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GUIDELINES FOR HELPING THECONFUSED OLDER PERSONConfusion and dementia in older peopleConfusion and dementia can occur in adults of any age, but are much morelikely in older people. However, they are not a normal part of ageing.Topics covered: Signs of dementia What to do if you are concerned that a person may bedeveloping dementia Supporting the person with dementia Communicating with the confused person Discussing sensitive issues Discussions and decisions about driving Discussions and decisions about care Behaviours that you may find challenging Assisting the confused person who is wandering Delirium.What is confusion?‘Confusion’ is a broad term that refers to a decline in normal cognitive ability, whichmay vary from mild to severe.The cognitive changes may be associated with dementia,delirium or other medical conditions. It may include a number of the following signsand symptoms: lack of alertness, poor attention span, disorientation to time andplace, trouble following a conversation, unclear or illogical speech, impaired shortterm memory, difficulty in planning and carrying out tasks, inappropriate behaviour,disconnection from reality or delusional beliefs.What is dementia?‘Dementia’ is a condition involving progressive decline of cognitive abilities such asshort-term memory, language and the ability to plan and carry out tasks. Dementia isan umbrella term for a large group of illnesses that cause this progressive decline.Theearly signs of dementia are subtle and can differ from person to person. However, thesymptoms appear over months and years and tend to get worse over time.Because of the progressive nature of dementia you may find that some of the strategiessuggested in these guidelines are more applicable at the earlier stages, while others will beapplicable at later stages.Mental Health First Aid Australiawww.mhfa.com.au1.
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONWhat to do if you areconcerned that a personmay be developingdementiaSigns of dementiaThe following signs may indicate a person is developing dementia.Cognitive signs Memory loss, e.g.: Forgetting things more often, and not remembering them later Repeatedly misplacing items by putting them in inappropriate places Forgetting the first part of an explanation by the time the explanation finishes Difficulty remembering much, or any, new information.Difficulty communicating or finding words, e.g.: Forgetting simple words Substituting inappropriate words.Difficulty with complex tasks or abstract thinking, e.g. forgetting completely whatnumbers are and what needs to be done with them Difficulty with planning and organizing, e.g.: Trouble following a familiar recipe or keeping track of monthly bills Difficulty concentrating and taking much longer to do things than before.Poor or decreased judgement, e.g.: Giving large amounts to telemarketers Paying less attention to grooming or not keeping clean. Inability to reason Difficulty with coordination and motor function Problems with disorientation, e.g.: Becoming lost on a familiar street Not knowing where they are, how they got there or how to get back home Losing track of dates, seasons and the passage of time. Loss of ability to do everyday tasks Hallucinations and delusions.Talking to the person about yourconcernsIf you are talking to the person aboutyour concerns about their memory andfunctioning, you should: Early detection of dementia may have benefitsfor the person, their family’s acceptance andthe long-term management of the condition. Ask the person how they are feelingabout their memory. Try to keep the conversation positiveby focusing on the benefits of earlytreatment for retaining skills andstrengths. Explain that you are concerned becauseyou care. Try to make the person feel at easeand reassure them that their memoryproblems are not their fault. Reassure them that you care for or lovethem regardless of their memory andfunctioning, as this will provide a sense ofsecurity for the person. Try not to be upset if the person refusesto accept what you are saying.Seeking professional helpYou should encourage the person to see adoctor if:Emotional signs The person shows signs of dementia. Others in the person’s life are worriedabout changes in the person’s memoryand functioning. The person is worried that there havebeen changes in their memory andfunctioning. Apathy, withdrawal and loss of initiative, e.g.: Uncommunicative Passive and requiring prompts to become involved.Personality changes, e.g.: Suspicious, fearful, paranoid Disinhibited or behaving inappropriately Agitated.Mood swings, e.g. rapid changes from calm to tears to anger, for no apparentreason.It is important to note that changes in memory or other signs above do not necessarilyindicate that the person has dementia, but may be related to other health problems.This list is adapted from lists from Alzheimer’s Australia (fightdementia.org.au),Alzheimer’s Association USA (alz.org), and the Mayo Clinic (mayoclinic.org)2.Note that if there is a sudden cognitivedeterioration in the person, immediatemedical attention is required. In some casesit may be a result of a reversible illness. (Seethe section entitled Delirium on page 10.)Before the person attends an initialappointment with a doctor, you can helpthem to prepare for the appointmentby thinking about and recording whatinformation would be useful at theappointment, e.g. medical and family history,a list of behavioural or memory changes youhave noticed in the person, questions forthe doctor. Consider going to the doctor’sappointment with the person, so that you
