INTRODUCTION
There is a difference between the everyday experience and understanding of confusion (for example missing the point or being suddenly caught out and feeling a sense of embarrassment) and confusion in the context of health care. Here, confusion is fundamentally a lack of orientation with respect to time, place and/or self. It is generally marked by poor attention and thinking, which leads to difficulties in comprehension, loss of short-term memory and usually, irritability alternating with drowsiness. Having confusion often means the person does not or cannot act as others would expect them to in any given context or situation. It is vital to appreciate that the lived experience of what it is really like for the person is one where they can feel bewildered, perplexed and unable to self-orientate and it is others around the person who appear to be saying and doing unusual things.
Further, acute confusion or delirium is a clinical sign or more accurately a syndrome (a collection of symptoms) which generally occurs suddenly as an impairment in a person’s mental state secondary to a medical condition or as a consequence of some medical treatment. Healthcare practitioners must be knowledgeable about confusion, particularly acute confusion, its possible underlying causes, what it is like to be confused and how to respond to the person and their families or carers in a way that is both compassionate and therapeutic. Confusion can also be seen to be present on a longer term basis, often as part of a neurological condition (for example head trauma or dementia) and again nurses need to have an overall appreciation of the causes and particularly how to respond to the person who is confused in the best way to support their health and overall best interests.
Figures for the rates of delirium vary according to which patient group or setting is being discussed. Delirium occurs in about 15–20 % of all general admissions to hospital (Meagher 2001). There is an increase with age: 0.4% in those over 18 years of age, 1.1% in those over 55, 13.6% in those over 85 years (Burns et al 2004). The incidence is higher in older people and for those with a pre-existing cognitive impairment and prevalence is higher in people with malignancy and HIV. Despite this relatively frequent occurrence, delirium remains under-diagnosed and often poorly managed, with up to 60% of cases being missed or diagnosed at late stage (Meagher 2001). Furthermore, patients with delirium have longer hospital stays by two to three times the usual length, a higher frequency of complications, e.g. infections and pressure sores, and increased mortality rates. Older people also have an increased risk of requiring long-term institutional care following an episode of delirium. Dementia usually affects older people and becomes more common with increasing age. Sometime after the age of 65 about 1 in 20 people develop dementia and this level rises until about 1 in 5 people over the age of 80 have dementia. Although still rare, dementia can affect younger people.
OVERVIEW
This chapter explores a selection of contemporary evidence around what is known about confusion, the various causes of confusion and strategies to help people who are confused.
Subject knowledge
In this section of the chapter, the physiological factors that may lead to individuals becoming confused are identified. This is followed by an exploration of the psychological and environmental factors that also may lead to and/or worsen the experience of confusion.
Care delivery knowledge
In this section, the assessment and care planning of people who are experiencing acute and longer term confusion is considered. The area of risk assessment is also considered.
Professional and ethical knowledge
In the Professional and Ethical Knowledge section, values and beliefs about confusion and attitudes towards people who experience confusion are considered. Increasing numbers of older people receive health care, and although this group of people are at greater risk of developing acute confusion, it does not follow that all older people will do so. Consequently, within this section there is a short discussion on ageism and discrimination. Capacity and consent are central concerns for professional practice in any context and this is considered next. This is followed by a more detailed look at confusion in older people, specifically the sort of confusion that can exist as part of dementia. Working with families and carers and involving them in care of the person who is confused can be a helpful strategy; however, the provision of information and support for the family and carers is essential if they are to have as positive an experience of care as is possible.
Personal and reflective knowledge
Finally, the Personal and Reflective Knowledge section summarizes the main points of the chapter to help you to consolidate your knowledge. You will find some reflective cues you can work with to help you identify your values and beliefs about caring for people who experience confusion. On pages 402–403 there are four scenarios, one relating to each of the branch programmes, and you might find it helpful to read through the relevant scenario before you start the chapter and use it as a focus for reflection while reading. These scenarios are followed by activities that you can use to develop your learning portfolio. You may also find it helpful to undertake one or more of the following suggestions to support the way you are organizing your learning.
