell, N. A., & Gillick, L.S. (1982). Adverse consequences of hospitalization in the elderly. Social Science and Medicine. 16. 1033-1038. Hegyvary, S.T. (1977). Foundations of primary nursing. Nursing Clinics of North America, 12(6), 187-196. Inouye, S.K. (1991). The recognition of delirium. Hospital Practice. 26(4A), 61-62. Inouye, S., van Dyck, C, Alessi, C, Balkin, S., Siegal, A., & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 113. 941-948. Inouye, S., Viscoli, C , Horwitz, R., Hurst, L., & Tinetti, M. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine. 119. 474-481. Knaus, W., Draper, E., Wagner, D., & Zimmerman, J. (1985). APACHE H: A severity of disease classification system. Critical Care Medicine. 13. 818-829. Lawton, M.B. (1982). Competence, environmental press, and the adaptation of older people. In M.P. Lawton, P.G. Windley, & T.O. Byerts (Eds.), Aging and the environment: Theoretical approaches (pp. 33-59). New York: Springer. Levkoff, S.E., Saltan, C, Cleary, P.D., Gallop, J., & Phillips, R.S. (1988). Identification of factors associated with the diagnosis of delirium in elderly hospitalized patients. Journal of the American Geriatrics Society. 36.1099-1104. Lipowski, Z.J. (1983). Transient cognitive disorders (delirium, acute confusional states) in the elderly. American Journal of Psychiatry. 140. 1426-1436. Lipowski, Z.J. (1987). Delirium (acute confusional states). Journal of the American Medical Association. 258(13). 1789-1792. Lobiondo-Wood, G., & Haber, J. (1990) Nursing research: Methods, critical appraisal and utilization (2nd ed.). St. Louis: Mosby. Lucas, M.J., & Folstein, M.F. (1980). Nursing assessment of mental disorders on a general medical unit. Journal of Psychiatry and Nursing Mental Health Services. 18(5), 31-33. Lusis, S.A., Hydo, B., & Clark, L. (1993). Nursing assessment of mental status in the elderly. Geriatric Nursing. 14. 255-259. McDougall, G.J. (1990). A review of screening instruments for assessing cognition and mental status in older adults. Nurse Practitioner. 15(11), 18-28. 83 Millar, H.R. (1981). Psychiatric morbidity in elderly surgical patients. British Journal of Psychiatry. 138. 17-20. / • Miller, B. F., & Keane, C.B. (1978). Encyclopedia and dictionary of medicine, nursing, and allied health (2nd ed.). Philadelphia: W.B. Saunders. Miller, C. A. (1990). Nursing care of older adults: Theory and practice, (pp. 49-62). Illinois: Scott, Foresman. Moore, T., & Mulrooney, M. (1991). Nursing interventions and acute confusional states in elderly surgical patients. CONA Journal. 13(4). 13-19. Mullen, J.O., & Mullen, N.L. (1992). Hip fracture mortality: A prospective, multifactorial study to predict and minimize death risk. Clinical Orthopaedics and Related Research. 280. 214-222. Nagley, S. (1986). Predicting and preventing confusion in your patients. Journal of Gerontological Nursing. 12(3). 27-31. Neelon, V.J. (1990). Postoperative confusion. Critical Care Nursing Clinics of North America. 2.579-587. Neelon, V.J., & Champagne, M.T. (1992). Managing cognitive impairment: The current basis for practice. In S.G. Funk, E. M. Tornquist, M. T. Champagne, & R. A. Wiese (Eds.), Key aspects of elder care: Managing fall, incontinence, and cognitive impairment (pp. 239-250). New York: Springer. Neelon, V.J., Champagne, M.T., McConnell, E., Carlson, J., & Funk, S.G. (1992). Use of the NEECHAM Confusional Scale to assess acute confusional states of hospitalized older patients. In S. G. Funk, E. M. Tornquist, M. T. Champagne, & R. A. Wiese (Eds.), Key aspects of elder care: Managing fall, incontinence, and cognitive impairment (pp. 278-289). New York: Springer. Nelson, A., Fogel, B., & Faust, D. (1986). Bedside cognitive screening instruments: A critical assessment. Journal of Nervous and Mental Disease. 174(2). 73-83. O'Brien, L.A., Grisso, J. A., Maislin, G., Chiu, G.Y., & Evans, L. (1993) Hospitalized elders risk of confusion with hip fracture. Journal of Gerontological Nursing. 19(2), 25-31. Palmateer, L.M., & McCartney, J.R. (1985). Do nurses know when patients have cognitive deficits? Journal of Gerontological Nursing. 11(2). 6-7.10-12, 15-16. Perreault, J. (1990). Population projections for Canada. Provinces and Territories 1989-2011. (Catalogue 91-520). Ottawa: Minister of Supply and Services Canada. Rea, L, & Parker, R. (1992). Designing and conducting survey research. San Francisco: Jossey -Bass. 84 Rockwood, K. (1989). Acute confusion in elderly medical patients. Journal of the American Geriatrics Society, 37. 150-154. Schor, J., Levkoff, S., Lipsitz, L., Reilly, C, Cleary, P., Rowe, J., & Evans, D. (1992). Risk factors for delirium in hospitalized elderly. Journal of the American Medical Association. 267. 827-831. Sehy, Y., & Williams, M. (1991). Functional assessment. In W.C. Chenitz, J.T. Stone, & S. Salisbury (Eds.), Clinical gerontological nursing: A guide to advanced practice, (pp. 119-134). Philadelphia: W.B.Saunders. Seymour, D.G., Henschke, P. J., Cape, R.D.T., & Campbell, AJ. (1980). Acute confusional states and dementia in the elderly: The role of dehydration/volume depletion, physical illness and age. Age and Ageing. 9, 137-146. Statistics Canada (1992). Health reports: Hospital morbidity 1989-90 (Catalogue 82-00351). Ottawa: Ministry of Supply and Services Canada. Statistics Canada (1994). Annual surgical procedures and treatments 1990-92 (Catalogue 82-217). Ottawa: Ministry of Supply and Services Canada. Vermeersch, P. E. (1990). The clinical assessment of confusion - A. Applied Nursing Research. 3,128-133. Weddington, W.W. (1982). The mortality of delirium: An under appreciated problem? Psychosomatics. 23. 1232-1235. Williams, M.A., Campbell, E.B., Raynor, W.J., Musholt, M.A., Mlynarczyk, S.M., & Crane, L.F. (1985). Predictors of acute confusional states in hospitalized elderly patients. Research in nursing and health. 8. 31-40. Williams, M.A., Holloway, J. R., Winn, M. C, Wolanin, M.O., Lawler, M.L., Westwick, C.R., & Chin, M.H. (1979). Nursing activities and acute confusional states in elderly hip-fractured patients. Nursing Research. 28. 