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONcan act as an advocate for them. If youattend the doctor’s appointment, ask theperson’s permission to be given confidentialinformation from the doctor.If the person is reluctant to gethelpThe person may be reluctant to visit a doctorbecause they may not have the insight torealise something is wrong or, if they do, theymay be afraid of having their fears confirmed.They may also be embarrassed or upsetabout their memory loss.If the person is reluctant to get help, youshould: Discuss the matter with them and tryto identify the reason behind theirreluctance.Acknowledge any fears or worriesthe person expresses and help themovercome these by providing care andreassurance.Tell them that a doctor’s visit will helpto rule out any physical or temporaryconditions causing their signs orsymptoms.Suggest that the person go for a generalmedical check-up.If the person remains reluctant to get help,identify another individual who has a goodrelationship with the person to supportthem to seek help. If the person refuses toseek help and their health or safety is at risk,get aged care assessment services involved.Supporting the person withdementiaSeeing the person behind thedementiaYou should think of the person as a ‘personwith dementia’ and not a ‘demented person’.Even though the person has failing memoryor reduced understanding, it does notmean that they do not have a sense of self,personality, or thoughts and feelings. Donot assume that the person cannot learnand enjoy new things. In the earlier stages,the person may still retain much of theirintellectual capacity and may still have thedesire to be a contributing member ofsociety.Helping the person with theirmemory problemsIf the person complains about memory loss,acknowledge it rather than dismiss it, e.g. say“It must be frustrating.” Let them talk aboutit, unless it seems to upset them more thanhelp them.You should also be aware of a range ofmemory strategies that you can use toassist the person. If the person has forgottenthat they have done something and keepsasking to do it (e.g. attending a doctor’sappointment), consider using the followingstrategies: Repeat the answer, in a kind andreassuring tone of voice. Acknowledge the emotions behind theperson’s concerns. Patiently accept the repetition, if theabove strategies do not help.If the person does not recognise what anobject is for, consider using the followingstrategies: Explain what it is for in a sensitivemanner to avoid the person feeling asense of failure. Demonstrate the use of the item. Use step-by-step prompts. Acknowledge any frustration the personmay be experiencing.Help the person’s memory by providingappropriate information for a situation,e.g. when introducing people, you mightsay, “Here’s your nephew John and his wifeSharon.” Avoid quizzing the person, e.g. asking“Do you remember everyone’s name?” Alsoavoid asking questions such as, “Do youremember?”, “Don’t you remember?” and“Have you forgotten?”, because it may upsetthe person and is unlikely to be helpful. Itis best to avoid pointing out any errors theperson makes, as this can be discouraging forsomeone with memory loss.Helping the person to completetasksUse strategies that will help the personmaintain as much of their independence aspossible and reduce the possibility that theperson feels they are being treated like achild or as incapable. You should not blamethe person for mistakes that arise from theirlack of ability or their misunderstanding ofwhat is needed of them.If the person is struggling with a task (e.g.dressing), consider using the followingstrategies: Acknowledge the person’s frustration. Offer help, or do the task with them,rather than just doing the task for them.3. Explain how to do the task in a sensitivemanner to avoid the person feeling asense of failure.Explain to them each step of the waywhat you are doing in a soft, reassuringway, e.g. “I am going to help you sit downnow. Then we can tie your shoes.”Allow plenty of time for the person tocomplete a task, because they may takelonger than they used to.Break down tasks into small, simple,concrete steps.Use step-by-step prompts.Help the person at the point at whichthey have become stuck.Avoid interrupting the person in themiddle of a task unless necessary.Do not give the person too many thingsto do at once, as this may increase theirlevel of anxiety.Attempt to reduce any stress on theperson because stress can increaseconfusion.Helping the person who isdisorientedDo not assume the person knows whoyou are. It may take time for the person tosense that you are friendly or to recogniseyou as someone they already know andtrust. You many need to introduce yourselfto the person each time you talk to them.You should use orienting names wheneverpossible, e.g. “Your son Jack.”If the person is not oriented to time, adjustyour communication to refer to daily eventsrather than dates or times, e.g. instead ofsaying, “John will be here at two o’clock”, say“John will be here after lunch.”If the person is going to be in an unfamiliarplace, try to ensure that they have somefamiliar people with them.Helping the person who hasregressed into the pastAs the person’s memory fails, they maybe more likely to live in the moment.However, they may also regress into the past.Regressions into the past are felt as actualcurrent experiences for the person. If theperson has regressed into the past, do notdismiss their resultant feelings and thoughts.If the person talks about deceased peopleas though they are alive (e.g. a parent whohas died long ago), try to understand whythey are talking about the person, in case itreferences a need that can be addressed.