SUBJECT KNOWLEDGE
PHYSIOLOGICAL
As a term used within health and social care, confusion has been somewhat of a ‘cover all’ and is often used inappropriately without a formal assessment. Its vernacular usage describes people experiencing a low level of disorientation or a minor change in their mental state. However, it is also used to mean an acute confusion, confusional state or delirium, which is a life-threatening condition requiring specific medical and nursing interventions for the underlying cause(s) (Eriksdotter Jönhagen 2002). The term ‘delirium’ is favoured by the international medical community, although in the UK it is not often so referred to by healthcare practitioners, especially nurses. Thus it is vital to clarify what is being talked about – confusion in a non-specific general sense or acute confusion/delirium – and to appreciate that acute confusion is the same as delirium. Additionally, nurses must appreciate that the label of confusion is simply a way of summarizing a syndrome with a collection of symptoms. These symptoms indicate that some other processes are occurring that require systematic medical assessment and diagnosis.
TYPES OF CONFUSION
When talking about confusion, it is helpful to ascertain if the person is confused in regard to place, person and/or time. Confusion is generally classified as short-term or long-term. Short-term or acute confusion (delirium) has a sudden onset, is reversible and involves no significant destruction of brain cells. It can occur in individuals regardless of age. People with extensive life threatening injuries can be at risk of experiencing an acute state of confusion (Pisani et al 2006). In older people almost any severe physical illness can bring about confusion. However, younger people and children can also develop acute confusion through various causes, including epilepsy (especially following a seizure), hyperpyrexia, post electroconvulsive therapy and poisoning. Delirium is also common in the last weeks of life, occurring in up to 44% of people with advanced cancer and in up to 88% of people with a terminal illness in the last days of life (Keeley 2007).
In contrast, long-term or chronic confusion occurs due to the effects of a continuing acute confusion/delirium or to degenerative and often progressive changes in the brain. The main underlying cause of this type of confusion is dementia. Dementia is a term used to cover numerous types of disease processes which tend to be slow in onset, are usually irreversible and involve substantial destruction of brain cells to the extent of interfering with social and personal functioning. The most frequently occurring dementias are Alzheimer’s disease, Lewy body dementia and vascular dementia.
PHYSIOLOGICAL FACTORS
There are six major physiological factors that can lead to the development of confusion:
• infections
• endocrine disturbance
• electrolyte imbalance
• poisoning
• trauma
• dementia.
Infection
Any infection which causes a fever can lead to confusion or delirium. Infections arise due to pathogens invading the body systems, commonly via the urinary or respiratory tracts, although there are many other possible entry sites for infections. Additionally, some infections, such as a chest infection, may cause hypoxia, preventing adequate oxygenated blood reaching the brain and worsening the confusion. Pathogens may also be transported from the primary site of infection via the circulatory system to infect the nervous system directly, again worsening the confusion. The problem of hospital acquired infections must also be considered, especially with people who are already vulnerable to infection.
Endocrine disturbance
Disorders of the endocrine system can interfere with the operation of the nervous system resulting in confusion. For example, a malfunction of the thyroid gland can lead to hypothyroidism, one of the symptoms of which can be confusion (El-Kaissi et al 2005). Similarly, if diabetes mellitus has not been stabilized, or if food has not been taken after the administration of insulin, hypoglycaemia and associated confusion can develop.
Electrolyte imbalance
The main cause of electrolyte imbalance is a sodium depletion. Sodium is an important element in maintaining osmotic stability within body tissues. In cases of chronic renal failure, congestive heart disease, cirrhosis of the liver, inappropriate intake of water or secretion of antidiuretic hormone, the resulting sodium deficiency leads to the electrolyte abnormality of hyponatraemia, often shown by tiredness and confusion. Although not as common, it can be induced iatrogenically (i.e. induced as a consequence of medical interventions, often polypharmacy), particularly in older people who are prescribed diuretics. Diuretics can cause excessive sodium to be excreted. In turn, this leads to electrolyte disturbances which then results in confusion.
Electrolyte imbalance is often seen towards the end of life where multiple organ failure sets in (Keeley 2007). Furthermore, the habitual use of laxatives, a common practice by some people with eating disorders and older people, can lead to problems of hydration, electrolyte imbalance and eventual confusion (Kumar et al 2007). Electrolyte disturbances can also result from an inadequate intake of food and drink, i.e. malnutrition. In addition, malnutrition can result in the body lacking the vitamins thiamine and B12. The deficiency of these leads to changes in mental health observed by characteristics such as forgetfulness, depression, irritability and confusion. Factors such as infections, vitamin deficiencies and electrolyte imbalances can mimic some of the signs of dementia. This is one of the reasons why, when a person is being assessed for a dementia, a full blood screen is taken.