25-35. Williams, M.A., Ward, S.E., & Campbell, E.B. (1986). Issues in studying confusion in older hospitalized patients. In S. Stinson, J. Kerr, P. Giovannetti, P. Field, & J. MacPhail (Eds.), International Nursing Research Conference Proceedings: New Frontiers in Nursing Research (pp. 390-391). Edmonton, Alberta: Faculty of Nursing, University of Alberta. Williams, M.A., Ward, S.E., & Campbell, E.B. (1988). Confusion: Testing versus observation. Journal of Gerontological Nursing. 14(1), 25-30. Wolanin, M.O. (1977). Confusion study: Use of grounded theory as methodology. In M.V. Batey (Ed.), Western Interstate Commission for Higher Education. Nursing Research Priorities: Choice or Chance. 8, 68-75. Wolanin, M.O., & Phillips, L.R. (1981). Confusion: Prevention and care. Toronto: C. V. Mosby. 85 Woods, N.F. (1988). Using advanced statistical procedures. In N.F. Woods & M. Catanzaro (Eds.), Nursing research: Theory and practice (pp. 420-433). St. Louis: C.V. Mosby. Yazdanfar, D. (1990). Assessing the mental status of the cognitively impaired elderly. Journal of Gerontological Nursing. 16(9), 32-36. 86 Appendix A. Concepts in the Functional Consequences Theory of Gerontological Nursing Functional consequences: The observable effects of actions, risk factors, and age-related changes that influence the quality of life or day-to-day activities of older adults. Negative functional consequences: Those that interfere with the person's level of functioning or quality of life. Positive functional consequences: Those that facilitate the highest level of performance and the least amount of dependency. Actions: purposeful interventions initiated by the older person or by nurses and other caregivers. Age-related changes: Inevitable, progressive, and irreversible changes that occur during later adulthood and are independent of extrinsic or pathological conditions. Risk factors: Conditions that increase the vulnerability of older people to negative functional consequences. Common risk factors are diseases medications, environment, life-style, support systems, psychosocial circumstances, and attitudes based on lack of knowledge. Older adults: People whose functional abilities are affected by the acquisition of age-related changes and risk factors. When older adults are affected by age-related changes and risk factors to the extent that they are dependent on others for daily needs, their caregivers are considered an integral focus of gerontological nursing. Goals of gerontological nursing: To minimize the negative effects of age-related changes and risk factors, and to promote positive functional consequences. This is achieved through the nursing process, with particular emphasis on interacting 87 with older adults and caregivers of dependent older adults to eliminate risk factors or minimize their effects. Health: The ability of older adults to function at their highest capacity, despite the presence of age-related changes and risk factors. This state considers the quality of life of individuals and encompasses psychosocial as well as physiological functioning. Environment: External conditions, including caregivers, that influence the functioning of older adults. These conditions are risk factors when they interfere with functioning and interventions when they enhance functioning. Note. From Nursing care of older adults: Theory and practice (p. 55) by C. A. Miller, 1990, Illinois: Scott, Foresman and Company. Reprinted with permission. 88 Appendix B. Risk Factors for the Development of Acute Confusion in the Hospitalized Elderly Age-related Changes *Decreased ability of the brain to adapt to metabolic disturbances *Sensory/perceptual deficits *Lowered resistance and ability to cope with stress related to changes in hypothalamus *Reduced ability to regulate body temperature * Reduction in cerebral blood flow and glucose metabolism Psychosocial Risk Factors *Emotional stress - post-operative states, relocation, hospitalization *Depression * Anxiety *Grief *Dementia *Social supports *Unfamiliar environment creating a lack of meaning in the environment *Nursing care delivery method * Knowledge and attitudes of care givers Physiological Risk Factors *Nutritional deficiencies a. B vitamins b. vitamin C c. hypoproteinemia *Cardiovascular abnormalities a. decreased cardiac output states- myocardial infarction, arrhythmias, congestive heart failure, cardiogenic shock b. alterations in peripheral vascular resistance-increased and decreased states c. vascular occlusion-disseminated intravascular coagulopathy, emboli *Cerebral disease a. vascular insufficiency-transient ischemic attacks, cerebral vascular accidents, thrombosis b. central nervous system infection-acute and chronic meningitis, neurosyphillis, brain abscess c. trauma-subdural hematoma, concussion, contusion, intracranial hemorrhage d. tumors-primary and metastatic e. normal pressure hydrocephalus *Endocrine disturbance a. hypo- and hyperthyroidism b. diabetes mellitus c. hypopituitarism 89 d. hypo- and hyperparathyroidism * Alterations in temperature regulation - hypo- and hyperthermia *Pulmonary abnormalities a. inadequate gas exchange states-pulmonary disease, alveolar hypoventilation b. infection-pneumonias *Systemic infective processes-acute and chronic a. viral b. bacterial-endocarditis, pylonephritis, cystitis *Metabolic disturbances a. electrolyte abnormalities-hypercalcemia, hypo- and hypernatremia, hypo- and hyperkalemia, hypo- and hyperchloremia, hyperphosphatemia b. acidosis/alkalosis c. hypo- and hyperglycemia d. acute and chronic renal failure e. volume depletion-hemorrhage, inadequate fluid intake, diuretics f. hepatic failure *Drug intoxications-therapeutic and substance abuse a. misuse of prescribed medications b. side effects of therapeutic medications c. drug-drug interactions d. improper use of over-the-counter medications e. ingestion of heavy metals and industrial poisons f. alcohol intoxication or withdrawl immobilization - therapeutic, physical, pharmacological Comfort and Pleasure Risk Factors *Pain - acute and chronic *Fatigue/sleep deprivation *Hypo/hyperthermia *Sensory deprivation/environmental monotony creating a lack of meaning in the environment *Sensory overload *Lack of meaningful routines Note. From "Acute confusional states in hospitalized elderly: A research dilemma" by M. Foreman, 1986. Nursing Research. 