Nurses’ descriptions of changes in cognitive function in the acute care setting

Abstract

Objective:  To describe nurses’ documentation of cognition and behavioural changes in patients in acute care settings. Hospitalised patients often present with multiple co‑morbidities including declining levels of cognitive functioning and this is particularly so for older people. Many older people will experience a delirium during hospitalisation. While prevention or prompt management of delirium is paramount to providing quality care, research suggests that health professionals regularly fail to differentiate between delirium and other cognitive changes in hospitalised patients.

Design: Four audits of progress notes were completed over a four week period at a Western Australian tertiary hospital to identify, quantify and categorise cognitive and behavioural changes in hospitalised patients. This paper describes data on nurses’ documentation collected in the course of those audits. On four consecutive Thursdays, the medical records of all patients identified by nursing staff as being confused were reviewed. Where no definitive cause for the confusion was documented, the case notes were examined for evidence of risk factors to determine a probable cause.

Setting: A Western Australian tertiary hospital.

Subjects: The medical records of all patients identified by nursing staff as being confused.

Main outcome measures: Documentation in patient medical records of a patient having cognitive or behavioural changes or being confused; use of a cognitive screening tool; or a diagnosis of delirium.

Results: A total of 1209 patients were surveyed over the four audit days with 183 patients (15%) being identified as confused. ‘Confusion’ was the most common descriptor used by nurses to describe cognitive and behavioural changes; in many cases it was the only term used. Many of these changes were indicative of delirium. Little use by any health professional of cognitive screening tools was found.

Conclusion: Cognitive and behavioural changes are a common problem in hospitalised patients who are elderly. The use of the term confusion to describe a range of cognitive and behavioural changes is a barrier to accurate identification of delirium, which is often the first indicator of serious underlying illness.