Drawing on your experience to date and/or on your next clinical placement consider the following:
• How do you feel about caring for someone who is acutely confused – and what has influenced these feelings?
• What factors have you encountered that have caused a delirium in a patient you have helped nurse?
• What blood test is undertaken to determine whether someone has an electrolyte imbalance?
• How do you know if diuretics are working effectively?
• How would you establish if someone was malnourished?
Poisoning
In addition to environmental toxins, poisons that cause confusion include alcohol and drugs. The misuse and abuse of alcohol or drugs which was once considered a problem only among the young is now becoming a growing problem among people of all age groups, including older people. The misuse of alcohol or other substances is a common cause of physical and mental health problems, especially in older men. Older adults are particularly vulnerable to the mental and physical effects of these substances because the changes that happen through ageing that mean these poisons cannot be metabolized rapidly by the liver as they can with a younger healthy person (McLoughlin & Farrell 1997).
Alcohol
Intoxication with alcohol can lead to short-term confusion and, sometimes, memory lapses associated with brain damage. In turn, this can result in physical, psychological and social problems. In the long term, prolonged excessive consumption of alcohol can cause vitamin B12 deficiency, leading to irreversible damage to the brain, and the development of Korsakoff syndrome, of which chronic confusion is one of the main features.
Drugs
Drug-related confusion may result from:
• an overdose; either accidental or intentional
• the drug’s cumulative effect
• an interaction between different drugs
• underlying predisposing factors such as the person’s reaction to the drug(s).
According to the National Institute of Drug Abuse (2007), confusion can result from the misuse and abuse of many of the most common recreational and hard drugs. In addition, confusion can be induced by certain neuroleptic drugs and compound analgesics. In addition, some stimulants and sedatives can also lead to disorientation with time, place or person if they are stopped suddenly, particularly in people who have abused illicit drugs or alcohol.
Ghodse (1995) noted that a wide range of psychoactive drugs can impair an individual’s general awareness and ability to concentrate. In particular, lysergic acid diethylamide (LSD or acid) results in altered perception and confusion. The illicit use of 3,4-methylenedioxymethamphetamine (MDMA, better known as ecstasy) has always been a public concern. MDMA, banned in the UK since 1971 as a class A drug, has been popularized as a recreational drug among contemporary youth culture arising from the mistaken belief that it has relatively harmless properties. MDMA inhibits the reuptake of serotonin leading to an accumulation of excessive amounts of the neurotransmitter within the neural synapses. This gives the euphoric feelings associated with taking the drug. Excessive serotonin also raises the body temperature, which can result in dehydration, inappropriate blood clotting, convulsions and coma (Jones & Owens 1996). Following publicity of this fact, many users attempted to compensate for the dehydration by drinking copious amounts of water. Day (1996) found that some users of MDMA drank so much water that they severely disturbed their electrolyte balance. In the long term, exposure to MDMA damages the neuroreceptors and reduces the secretion of serotonin (Kish et al 2000), which is associated with depression, memory impairment and, subsequently, confusion.
For multiple reasons, older people are more likely to be prescribed medication for new conditions and to continue with existing long-term medication. Occasionally, due to the side-effects of the drugs, or due to the interaction of a combination of drugs, confusion in the form of an iatrogenic dementia can develop (Strickland et al 1999).
To celebrate a milestone birthday, Jeremy Banko, with a group of his friends, went out drinking and then on to a night club. After he collapsed on the dance floor, he was taken to the nearest accident and emergency department. The paramedics established from his friends that Jeremy took some ecstasy tablets approximately 45 minutes prior to collapsing. During the assessment the nurse observed and documented that Jeremy was alternately very talkative and very quiet, hypotensive, tachycardic, pyrexial and he appeared to be dehydrated; he was also showing signs of agitation resulting in verbal aggressive behaviour and was overly responsive to being touched.
• How do you feel about what Jeremy allegedly did and what are the likely consequences for the way you would care for him?
• What immediate nursing actions would be taken to stabilize Jeremy’s physiological condition?
• What medical interventions may be made to limit the effects of the drug?
• How would the nursing and medical actions be affected by Jeremy’s mental state?
• How might Jeremy be supported to enjoy safer nights out with his friends and take more responsibility for his health?