35(1), p. 36. Copyright 1986 by Nursing Research. Permission to adapt requested; and "Transient cognitive disorders (delirium, acute confusional states) in the elderly" by Z. J. Lipowski, 1983, American Journal of Psychiatry, 140(11), p. 1436. Copyright 1983 by the American Psychiatric Association. Adapted with permission. Appendix C Patient # Folstein Mini-Mental State Exam Date _ _ Maximum Score Score 5 ( ) 5 ( ) ( ) ORIENTATION What is the (year) (season)(date)(day)(month)? Where are we? (province)(country)(town)(hospital)(floor) REGISTRATION Name three objects: one second to say each. Then ask the patient all three after you have said them. Give one point for each correct answer. Then repeat them until he learns all three. Count trials and record. Trials ATTENTION AND CALCULATION Serial 7's. One point for each correct answer. Stop after five answers. Alternatively spell "world" backwards. RECALL Ask for the three objects repeated above. Give one point for each correct answer. LANGUAGE 9 ( ) Name a pencil and a watch, (two points) Repeat the following: Follow a three stage command: "Take a paper in your right hand, fold it in half, and put it on the bed", (three points) Read and obey the following: Close your eyes.(one point) Write a sentence, (one point) Copy a design, (one point) 5 ( ) 3 ( ) TOTAL SCORE Assess level of consciousness along a continuum. Alert Drowsy Stupor Coma C L O S E Y O U R E Y E S . 92 C O P Y T H I S D E S I G N Note. From "Mini-mental state - a practical method for grading the cognitive state of patients for the clinician." by M. Folstein, S. Folstein, & P. McHugh, 1975, Journal of Psychiatric Research. 12. p. 198. Copyright 1975. Permission to reprint requested. Appendix D Clinical Assessment of Confusion - A (revised) PATIENT #: DATE/TIME: A=not present, Bintermittently present, C=continuously present A B C COGNITION 1) forgetful 0 2 4 2) decreased ability to concentrate 0 2 3 3) altered conceptualization (nonsense speech) 0 2 3 Max. 10 Sum = _ GENERAL BEHAVIOUR (pulling tubes, getting out of bed) 0 2 3 0 2 3 0 2 3 0 2 3 0 2 3 0 1 2 0 1 2 0 1 2 0 1 2 0 2 3 0 2 3 0 2 3 0 1 2 0 1 2 Max. 23 Sum = MOTOR ACTIVITY 13) speech slurred  14) altered voluntary motor response  15) absence of any meaningful response  16) altered involuntary motor response  17) little body movement Max. 13 Sum = _ ORIENTATION 18) no idea of place 0 2 4 19) calling people from past 0 2 4 20) calls someone known to him/her by another name 0 2 4 Max. 12 Sum = _ PSYCHOTIC/NEUROTIC BEHAVIOURS 21) delusional 0 2 4 22) paranoid ideation 0 2 4 23) talking to people not actually present 0 2 4 24) behaviour regressed,repulsive,and/or repetitive 0 2 4 Max. 16 Sum = (Maximum = 74) TOTAL SCORE mild ACS = 9-14 / moderate ACS = 15-24 / moderate to severe ACS = >28 Note. From "The clinical assessment of confusion-A." by P. E. Vermeesch, 1990, Applied Nursing Research. 3(3), p.133. Adapted with permission. Appendix E Clinical Assessment of Confusion - A PATIENT #: DATE/TIME: COGNITION 1) extreme forgetfulness 4 2) forgetful 3 3) decreased ability to concentrate 3 4) altered conceptualization (nonsense speech).... 3 Max. 13 Sum = GENERAL BEHAVIOUR 5) noisy 3 6) not recognizing limitations of illness 3 (pulling tubes, getting out of bed) 7) restlessness 3 8) difficulty relating to others 3 9) antagonistic 3 10) withdrawn 2 11) irritability 2 12) demanding .. 2 13) apathy 2 Max. 23 Sum = MOTOR ACTIVITY 14) speech slurred 3 15) altered voluntary motor response 3 16) absence of any meaningful response 3 17) altered involuntary motor response 2 18) little body movement 2 Max. 13 Sum = ORIENTATION 19) no idea of place 4 20) calling people from past 4 21) calls someone known to him/her by another name 4 Max. 12 Sum = PSYCHOTIC/NEUROTIC BEHAVIOURS 22) delusional 4 23) paranoid ideation 4 24) talking to people not actually present 4 25) behaviour regressed,repulsive,and/or repetitive . . . 4 Max. 16 Sum = (Maximum = 77) TOTAL SCORE = mild ACS = 9-14 / moderate ACS = 15-24 / moderate to severe ACS = >28 Note. From "The clinical assessment of confusion-A." by P. E. Vermeesch, 1990, Applied Nursing Research. 3(3). p. 133. Reprinted with permission. Appendix F Visual Analogue Scale for Confusion PATIENT #: DATE/TIME: Place a slash on the line indicating your perception of this individual's degree of confusion: (10cm.) no confusion extremely confused Note. From "Predicting and preventing confusion in your patients" By S. Nagley, 1986, Journal of Gerontological Nursing. 12(3). p. 31. Reprinted with permission. 96 Appendix G. Nursing Ward Introductory Letter and Protocol for Patient Selection The Relationship Between Acute Confusion and Select Patient Characteristics and Environmental Variables in Elderly Patients Admitted to an Acute Orthopaedic Service Acute confusion is a common complication of hospitalization in the elderly that results in increased morbidity and mortality for this patient population. The occurrence of acute confusion in this patient population is rarely contributed to one single factor, but rather is the result of an interplay between patient characteristics and environmental variables. A number of predisposing factors for the development of acute confusion in the hospitalized elderly have been identified. These include such things as immobility, age, pre-existing dementia, inability to live independently, disruptions in patterns of daily living, sensory impairments, pain and confinement. Elderly individuals admitted to hospital for orthopaedic problems consistently present with a high number of the patient characteristics and environmental variables identified as risk factors for the development of acute confusion. However, from this author's experience, not all of these patients become acutely confused. The specific patient characteristics and environmental variables associated with the development of acute confusion in elderly patients admitted to hospital for orthopaedic problems that distinguishes those who become acutely confused from those who do not has not been clearly identified. To do so may allow a differentiation between those individuals who become confused and those who do not. This creates the potential for nursing intervention to prevent or minimize acute confusion in this population. The purposes of this study are: 1) to identify acute confusion in elderly patients admitted to the acute orthopaedic service at Vancouver Hospital, Centennial Pavilion, and 2) to develop a risk profile by examining the patient characteristics and environmental variables present for both those individuals who become acutely confused at some point during the first week of hospitalization and for those who do not. The research questions that are being examined are: 1) What percentage of patients aged 65 or older admitted during the study period to the orthopaedic wards at a British Columbian Lower Mainland tertiary care hospital develop acute confusion in the first week of hospitalization? 