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONCommunicating with theconfused personBeing understood during aconversation Listening with interest Nodding your head appropriatelyTry to connect with the person by drawingupon their remaining social skills, e.g. “Hello,how are you?” and “Pleased to see youtoday.” Continue sharing your day-to-daythoughts and feelings with the person, usinga warm, easy going and pleasant manner,as it lets them know that they are valued.Encourage the person to continue toexpress themselves, even if they are havingtrouble making themselves understood.When assisting the person, treat them withrespect by trying to be patient and nottalking down to them.Look for signs of understanding, e.g. theperson’s body language and facial expression.However, do not assume that the personunderstands you because they are noddingor giving a superficial response. In order toincrease the likelihood that the person willunderstand you when talking to them, youshould: Reflecting back what they have said.If the person does not talk much, this doesnot mean that their thoughts and feelingsare absent. Pauses in the conversation donot need to be filled with words. Silenceis not necessarily a negative thing – it canbe a way to connect with the person. Beaware that you may have more of a problemwith silence than the person does. Do notautomatically interpret the person’s silenceas anger or depression. Position yourself so that you are at thesame eye level as the person, or lower. Stay still and ensure that the person cansee your face and gestures. This maymake it easier for them to follow theconversation and stay attentive. Use concrete words (words you canpicture), rather than abstract words,idioms, metaphors or slang.Gaining and keeping the person’sattention Avoid expressions that can be taken tooliterally, e.g. ‘shake a leg’. Avoid using pronouns, including thirdperson pronouns, e.g. instead of saying,“Here it is,” say, “Here is your hat.” Orinstead of saying ‘he’ or ‘she’, identifypeople by their actual name. Focus on one main idea at a time andavoid discussing too many things at once. Use short sentences and pause betweenthem to allow time for the informationto be understood.Your best chance of getting and maintainingthe person’s attention is to have a oneon-one conversation with the person in aquiet setting. Eliminate or reduce distractingnoises, such as television, music or otherpeople’s voices. Avoid startling the personby approaching them slowly and from thefront, without sudden movements, so thatthey have time to focus.If the person does not respond, or if it lookslike they are not paying attention, try againafter a break when the person may be morefocused. Be aware that the person may notbe able to attend to a discussion or taskfor very long. Therefore, look for signs offrustration. If the person does not want totalk, turns away, or says or gestures “No!”, donot force them to talk. Be prepared to give the person your fullattention. Establish friendly eye contact whenspeaking to the person to assure themthat they have your full attention. Try to use positively framed instructions,and limit the number of negative words,such as ‘don’t’. For example, say “Stayhere”, rather than, “Don’t go away.” Adjust the pace of your speech dependingon how well the person appears to beunderstanding you. If you have repeated a sentence orquestion using exactly the same wordsand the person still does not seem tounderstand or does not respond, tryrepeating it in a different way.It is also important for you to understandthe person. Keep in mind that the person’swords and answers to questions may notreflect what they meant to say. Let theperson know if you have understood them byproviding validation and acknowledgementto the person.You can do this by:4.Communicating in a groupsituationIf others are present in the conversation, youcan include the person by: Addressing the person directly Using appropriate body language, e.g.facing the person Trying to ensure that only one personspeaks at a time Avoiding interrupting the person inthe middle of a conversation, unlessnecessary Letting the person respond forthemselves and not answering questionsfor them.The person’s feelings and behaviours may beaffected by the negative actions of others (e.g.patronising or angry behaviour). Even thoughthe person has failing memory or reducedunderstanding of a conversation, the personstill has resultant feelings and emotions,which may last for many hours. Help otherscommunicate with the person by modellingappropriate communication and letting themknow what to expect when talking with theperson. If you observe someone using babytalk with the person, take them aside and tellthem they need to