Comment & Opinion

Sue Smith, MSc, RGN, RHV

Confusion—or how not to lose touch with the real world...

Is it just me, knowing more people with relatives suffering from dementia, or is the incidence of dementia in all its forms, including Alzheimer's Disease, increasing? I suppose the growing number of people over 80 (I refuse to demean this age group by the collective term 'the elderly') means it is inevitable.

But I do wonder if this term is becoming more of a catch-all diagnosis without due regard to other potential causes of 'confusion'.

In an earlier column I wrote of the differing visual-impairment effects that can lead to disorientation (issue 5: From the blurring of cataracts to the partly-made jigsaw puzzle effects of diabetic retinopathy. I mentioned how the simple measure of putting coloured food on a white plate, or white food on a coloured plate, can markedly improve 'sloppy' table manners. Severe hearing loss is another sensory deprivation that results in a loss of orienting clues to our environment. Verbal clues that help us to know who, and where, we are. But it is an invisible loss and carers may just think we are 'stupid' when we respond inappropriately.

We all know that dehydration or untreated urinary tract infections can cause confusion, As can that old chestnut the 'polypharmacy of the elderly', when the interactions between different drugs pass unnoticed as an older person's increasing health needs require more prescription drugs. Both these states are simple to rectify--they just need a bit of lateral thinking, and a willingness not to jump to the over-simple conclusion that 'old' equals 'demented'.

As I get older this conclusion frightens me.

Another unremarked cause of confusion hit home when my mother was discharged from hospital after six weeks in a Stroke Unit. Ok, she had had a stroke, she was nearly 90, and those giving her care had not known her before the stroke. They didn't know (or bother to find out) that right up until the stroke hit, she had been a bright woman, living on her own since the death of her husband 20 years before. She was still driving safely (a proud member of the Institute of Advanced Motorists) and could reverse her car smartly into a space that would thwart many youngsters. She was cooking and entertaining friends and family, doing the crossword every day, and always marking the birthdays of her ever-increasing circle of family and friends with cards and a phone call--always on the right day.

On her return home, having worked hard in the rehab unit, she was still very 'with-it' although she needed a walking frame and help with a bath. However she was confused about dates and the time of year (early autumn) and would spend hours pouring over her diary trying to work out whose birthday she had missed while in hospital. This confused and troubled her. It was very easy to put all this down to post stroke dementia, but I was not convinced.

I thought back to her six-weeks in hospital. The care and rehab were very good. But--the ward was on the second floor of a large hospital and the windows were high on the walls. It was not possible for patients to see the world outside.

Inevitably the 8-bedded ward was lit all the time. Maybe some lights were lower at night, but it was never dark. The clock on the wall was high, and at an angle that made it difficult for patients in bed to see. 

Meals were brought, without comment, by the contract caterers. The tray was left on the bed table--maybe in reach of the patient, maybe not. The catering staff collected the trays. They were not nurses it was of no concern to them to note what had been eaten or drunk. Or if the tray was untouched (and maybe out of the patient's reach).

The point I am making is that the usual clues we take for granted in our busy everyday lives were absent from the stroke unit--and many hospital wards.  There were no clues about the weather, the time of year (no trees or flowers to be seen to tell us if the buds were opening so it was Spring, or the leaves were falling and it was Autumn). No shops to see to give clues as to whether Hallowe'en, Christmas or Easter were approaching. No real change in lighting to indicate if it was day or night--when you were stuck in bed. Or even if the days were lengthening or shortening.

In the days of yore, when we went on duty in the morning we used to walk into the ward and say "Good morning ladies, it's a beautiful day out there", or "it's freezing out there and looks as if it might snow" or "it's pouring cats and dogs, I got soaked on the way to work this morning".  Indirectly giving our patients clues as to weather--and the time of year.

Then (because it was so long ago, and we didn't have 'catering services' to do the meals) we would walk in with the breakfast trolley, and announce "breakfast time". Or whatever meal it was. We would then make sure the patient could reach their food, and give some encouragement to those who we knew would need it.

I'm sure these things still happen in many places. Or I would like to be sure! But not on my mother's ward. When I thought about this, I realised that she had been subject to what psychologists would label sensory deprivation. She wasn't in a tank of water in a darkened room--but the effect was similar.

Once I realised that this was what could be causing her disorientated confusion--and troubling her, my mind went back to playgroup days.  I made a board to stand in a prominent place in her sitting room. I made cards to stick on the board, (and change daily) giving the date, the day of the week, the weather, and anything key that was happening that day (such as my whereabouts, or who was due to call).

After doing this for about a week, and including clues in everyday conversation to bring her back to the real world, her condition and memory improved markedly. She was again using her diary to remember whose birthday was coming up, or asking me to get Christmas cards to help her write. She even explored her cupboards to find something suitable to give me for my birthday present, on my birthday, as she could no longer get to the shops. I was touched.

If I had my life again, (or was still working in the community) I would develop some system to enable patients to re-orientate themselves to their everyday world after a lengthy stay in hospital. Or, develop a system in longer-stay wards to ensure that patients did not lose touch with the outside world. Daily routines such as meal times and bedtime, that we assume patients will recognise, need to be flagged up. If not, their lives will become blurred and they will risk being labelled 'confused'.

My mother had been admitted in August at the height of a hot summer--she returned home as the nights were drawing in, and the leaves were beginning to fall. She had missed out on these gradual changes that we do not even realise we are noticing, but which ensure we know what is happening in the real world.

Shouldn't this be part of everyday 'holistic care'?

Your thoughts are welcome, email me at


...Including clues in everyday conversation to bring her back to the real world, her condition and memory improved markedly.