2) What are the patient characteristics and environmental variables common among those individuals who become acutely confused? 3) What are the patient characteristics and environmental variables that differentiate those individuals who become acutely confused from those who do Investigator: Cindy Kozak Telephone: 875-4062 Masters of Science in Nursing Student University of British Columbia Dr. Anna Marie Hughes Telephone: 822-7437 Faculty Advisor not? 97 page 2 of 2 I appreciate your participation in this study, which will take place on your ward for approximately three months (May to July). I will be on the ward every afternoon during the study period to obtain participants and conduct assessments. All patients admitted to the ward who meet the criteria outlined in the Protocol for Patient Selection are potential participants. On obtaining consent to participate, I will be conducting an initial mental status assessment on each patient using the Folstein Mini-Mental State Exam. I will also be asking the nurse caring for the patient at that time to assist me to complete a behavioural assessment tool for confusion and visual analogue scale of confusion. These tools are attached for your information. They take approximately five minutes to complete. Assessment with these three tools will be repeated on hospital days three, five and seven at a similar time of day. Patients will be considered acutely confused if they have a change in scores on the assessment tools from their baseline assessment. The patient's participation in the study will be considered complete when acute confusion is detected or on the seventh day of hospitalization, which ever comes first. Should you have any questions about the study, please contact myself or my faculty advisor, Anna Marie Hughes, at the numbers listed above. 98 Protocol for Selection of Patients 1) The Manager or delegate will review the daily ward admission list and identify those patients who meet the following criteria: 1) admitted to the orthopaedic ward within the past 24 hours 2) age 65 years or older 3) initial admission to hospital is to the orthopaedic service. If patients are initially admitted "off service" or to another hospital, transfer of the patient from another ward or acute care hospital has occurred in less than 24 hours from their initial injury 4) admission to hospital is not for terminal or palliative care 5) a hospital stay of greater than 72 hours is anticipated and no transfers to other hospital wards are planned for the first 7 days of the hospital stay 6) conscious on admission 7) able to communicate (speak/write) in English 8) not intoxicated on admission; confusion related to delirium tremens is not the focus of this study. Patients developing delirium tremens during their hospital stay will also be excluded. 2) Patients who meet the above criteria will be approached by the Manager or delegate to determine their interest in receiving further information about the study. If they are not interested, the Manager will request permission for the investigator to obtain descriptive information about the patient. If they are interested, the Manager or delegate will inform the investigator. 3) The ability of the patient to give consent will be assessed by the Manager or delegate according to criteria presently used in the hospital. If the patient meets all other criteria, and is not deemed able to give consent on their own behalf, the purpose and description of the study will be discussed with the appropriate significant other (henceforth referred to as the representative), using the hospital consent guidelines to identify who this individual would be. 4) The investigator will visit the ward every afternoon and meet with the Manager or delegate to determine if patients have been identified as potential participants. The investigator will meet with these patients or the representatives and explain the study in more detail. Written consent for participation will be obtained. 5) The investigator will meet briefly with those patients who do not wish to participate in the study to obtain some brief descriptive information. Information requested will include patient age, sex, living situation prior to admission, admitting diagnosis, secondary diagnoses and type of admission. page 2 of 2 6) The Manager or delegate will maintain a record during the study period of the number of patients excluded from the study because they did not meet the languag criteria or were intoxicated on admission. This record will be used to describe the population the sample was drawn from. Appendix H Hospital Consent Guidelines May 1992 TABLE OF CONTENTS A. PROCEDURE FOR OBTAINING CONSENT I. WHO CAN OBTAIN CONSENT 1 II. WHO CAN GIVE VALID CONSENT 1. Defining and determining competence 1 2. Competent adults and minors 2 a) Competent adults b) Competent minors 2 3. Incompetent adults and minors 2 a) Legal and factual Incompetence I) Legal Incompetence 2 B) Factual Incompetence 2 b) When to seek declarations of Incompetence 3 c) Who decides for the Incompetent 3 d) Emergencies 4 e) Minors under the care of individuals other than their parent 4 f) Chfld of a divorced/separated couple 5 g) Disagreements between custodial parents S h) Disagreements between parents and physicians 