talk with the person in anadult manner.Asking the person questionsAdjust the way you ask questions using eitheropen- or closed-ended questions dependingon the purpose of the conversation with theperson, e.g. closed-ended questions may beuseful for helping the person in an everydaytask, whereas open-ended questions mayencourage conversation with the personabout feelings. Questions that call for shortanswers may make the person feel successfulinstead of embarrassed and frustrated overtheir inability to form and keep in mind alengthy answer.Ask one question at a time and avoidquestions that require a lot of thought ormemory, e.g. don’t ask “What did you dotoday?” Instead, shape the question toaddress current feelings, e.g. “Are you havinga good day?”.
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONOffering the person optionsOffer options instead of commands, inorder to give the person a greater sense ofcontrol over their life. However, be awarethat the person may become more confusedif they are offered too many options at once.When offering the person a choice, list theavailable options so that the person can usethe information to answer, e.g. “Would youlike tea or coffee?” rather than “What wouldyou like to drink?”Non-verbal communicationNon-verbalcommunication,includingbody language and tone of voice, may bemore effective than spoken words whencommunicating with the person. Gestures,facial expressions, props, and non-verbaland visual cues may be helpful in reinforcingyour verbal messages. Be aware of yournon-verbal cues, such as behaviour, facialexpressions, tone of voice and eye contact,making sure they match what you are saying.Your behaviour may send a message to theperson, e.g. non-threatening tone of voiceand body language may help to gain theperson’s confidence in your ability to assist.Conversely, your tone of voice may indicatefrustration, and talking loudly or loomingover the person may indicate hostility or athreat. Also, your tone of voice or displayof emotion may be mirrored by the person,e.g. an anxious tone may trigger anxiety inthe person.A gentle touch of the arm or hand cancommunicate to the person that you areinterested and really care. If you have a closerelationship with the person, touch can be apowerful way of connecting with the personand can show you are interested in them andcare. However, pay attention to non-verbalcues that may indicate that the person doesnot want to be touched.Look for and respond to the physical andnon-verbal cues that may indicate theperson’s needs or feelings, e.g. the personwho appears anxious or agitated may be inpain, need to go to the toilet or be troubledby something going on around them.Challenges experienced duringcommunicationWhen communication is difficult, try tobe patient and do not give up trying tounderstand the person. There are somethings you can do to help overcomecommunication difficulties.To encourage the person to continuecommunicating you can show them you arelistening by maintaining eye contact, smilingand talking in a gentle tone.If the person is having trouble expressingthemselves, or their words are mixed up andseem nonsensical: Listen to the person, because these mayhave meaning for them.Avoid expressing annoyance.Let the person know it is all right andencourage them to continue to explaintheir thoughts without interrupting,speaking for them or ‘filling in the blanks’too quickly.Smile and say, “I am having a problemunderstanding.” This implies that theperson is not the problem.Focus on and acknowledge the emotionthat the person is trying to convey,because this will help the person feelunderstood even if they cannot find theappropriate words.If you think you understand what theyare trying to say, clarify this them.If the person repeats questionsstatements over and over again: orListen to the person and try to guesswhat their underlying concern is andreassure them about this, e.g. a repeatedquestion about the time might bebecause they are worried they will missan event.to cope with difficulties in conversation, e.g.