Trauma
Physical damage to the brain can result in confusion (Engel & Romano 2004). The nature of the confusion is governed by the part of the brain affected and the extent of the injury. If the injury is minor and reversible then it is likely that the confusion will reverse as the trauma subsides. For example, confusion arising from concussion reduces as the concussion resolves. On the other hand, if the confusion arises from a major trauma that has caused permanent damage to the brain, complete recovery is unlikely. Agitation, restlessness, and aggression arising from confusion are frequently found in the early stages of recovery from traumatic brain injury. These behavioural symptoms can slow down or disrupt patient care and impede rehabilitation efforts (Levy et al 2005). In severe cases of traumatic head injury, residual confusion may persist and may need careful management and in particular avoiding triggers that induce agitation, restlessness, and aggression.
Dementia
Alzheimer’s disease
Alzheimer’s disease is presently the commonest type of dementia in the developed world. However, it is becoming clearer that there are many variations of Alzheimer’s and that we no longer think of it as one type only. Ultimately, in Alzheimer’s disease(s), the cerebral cortex can be seen to atrophy. This means that there is shrinkage of the brain in the areas that are responsible for cognitive and intellectual functioning. It occurs as the result of several processes from the build up of amyloid plaques and neurofibrillary tangles. These plaques are found outside of the neurons and impair their function.
The neurofibrillary tangles are composed of a protein called tau protein. Tau proteins play a crucial role in the structure of the neuron. In people with Alzheimer’s tau proteins cause abnormality through overactive enzymes resulting in the formation of neurofibrillary tangles which in turn cause the death of the cells. In Alzheimer’s disease the number of tangles becomes so large that they interfere with the functioning of the brain. See the Evolve presentations for further details on types of dementia, more information on the medical diagnosis of delirium and dementia and what nurses need to know.
It has generally been thought that the signs found in people with dementia reflect the widespread and progressive deterioration of function in the cortex and extending into sensorimotor cortical areas as well. Consequently, Alzheimer’s disease is characterized by progressive mental and functional deterioration. This results in changes to people’s:
• memory
• language
• cognitive abilities (e.g. concentration, problem solving, sequencing of tasks, way finding)
• personality
• mood
• emotions
• physical health.
However, it is now known that some of the consequences seen in people with dementia are not entirely due to physiological changes associated with dementia but more to do with how others treat the person with dementia and negative effects from the environment. Kitwood (1997: 49–53) captures this very well proposing the following ‘equation’ to explain’ what we see in dementia:
1 D = P + B + H + NI + SP
P = Personality, which includes coping styles and defences against anxiety
B = Biography, and responses to the changes in circumstances associated with later life
H = Health status, including the acuity of the senses
NI = Neurological impairment, separated into its location, type and intensity
SP = Social psychology (relationships between people) which constitutes the fabric of everyday life
Thus D, which = dementia, can be viewed as the product of a complex interaction between the five elements of the above equation.
Vascular dementia
In the developed world, vascular disease is thought to be the second most common cause of dementia. Vascular disease is at least partially preventable and treatable, so increasing awareness of the association of managing blood pressure for example, may decrease the incidence of dementia in the longer term. Vascular dementia may progress in stages; each stage can consist of some deterioration with the possibility of a period of partial recovery. This type of dementia can also be called Multi-Infarct Dementia and its features include:
• Sudden difficulty or in comprehension when doing routine tasks
• Confusion
• Irritability or aggression
• Balance and co-ordination difficulties
• Absence of speech or changes in speech
• Drowsiness or sleepiness
• Occasionally people may have convulsions or seizures. These might only happen once or may continue to be a problem for the person intermittently and may signal the beginning of another phase of deterioration.
Lewy body dementia
Another form of dementia that is being more frequently diagnosed is Lewy Body dementia and is said to be a variant of Alzheimer’s. Lewy bodies are tiny, spherical protein deposits found in nerve cells in the brain. Their presence disrupts the brain’s normal functioning, specifically interrupting the action of important chemical messengers, including acetylcholine and dopamine. The onset of Lewy Body can be very similar to that of Alzheimer’s. Early symptoms include changes to:
• Language
• Memory
• Ability to judge space and distance
• Slowness of movement
• Stiffness and tremor
• States of confusion – which may vary in degree from day to day
• Hallucination – (auditory or visual)
• Parkinsonian symptoms – such as tremors or jerkiness
• Delusions – can be quite common
• Depression – can be quite common.