5 i) Substituted judgements and best interest judgements 6 III. CONDITIONS OF A VAUD CONSENT 1. Consent must be voluntary 7 2. Consent must be Informed 7 a-f) What the patient must be told g) Waiver of disclosure 8 3. Consent must be specific 9 a) Limit on treatments 9 b) Planned repeated treatments 9 c) Duration of consent 9 B. CONSENT IN EXCEPTIONAL CIRCUMSTANCES 1. Prisoners 2. Psychiatric patients 3. Patients who are competent but physically handicapped, unable to verbalize, or sign a consent 4. Deaf, foreign-speaking, blind, or illiterate patients who are competent 5. Organ donation 6. LMng wffls 7. Consent to test for HIV 8. Consent to photographs, moving pictures, sound recordings, or television 9. Autopsy 10. Emergency treatment 11. DNR 12. Withdrawal of treatment 13. Unconscious, sedated, or drugged patients 14. Refusal of treatment, including blood products a) Minors b) Adults 15. Experimental drugs or procedures C. DOCUMENTATION OF CONSENT 1. General rules a)-b) What should be documented 2. Special circumstances a) Factual incompetence b) Waiver of disclosure c) Interpreters d) Organ donors who withdraw consent e) Consent by telephone 0 Consent by telegram or fax g) Alteration of consent forms CONSENT GUIDELINES May 1992 A. PROCEDURE FOR OBTAINING CONSENT I. WHO CAN OBTAIN CONSENT 1. The physician has the obligation to obtain consent Physicians may obtain the assistance of others in the task of Information disclosure. They must, however, satisfy themselves that those disclosing have the necessary qualifications to Inform adequately. It remains the physician's responsibility to ensure that the patient has been adequately informed II. WHO CAN GIVE VALID CONSENT 1. Defining and determining competence An individual is competent if and only if he/she can understand the nature, consequences, and alternatives to treatment, as explained by the physician. The test of competency is the ability to repeat the diagnosis and proposed treatment in one's own words or manner. Competency does not require actual understanding, or the ability to evidence a choice, or the reasonableness of the conclusion. All individuals are presumed to be competent unless they are minors under 16 years of age or have been determined by a court to be incompetent 104 -2-Consent Guidelines 2. Competent adults and minors a) Competent adults, i.e., individuals 16 or over, can give a valid consent • b) Competent minors below the age of 16 can provide a valid consent in exceptional circumstances. The determination of competency in this situation should be made by the attending physician and confirmed by a second physician. The circumstances of the consent should be noted in the chart A particular effort should be made to convince the patient to agree to parental involvement If a minor'under the age of 16 is competent to provide consent and the parents refuse consent, consent may still be given. However, it should be recognized that this situation may cause considerable upset and difficulty for both the minor and the physician, and should be carefully documented. 3. Incompetent adults and Incompetent minors a) Legal and factual Incompetence i) Legal Incompetence An individual is legally incompetent if he/she is under 16 or there has been a court declaration of incompetency pursuant to the Patient's Property Act, R.S.B.C. 1979, C. 313. ii) Factual Incompetence An individual is factually incompetent if he/she cannot understand the nature and consequences of treatment but has not been declared incompetent by a court A determination of incompetency should be made by the attending physician and confirmed by a second physician, preferably a psychiatrist There should be adequate notation of these conclusions in the chart 105 , -3-Consant GuWeflnea b) When to seek declarations of Incompetence While in law no one can give a valid consent for a factually incompetent individual, it is often impractical to make an • application for a judicial declaratJon of Incompetence. However, such a declaration should be considered If: 0 tto individual's incompetency permanent and the patient Is a permanent resident or long-term patient at the facility or , I) there is family conflict concerning whether consent to treatment win be given or not c) Who decides for the Incompetent Decisions on behalf of incompetent individuals should be made by: I) the parent or legal guardian for patients who have not yet attained the age of 16 and are incompetent or u) the committee of the person appointed by order of the Court pursuant to the Patients Property Act, R.S.B.C 1979, c. 313 or iii) if it is either impossible or impractical to obtain the consent of the legal guardian or committee, an attorney under an enduring power of attorney or • • iv) failing ail of the above, the next of kin in the following descending order of authority: spouse including common-law spouse of approx. 2 years, a child of legal age (19 or over), a parent, a sibling, a grandparent However, when there is reason to think that a relative lower on the list is closer to the patient than those higher, the consent of the lower person should be sought None of the above listed can give a valid consent in the absence of their appointment under an enduring power of attorney or as the committee pursuant to the Patients Property Act. The sole reason for securing their consent is to minimize the chance of lawsuit or Consent Guidelines -4 -v) the Superintendent of Family and Child Service for consent to the emergency medical care and treatment of a child apprehended pursuant to the Family and Child Service Act or vi) if none of the above is available to provide consent, the hospital should contact the Public Trustee and see if they are prepared to seek a declaration of incompetency and act as the committee of the person. If they are unprepared to do this, the hospital should proceed on its own to seek such a declaration and have someone appointed as the committee who can then provide a valid consent. d) Emergencies In an emergency situation, physicians can proceed with treatment as specified in B. 10 below. e) Minors under the care of individuals other than their parent Such caregivers, even with a "letter of authority," do not have the power to give or withhold consent If the treatment can wait until the parents can be contacted, it should not be given until a valid consent can be obtained from the parents in person, or by telephone, fax, or telegraph. If the treatment is urgent but is still not emergency (e.g. treatment for infection or pain, or surgery that is inevitable but which can be delayed only with increased risk to the patient) a second physician's signed opinion should be sought to verify the urgent need of the procedure. The consent form should be signed by the assigned individual responsible for the minor, and any letter of authority should be attached to the consent form. The consent may be strengthened by the signature of the child where appropriate. 