‘talk around the topic’ before finding theright word or phrase.Factors in the person’s environment maymake communication more difficult. A busy,cluttered, noisy or unfamiliar environmentmay cause distress or confusion for theperson. Furthermore, the person maymisunderstand aspects of their environment,which may increase confusion or frustration,e.g. mirrors might make the person think thereis somebody else in the room. If the personis having communication problems, checkthat they are not being affected by somethingunrelated, e.g. their hearing aid may not beworking or they are wearing the wrong glasses.Talking with a confused person mayrequire skilled communication and you maymake mistakes. If you feel you have donesomething wrong when communicating withthe person (e.g. acted impatiently), apologiseto demonstrate your respect.Discussing sensitive issuesPlease note that the guidelines in this sectionare likely to be most helpful and appropriate fora family caregiver.Because dementia is progressive, there willbe times when discussions will be neededabout major changes in the person’s life. Ifpossible, wait until the person is relaxed andfocused before trying to discuss a sensitiveissue with them, e.g. the person may be moretired or confused in the evening and moreresponsive after they have rested. Whendiscussing a sensitive issue, such as diagnosis,planning for the future, stopping driving ordeciding when to move to a higher levelof care, you can use the communicationstrategies above. In addition, you should: Avoid expressing annoyance.If the person begins rambling: Avoid looking away or acting distractedbecause the person will sense the lackof interest and this may close downcommunication.If you suspect the person is in pain: Point to or touch the area you thinkmight be hurting and ask the person tonod if it hurts there.Sometimes, the best thing to do is remainsilent and let the person find their own way5. Choose a place familiar to the personas a setting for such a conversation,because this is likely to help facilitatecommunication and minimise anxiety.Approach the person in a calm, gentle,non-judgemental manner, because thissets the mood for the subsequentconversation.Begin the conversation with neutraltopics to help build trust and help theperson feel relaxed, e.g. talking about theweather or family.Consider enlisting the help of anotherperson who can remain calm andobjective.
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONWhen discussing topics that evoke a strongemotional response from the person, donot reject or dismiss what the person saysabout their feelings, e.g. “Oh, you don’tneed to worry about that.” Rather, validateand acknowledge how the person is feeling,e.g. “I can see this is upsetting, that’s veryunderstandable.” If the person showsnegative emotions (e.g. tearful, angry), takethem somewhere private where they canexpress this without feeling embarrassed.Discussing the diagnosisIn preparing to talk with the person abouttheir diagnosis, learn as much as possibleabout their particular type of dementia.Find out about organisations that provideresources or services to people withdementia and their carers.Keep in mind that discussions at diagnosiscan provide a basis for more detaileddiscussions later on, e.g. discussions aboutdementia progression or advice on topicsthat may be discussed later. When discussingthe person’s diagnosis: Choose how you explain to the personwhat is happening based on their abilityto understand, e.g. a straightforwardexplanation (“You have dementia”)versus a more gentle approach (“Youhave a memory problem”). Reassure the person and let them knowthat they will be supported and helped. Let them know that there are thingsthey can do themselves that can supporttheir memory and maintain theirindependence. Remain open to the person’s need totalk about their diagnosis, increasedlimitations and negative feelings as theirdementia progresses.Give the person the opportunity to talkabout their experiences and how theysee themselves as they lose some oftheir functioning and capabilities.The person may not acknowledge theirdiagnosis. This could be due to an inability tounderstand or a self-protective mechanismto help them cope. If the person does notacknowledge their diagnosis, do not tryto force them to recognise it. If needed,get advice from the person’s healthcareprofessionals on how to talk to the personabout their diagnosis.Making decisions and planningfor the futureWhile the person may appear to be drivingsafely, they may:Arrange times to meet with the personto discuss their wishes, concerns and anypreferences for the future. Allow the personto make whatever decisions they are capableof making, as long as these do not involvedanger to the person or to others. Let theperson know that any decisions made aboutthe future can be revisited if they wish todo so. Be relying entirely on the habits ofdriving and may be unable to respondappropriately to a new situation Not be capable of reacting quickly toan unexpected problem or making adecision needed to avoid an accident Forget unsafe driving incidents andtherefore have a false sense of confidenceabout their driving ability.If the person has concerns about facingthe future, reassure the person about theadvantages of planning, e.g. “Don’t be scaredof planning ahead. It will make life much easierin the future.” It may be helpful for both youand the