In a few cases, the person experiences changes in their heart rate and blood pressure to the extent it may result in unsteady balance/fainting. Abilities and mood can change very quickly, and might fluctuate. This can make life very puzzling for the family and/or carer.
Pick’s disease
Pick’s Disease, also referred to as frontal lobe dementia, usually begins in younger people (aged 40 to 65 years) and can have many similarities to that of Alzheimer’s. Early symptoms are alterations in the personality and may consist of some of the following:
• Lack of inhibition (may behave in inappropriate ways, e.g. anti-social/aggressive)
• Loss of judgment
• Some loss of language
• Some loss of memory
• Difficulty recognizing ordinary objects
• Obsessional (repeating) behaviour
• Overeating (especially sweet things)
• Putting objects (other than food) into their mouth
• Inappropriate emotions e.g. crying, laughing, grimaces and gesturing
• Often unable to recognize people close to them.
Other dementias
About 10% of people with Parkinson’s Disease also develop dementia. Other less common forms of dementia include: Huntington’s Disease; Aids Related Dementia; Creutzfeldt-Jakob Disease (C.J.D.) and Korsakoff’s Disease or Alcohol related dementia. People with Down’s Syndrome and other learning disabilities as they are living longer, are developing dementia at increased rates. It is said that up to 40% of people with Downs will develop a dementia if they live to the age of 60 (Arshad et al 2001). The term ‘younger onset dementia’ is used to describe any form of dementia diagnosed in people under the age of sixty-five. Although most dementias affect people who are over this age, occasionally younger people in their 30s, 40s and 50s are diagnosed with dementia.
Another model of physiological causes of confusion is shown in Evolve presentation 17.2.
PSYCHOSOCIAL FACTORS
PSYCHOLOGICAL CAUSES OF CONFUSION
Confusion can arise from a number of psychological factors and may be due either to already existing predisposing factors within the person or to precipitating factors (Inouye 1999). It is vital to appreciate that psychological factors always have some contribution to make to delirium, in terms of how the person is able to keep away or minimize the effects of changes in their mental state or in terms of how they respond to the effects of delirium (MacLeod 2006). Functional disorders that give rise to perceptual dysfunctions, such as delusions or hallucinations, can also lead to confusion as the person’s sense of reality changes and they experience and react to a reality that is not shared by others around them.
Psychological symptoms of depression are common in patients with delirium. Up to 40% of patients referred to mental health services with suspected depressive illness have delirium (Meagher 2001). Distinguishing delirium from depression is particularly important since in addition to delaying appropriate treatment, many antidepressants have marked anticholinergic activity and if given to a individuals with acute confusion, can worsen the confusion/delirium. It is necessary to keep in mind that a person can develop an acute confusion or delirium on top of an existing dementia. Whatever psychological factors are involved in the causation of delirium, a delirium presents significant distress which in turn has further psychological impact. A structured approach to recognizing, assessing and managing delirium and compassionately supporting the person through their experience is therefore essential.
THE EXPERIENCE OF DELIRIUM
Acute confusion or delirium is not simply a clinical sign or a syndrome. For those experiencing delirium it is a lived experience – and possibly a fearful one (Fagerberg & Eriksdotter Jönhagen 2002). Additionally, it is one where most people retain and recall their experience, like vivid but strange dreams, and this may have implications for subsequent psychological care (Fleminger 2002). Given the way in which the person can present during a delirium in regards to their varying grasp of reality, this is easy to lose sight of (Burns et al 2004).
Schofield (2007) describes the experience of delirium as being either hyperactive or hypoactive.
With the hyperactive experience, the person can experience changes from misperception that result in them being:
• restless
• excitable
• on guard – suspicious
• wanting to be continuously on the move
• searching
• shouting
• resistive
• experiencing visual hallucinations.
With a hypoactive experience you will find that the person becomes less active both physically and psychologically. Consequently the person can be:
• less alert
• slower in responses and speech
• apathetic
• sleepy and harder to rouse
• indifferent to what is going on around them.
The few accounts of experiences of delirium in the literature indicate that many people experience a mix of both of the above (Schofield, 2007 and Sörensen Duppils and Winbald, 2007).