107 Consent Guidelines f) Child of a divorced/separated couple A parent who has joint guardianship of the child either by reason of living together with the other parent or by Court Order or by separation agreement has authority to provide, consent to treatment for the child. The custodial parent either by reason of the child's residence with that parent or by Court Order or by separation agreement has authority at all times to provide consent for the treatment of the child. A parent with access rights vis-a-vis the child who is not a joint guardian may consent to urgent treatment on behalf of the child if efforts to obtain the consent of the custodial parent are fruitless. g) Disagreements between custodial parents If one parent consents and the other refuses, the consent of the lone parent is effective. The burden is on the objecting parent to take legal action to prevent the treatment from being given. h) Disagreements between parents and physicians If parents refuse treatment that is deemed by the attending physicians to be necessary for the child and if the circumstances are such that failure to provide the treatment may jeopardize the child's safety or well-being, then the child may be considered to be "in need of protection" within the meaning the Family and Child Service Act, KS.B.D. 1979, c. 119.1. The physician or other persons attending have a responsibility under sec. 7(1) of that Act to report to the Superintendent of Family and Child Service or their designated representative the circumstances Involving the child. It is also recommended that the hospital social worker become involved with the situation in order to attempt to resolve matters prior to the Superintendent being notified. Substituted ludqements and best Interest Judgements Decisions for incompetent patients must be made, in priority order, of: i) Substituted Judgement, where the patient's decision makers make the decision they reckon the patient would have if he/she were able to. Information about the patient's preferences and values wffl typically come from the patient's family, friends, advance directives in the form of a fiving wiH, or other clear oral directives. The weight to be attached to such directives depends on how weB the patient was acquainted with the condition he/she anticipated, and the length of time between making the declaration and the treatment decision. The patient's advance directives should be given decisive weight in the absence of some clear reason to set them aside. Best Interest Judgement, where Substituted Judgement is not possible. If there is not enough -known about the patient's directions, preferences, and values to make an individualized decision, the patient's,decision makers should choose so as to promote the patient's interests as they would probably be conceived by a reasonable person in the patient's circumstances, selecting from within the range of choices that reasonable people would make. - 7 -Consent Guidelines III. CONDITIONS OF A VAUD CONSENT 1. Consent must be voluntary Patients must be free of any suggestion of duress or coercion, either by the actions or words of physicians or others, to consent to or refuse treatment In this context physicians must keep clearly in mind that there may be circumstances when the initiative to consult a doctor was not the patient's, but rather that of a third party, friend, employer, or police officer. Under such circumstances the doctor may be aware that the patient is only reluctantly following the course of action suggested or insisted upon by the third party. In these situations doctors should be more than usually careful to assure themselves that patients do not indicate opposition to what has been suggested and that the will of other persons is not imposed on the patient 2. Consent must be Informed a) In order for a patient to be properly informed, the patient must be Informed of: 0 ii) Hi) iv) v) vi) vii) b) The physician must ensure that, at a minimum, the patient has been given all information on these matters which a reasonable person would want to know in the circumstances. If the physician knows about any special concerns of the patient, which the reasonable person would not care about but this person does, the physician must provide any information relevant to them. Physicians must make a reasonable effort to become aware of any such concerns, as well as of the personal circumstances of all their patients which are relevant to the disclosure of information. the nature of the procedure the benefits of the procedure the risks of not having the procedure the risks of having the procedure any reasonable alternative procedures available the risks of the alternative procedures the physician's opinion of which option is best or that the options are equivalent 110 Appendix I. Letter of Information and Consent to Participate TITLE OF PROJECT: The relationship between acute confusion and select patient characteristics and environmental variables in elderly patients admitted to an acute orthopaedic service. INVESTIGATOR: Cindy Kozak, RN., BN. Telephone: 875-4062 Masters of Science in Nursing Student University of British Columbia Anna Marie Hughes, RN., EdD. Faculty Advisor Telephone: 822-7437 Dear Patient and/or Family Member, Frequently older patients admitted to hospital experience temporary confusion. Patients with orthopaedic conditions experience