person to share any sadness andconcern about the future.Even if the person is currently safe to drive,they can become disoriented and lost, evenon familiar roads. Discuss ways that theycan communicate with someone shouldthey become lost. Make sure they haveappropriate identification in case they needto ask someone for help.If the person does not have a Power ofAttorney or an Advance Care Directiveon relevant topics (e.g. care preferences,management of finances and arrangementsafter death), encourage or assist them tomake an appointment with an appropriateprofessional to develop these. (See Boxfor more information on Advance CareDirectives and Power of Attorney.)Do not try to keep the person drivinglonger by acting as a ‘co-pilot’ (e.g. by givinginstruction and directions to the personwhen they drive), because in an emergencysituation there is rarely enough time forinstructions to be given and acted upon toavoid an accident.What is an Advance Care Directive?An Advance Care Directive is a documentdescribing how the person wants to betreated when they are unable to make theirown decisions due to their present state ofillness. In most countries, this is not a legaldocument; it is an agreement made betweenthe person, their family, and hopefully theirusual healthcare professional.What is a Power of Attorney?A Power of Attorney is a legal documentwhere the person appoints someone of theirchoice to manage their legal and financialaffairs. In some countries this includesmaking decisions about health care.Discussions and decisions aboutdrivingA diagnosis of dementia is not automaticallya reason to take away the right to drive.However, while the person might be drivingsafely early on, their progressive decline incognitive abilities means a time will comewhen they will be at high risk of causing anaccident.6.You should be aware that no examinationor single indicator exists to determine whenthe person poses a danger to themselvesor others by driving. However, the followingmay indicate that the person should stopdriving: You would not want a child or grandchildto be driven by the person. The person has been involved in recentaccidents while driving. The person is more frequently becominglost while driving. The person modifies their drivingbehaviour to accommodate changes inskill, e.g. driving shorter distances, drivingonly on familiar roads, avoiding nightdriving.Talking with the person about drivingIt is important to talk to the person aboutdriving issues (e.g. safety and liability),being aware that stopping driving can be asensitive issue because it may be linked toindependence for the person. You shouldcommunicate with the person about theirdriving early, because this can help theperson decide on a course of action beforean accident occurs. Find out about relevantlocal laws regarding driving after a diagnosis
GUIDELINES FOR HELPING THECONFUSED OLDER PERSONof dementia. Encourage the person to beginto plan for when they stop driving, e.g. whattransport they will use, setting up automaticbill payment online and delivery services.If the person has had an increase in frequencyof unsafe driving incidents, have a discussionwith them about restricting their driving.Initiate the discussion about driving in a waythat is less likely to lead the person to bedefensive about their abilities, e.g. ratherthan saying, “Your driving is terrible, you aregetting lost, and you’re just not safe”, you cansay “I am concerned about your safety, howare you feeling about your driving?” Includethe person, as far as possible, in decisionmaking regarding any driving restrictions.If you are going to have a frank discussionwith the person about concerns overtheir driving ability, be prepared for a widerange of reactions, e.g. sadness, relief, anger,defensiveness. When discussing drivingrestrictions, you should: Acknowledge how difficult it may be forthe person to give up driving. Look for ways to help the person saveface and maintain their self-esteem,because giving up driving can meanthe person admitting their increasinglimitations. Listen to the concerns of the person,because it will be helpful for them to feelas if their concerns and feelings are beingrecognised and heard.If the person refuses to talk aboutdriving or is not convinced theyshould stopIf the discussion with the person does not gowell, do not blame yourself. Remember thatthe person’s impaired insight may be makingit diffi
conditions causing their signs or symptoms. Suggest that the person go for a general medical check-up. If the person remains reluctant to get help, identify another individual who has a good relationship with the person to support them to seek help. If the person refuses to seek help and their health or safety is at risk,