THE EXPERIENCE OF DEMENTIA
There have for many years been accounts written by families and carers about the person with dementia. Echoing this, much of the research was also carried out with families and carers as it was thought that people with dementia could not contribute and indeed did not have anything useful to contribute. Until the last 10 years there has been little written by people with dementia themselves. However, there are now more accounts being written by people with dementia about their experiences of living with dementia. The writing takes on various forms such as narrative, poetry and factual accounts of receiving treatment and care. People with dementia are also sharing their experiences through paintings and other creative forms of expression. These expressions often provide very candid and personal descriptions of experiences, thoughts and feelings.
To ‘hear’ more from people with dementia visit http://www.dasninternational.org/presentations.php
Being given a diagnosis of dementia can lead to a range of emotions and responses including depression and anger. However, it can also lead people to clarify what is important to them in their life and to make plans for their future. It is vital that nurses, whatever their own values and beliefs about dementia, are able to care for and support people with dementia to live as meaningful and as free a life as possible, regardless of the effects of dementia. Thus ‘cognitive’ rehabilitation is important in the earlier stages of dementia. As the dementia progresses and people need more care, the emphasis should again be on nursing contributing to the person living as full and actively meaningful a life as possible, until palliative and end of life care is needed.
ENVIRONMENTAL INFLUENCES ON CONFUSION
A variety of environmental factors can contribute to and exacerbate confusion. They include:
• excessive and prolonged noise and/or light
• lack of personal space
• prolonged poor lighting
• distortion of light and darkness
• a lack of familiar people along with too many unfamiliar people
• unfamiliar routine and the busyness of the routine.
Some people experience an increase in their symptoms around dusk when natural lighting changes in their environment. This is sometimes referred to as sundown syndrome or sundowning (Dewing, 2000 and Sörensen Duppils and Winbald, 2007). As well as changes in light causing problems, noise, particularly excessive noise, is highly ‘toxic’ to people with confusion (Schofield & Dewing 2001). Marshall (2001) contends noise is as disabling to people with confusion as stairs are to people who use wheelchairs.
A familiar environment is particularly important in the care of all people experiencing delirium (Simon et al 1997) and those living with a dementia. Most people function adequately in their own or their usual environment, but will deteriorate rapidly if moved to a new unfamiliar environment. This is because the nature of the syndrome and disease makes their intellectual functioning less effective, combined with the effects of an unfamiliar environment that creates more demands on the person than they have the competence for. Indeed this excess challenge can mean people lose preserved abilities at an accelerated rate, even temporarily. This, in dementia, is sometimes referred to as ‘excess disability’ and in part it explains why a person changes their competence from one setting to another within a short time scale.
Attention to reducing the ‘strangeness’ of the immediate environment should consequently form a core part of any care planning. It also plays a role in a therapy known as reality orientation therapy – a strategy that can be used to help some individuals who are confused. However, it should be noted that after a certain point in the dementia process reality orientation can bring people more distress than benefits. The layout of wards, units and the home, including hallways, doorways and exits, directional signing, signing of spaces and places (e.g. toilets and dining areas) and the design and décor of an area can all be modified or adapted to better suit the needs of people with confusion. People with dementia need similar clear and uncluttered environments; however, they should also be sensorily stimulating and promote interest (learning), pleasure and fun.
Drawing on your experience of a particular care setting where you have nursed someone who has experienced acute confusion or dementia, reflect on:
• How you feel the environment influenced the person’s competence?
• What did you do to make the immediate bed-side area (or the area where care was being offered) less strange for the person?
• What else do you feel you could have done?
• Looking more broadly at that setting, what changes could have been made to make the place feel less strange?
See Evolve presentation 17.1, which looks at delirium and dementia from the perspective of people who have it or are living through it.
CARE DELIVERY KNOWLEDGE
NURSING ASSESSMENT OF PEOPLE EXPERIENCING ACUTE CONFUSION/DELIRIUM
It must be remembered that confusion per se is a symptom of an underlying pathological condition rather than a condition in its own right. Where an acute confusion is suspected, the purpose of assessment is to identify and rapidly treat the condition causing the confusion (Wills & Dewing 2001). The individual who is confused will probably have difficulty in comprehending what is said to them and in communicating back, so it is essential that the assessor has good interpersonal skills. This is facilitated by achieving a calm and focused presence, a clear yet gentle approach and the use of active listening and observation skills. Three major areas should form the focus of assessment: physiological, psychological and environmental. If any assessments have been carried out, you should familiarize yourself with these as it may avoid duplication of questions for the patient and/or family.
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