decreased mobility, pain, and potential surgery which can contribute to an individual's risk of developing confusion while in hospital. It is not known which specific patient characteristics are related to developing confusion. This study has two purposes: 1) to identify individuals over the age of 65 hospitalized with an orthopaedic condition who develop acute confusion; 2) to identify which factors are associated with the development of confusion. Your participation in the study will involve being interviewed within the next 4 hours to obtain some background information and to make an initial assessment of your thinking abilities. This assessment takes approximately 20 minutes. This assessment will be repeated on your third, fifth and seventh days in the hospital. The nurse caring for you on the days of the assessment will also be asked for her or his assessment of your thinking abilities. The total amount of time required for your participation in this study during your hospital stay is approximately two hours. You may choose to refuse to answer any questions and may withdraw from the study at any time. Such a decision will not affect your ongoing hospital or nursing care. There is no monetary compensation for your participation. There are no anticipated risks to your participation in this study. Information gained in the study may assist with the early identification of older adults who are at risk for becoming confused and allow for care which may prevent this from occuring. If you choose to participate in the study, your identity will be kept strictly confidential. Only a code number will appear on the information gathered. Your name will be known only to this investigator. No one other than the investigator and her supervisory committee will have access to the information gathered. The information may be used for secondary analysis. A summary of the data may be used in publications and presentations. Individuals will not be identified in any of the information presented. Ill page 2 of 2 If you have any questions about the study, please contact me or my faculty advisor at the numbers listed above prior to giving consent. I, " • • • • • • • • • • : , . have been fully informed about this study, have had an opportunity to have questions answered, and consent to participate in this study. I acknowledge receipt of a copy of this consent form. signature of participant date OR signature of individual giving consent date signature of witness date 112 Appendix J Acute Confusion Data Collection Form Col. No. Patient number: 1-3 Card no.: 1 DEMOGRAPHICS 4 Age: 5-7 Gender: l.Male 2. Female 8 Date of admission: Education level: 1. <grade 6 (circle one) 2. grade 6-grade 12 3. >grade 12 4. not available 9 Level of independence prior to admission (circle one): 1. house/apartment/condo/boarding room/hotel (independent living) 2. community care facility: personal care level 3. community care facility: intermediate care level 1 to 3 4. community care facility: extended care level 5. other 6. not available 10 With who was patient residing (primary companion-circle one): 1. alone 5. friends 2. spouse 6. other 3. relative (not children) 7. not available 4. children 11 AGE-RELATED CHANGES: 1) no 2) yes 12 1. Hearing deficit 1. yes 2. no 13 2. Vision deficit l.yes 2. no 14 RISK FACTORS PSYCHOSOCIAL Ward admitted to 1. W6 (recon) 2. W9 (trauma) 15 Community support in use at time of admission(circle all that apply): Type of support: 1. neighbors/family/friends 6. none available (score 0) 2. meals on wheels 7. other 3. home care 8. no info available 4. adult day care 9. not applicable (in facility) 5. homemaker 10. none needed Number of supports: 1) none 2) 1-3 3) >3 16-25 26 Mobility prior to admission (self report, patient or representative): 1. physically active (1) 3. limited mobility/sedentary (3) 2. moderately active(2) 4. bedfast (4) 27 113 Pre-admission independence score: Actual number of supports + mobility score 28-29 Number of previous hospital admissions 1) none 2) 1-5 3) >5 30 Type of admission: 1. elective 2. emergency 31 If emergency, length of time from injury to admission: hours 32-34 Surgical Intervention: l.no 2. yes 35 Date of surgery Days from admission to surgery: 36-38 Number of transfers during hospitalization: (Include emerg-ward, ward-OR, A. interward PAR-ward, room to room; do B. intraward: not include transfers for xray; 1. none 2.1-3 2. >3 39-40 )41-42 43 Emotional stress score: (number of admissions score + type of admission + surgical intervention + transfer score) + + + = 44-45 Support systems while in hospital(circle all that apply): Type of support 1. spouse/children 4. friend 2. siblings 5. other 3. other relatives 1. none. 2.1-3 3. >3 46-50 51 Continuity of care score: Number of shifts from time of admission until discharged from study = Number of nurses assigned to patient on those shifts 52-53 PHYSIOLOGICAL Primary diagnosis: 1. hip fracture 7. knee replacement (on hospitalization- 2. lower extremity fracture 8. multiple trauma circle only one) 3. upper extremity fracture 9. other 4. reconstructive hand surgery 5. reconstructive foot surgery 6. total hip replacement 54 9. 114 Secondary diagnosis (on admission-circle all that apply): 55-63 1. none *2. dementia 3. cardiovascular disease (peripheral vascular disease/arteriosclerosis, angina, congestive heart failure, MI, arrhythmias) 4. cerebral disease (TIA's, CVA, infection, subdural hematoma, tumor, concussion) 5. endocrine disturbances (hypo-/hyperthyroid, diabetes, parathyroid disease) 6. pulmonary abnormalities (pneumonia, COPD, asthma) *7. depression 8. head injury 9. other Number of secondary diagnoses: 64 1. none 2.1-5 3. >5 Type of anesthesia: 1. none 3. general 65 2. spinal/regional Length of surgery (minutes under anesthesia): 66-68 Non-analgesic medications while in hospital (circle all that apply): 69-75 1. digoxin 2. ASA 3. anticholinergics (Parkinsons, histamines, eye drops) 4. diuretics 5. anxioloytics (ativan, 6. antihypertensives 7. NSAIDS Number of non-analgesic medications: 76 1) none 2) 1-3 3) >3 115 PATIENT NUMBER 1-3 CARD 2 4 ANALGESICS: Total dose Code: Type (morphine equiv. 1. Morphine I.V. Hosp. Day 1 1. 1. 5282. 2. Morphine I.M. (= adm.day) 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 PATIENT NUMBER 1-3 CARD 3 4 1. Morphine I.V. Hosp. Day 2. 1. 1. 5-8 2. Morphine I.M. 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 PATIENT NUMBER 1-3 CARD 4 1. Morphine I.V. Hosp. Day 3. 1. 1. 5-8 2. Morphine I.M. 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 116 PATIENT NUMBER 1-3 CARD 5 4 1. Morphine I.V. Hosp. Day 4. 1. 1. 5-8 2. Morphine I.M. 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 PATIENT NUMBER 1-3 CARD 6 4 1. Morphine I.V. Hosp. Day 5. 1. 1. 5-8 2. Morphine I.M. 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 PATIENT NUMBER 1-3 CARD 7 4 1. Morphine I.V. Hosp. Day 6. 1. 1. 5-8 2. Morphine I.M. 2. 2. 9-12 3. Morphine S.C. 3. 3. 13-16 4. Morphine epi. 4. 4. 17-20 5. Epimorph+bip. 5. 5. 21-24 6. Intrathecal morph 6. 6. 25-28 7. Demerol I.M. 7. 7. 29-32 8. Codeine IM 8. 8. 33-36 9. Codeine po 9. 9. 37-40 10. Tylenol #3 10. 10. 41-44 11. Tylenol plain 11. 11. 45-48 12. OTHER 12. 12. 49-52 TOTAL. 53-56 117 PATIENT NUMBER CARD 8 1. 1. 5-8 2. 2. 9-12 3. 3. 13-16 4. 4. 17-20 5. 5. 21-24 6. 6. 25-28 7. 7. 29-32 8. 8. 33-36 9. 9. 37-40 10. 10. 41-44 11. 11. 45-48 12. 12. 49-52 TOTAL. 53-56 1. Morphine I.V. Hosp. Day 7. 2. Morphine I.M. 3. Morphine S.C. 4. Morphine epi. 5. Epimorph+bip. 6. Intrathecal morph 7. Demerol I.M. 8. Codeine IM 9. Codeine po 10. Tylenol #3 11. Tylenol plain 12. OTHER Total analgesic dosage in morphine equivalents during seven days: 1. none 5.120-160 mg. 2.1-40 mg. 6.160-200 mg. 3.41-80 mg. 7. >200 mg. 4.81-120mg. Mean daily analgesic dosage: Mobility status at time of mental status testing(choose one): Code: 1. independent 1. PTA 2. independent with aids 2. Hosp. day 1 3. standby assist 3. Hosp. day 2 4. 1 person 4. Hosp. day 3 5. 2 person 5. Hosp. day 4 6. bed to chair 6. Hosp. day 5 7. bedrest (standing at bedside only) 7. Hosp. day 6 8. Hosp. day 7 Mobility score: add all up to and including day of discharge from study: Total abnormal physiologic results to day of discharge from study: See work sheet. (one point for each abnormal result each time it is abnormal) Total number of complications up to day of discharge from study: See work sheet. Metabolic risk score : Abnormal physiologic results +complication score 118 PATIENT NUMBER 1-3 CARD 9 4 COMFORT AND PLEASURE Sleeping pattern from nurses notes: 1 dav 1. no note = 0 2. hosp. day 2. sleep disturbance = 1 3. hosp. day 3. no sleep -2 4. hosp. day 4. 5. hosp. day 5. 6. hosp. dav 6. 7. hosp. dav 7. Sleep deprivation score: total up to day of discharge from study: . fiosp. 6 7 8 9 10 11 12-13 Patient self report of comfort: 1. hosp. dav 1. A 2. hosp. dav 2. Report </= to acceptable =1 3. hosp. day 3. Report > acceptable = 2 4. hosp. day 4. Unable to report = 0 5. hosp. day 5. 6. hosp. dav 6. 7. hosp. dav 7. Pain score: total score up to day of discharge from study: 14 15 16 17 18 19 20 21-22 Environmental stimulation Accomodation(at time of MST) 1. hosp. day 1. 1. private (1) 2. hosp. day 2. 2. ward: no roommates (I) 3. hosp. dav 3. 3. ward: 1 roomate (2) 4. hosp. day 4. 4. ward: 2 roommates (3) 5. hosp. dav 5. 5. ward: 3 roommates (4) 6. hosp. day 6. 7. hosp. dav 7. Environmental stimulation score: total score up to day of discharge from study: 23 24 25 26 27 28 29 30-31 Measures: 1. MMSE score Hospital day 1. 3. 5. 7. 32-33 34-35 36-37 38-39 2. CAC-A score Hospital day 1. 3. 5. 7. 40-41 42-43 44-45 46-47 3. CAC-A rev. score Hospital day 1. 3. 5. 7. 48-49 50-51 52-53 54-55 119 4. VAS-C score Hospital day 1. 3. 5. 7. 56-58 59-61 62-64 65-67 Cognitive changes only l.'no 2. yes 68 Behavioural changes only 1. no 2. yes 69 Confused on admission 1. no 2. yes 70 ACUTE CONFUSION 1.NO 2. YES 71 Detected on which day: 0. n/a 1. hosp. day 3 2. hosp. day 5 3. hosp.day 7 72 Data collection Worksheet Category Adm day Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Date: Lab results Hg (ab<100) HCT(<loN) Urinalysis (WBC/RBC) Na(<130) K (<3.5) BUN (>80) Cr(>8) 02 sat (<95%) temp (>38.5) pulse (>100) resp (>24) WBC BP (sys 20+ adm) Complications urinary retention (I/O cath needed) cardiovascular (hx states MI, atrial fib, CHF, DVT, etc) respiratory (hx states pneumonia, PE, etc) fluid balance (= > 1000 cc or intake < 1500 cc/day: specify which) nutrition (< 75% of meals) constipation (no BM by hosp day 4) 121 Appendix K Data Collection Form: Nonparticipants Patient number: 1-3 Card no.: 1 4 Age: 5-7 Gender: 1. Male 2. Female 8 Education level: 1. <grade 6 (circle one) 2. grade 6-grade 12 3. >grade 12 4. not available 9 Level of independence prior to admission (circle one): 1. house/apartment/condo/boarding room/hotel (independent living) 2. community care facility: personal care level 3. community care facility: intermediate care level 1 to 3 4. community care facility: extended care level 5. other 6. not available 10 With who was patient residing (primary companion-circle one): 1. alone 5. friends 2. spouse 6. other 3. relative (not children) 7. not available 4. children 11 Mobility prior to admission (self report, patient or representative): 1. physically active 3. limited mobility/sedentary 2. moderately active 4. bedfast 12 Number of previous hospital admissions 1) none 2) 1-5 3) >5 13 Type of admission: 1. elective 2. emergency 14 Primary diagnosis: 1. hip fracture 6. total hip replacement (on hospitalization- 2. lower extremity fracture 7. knee replacement circle only one) 3. upper extremity fracture 8. multiple trauma 4. reconstructive hand surgerv 9. other: 5. reconstructive foot surgery 15 9. 122 Secondary diagnosis (on admission-circle all that apply): 1. none *2. dementia 3. cardiovascular disease (peripheral vascular disease/arteriosclerosis, angina, congestive heart failure, MI, arrhythmias) 4. cerebral disease (TIA's, CVA, infection, subdural hematoma, tumor, concussion) 5. endocrine disturbances (hypo-/hyperthyroid, diabetes, parathyroid disease) 6. pulmonary abnormalities (pneumonia, COPD, asthma) *7. depression 8. head injury 9. other Number of secondary diagnoses: 1. none 2.1-5 3.>5 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0086913/manifest

Comment

Related Items