When “More Confused Than Usual” Is the Most Important Finding

Make it stand out

Authored By: Joelle Dangerfield, MSN-Ed, APRN, AGNP-BC, Associate Director of Clinical Services | Third Eye Health

“She’s just more confused than usual.”

In post-acute care, that sentence deserves our attention. It may come from a nurse, a nursing assistant, or a family member who cannot yet explain exactly what is wrong but knows that something has changed.

For the clinician receiving the call, especially after hours, that observation may be an early sign of delirium and the starting point of an important assessment.

The person reporting the change may know things that are difficult to capture in a chart: how the patient usually answers questions, how much help they need at meals, whether they typically participate in conversation, or if they recognize familiar staff. Without that context, today’s change is hard to interpret.

What does baseline mean for a patient with dementia?

A patient with dementia may routinely be unable to name the date but still recognize their nurse, follow simple directions, and enjoy a conversation. Another may speak very little but remain awake, engaged and able to feed themselves.

If the first patient suddenly cannot follow directions, or the second becomes unusually sleepy and stops eating, those changes matter.

“Confused at baseline” is useful context. It should also prompt us to ask what confusion normally looks like for that individual.

A diagnosis of dementia does not explain every new change in cognition or behavior. Recent changes over hours or days can indicate delirium and warrant assessment, including in patients who already have cognitive impairment.

What does hypoactive delirium look like?

Agitation is hard to overlook. A patient who is calling out, resisting care or attempting to get out of bed will usually draw attention quickly. A patient who becomes quiet may be easier to miss.

They may respond more slowly, lose interest in meals, appear withdrawn or move less. These can be features of hypoactive delirium. Someone who knows the patient may recognize that a calm appearance is unusual for them.

Our questions should make the observation more specific.

When a nurse reports increased confusion, useful follow-up questions include:

• What can the patient usually do that they cannot do now?

• When were they last at their usual baseline?

• Did the change begin suddenly, develop gradually or fluctuate?

• What are their current vital signs, and what other information relates to the reason for the call?

• What else has changed in their intake, mobility or sleep?

• Have there been new medications, dose changes, missed doses or extra as-needed (PRN) doses, especially of sedatives, opioids or anticholinergics?

These questions help turn a general concern into a clearer description of an acute change in condition.

From there, our clinicians also look at vital signs, glucose when appropriate, medication exposure, associated symptoms and examination findings. Medication effects, acute illness, pain, urinary retention or constipation, and metabolic problems are among the possible causes of cognitive changes in older adults. An observation like this starts the assessment, though it can’t establish the diagnosis on its own.

In telemedicine, bedside staff bring essential context.

A video visit allows us to observe the patient’s alertness, interaction, speech and ability to follow directions. The bedside nurse helps us interpret those findings against what is usual for that patient.

The first sign might have come from a nursing assistant at breakfast, or from a family member who heard something unfamiliar during a phone call, and either observation belongs in the clinical picture.

Strong telehealth assessment depends on listening to those observations, clarifying them and connecting them with the available clinical information. Our FAQs cover when our clinicians are available and how quickly they respond after hours.

Part of that assessment is recognizing when the patient needs immediate emergency evaluation. Sudden neurologic symptoms, markedly reduced responsiveness or other signs of instability call for prompt escalation based on the findings and goals of care. When a change can be managed safely in the facility, our care process supports treatment in place without a transfer.

The documentation should preserve the change.

Consider the difference between:

“Patient confused. History of dementia.”

And:

“Per nursing, patient usually recognizes familiar staff and follows simple directions. Since this afternoon, patient has been less interactive, unable to follow usual directions, and requiring additional assistance with eating.”

The second description gives the next clinician something meaningful to follow. It explains why the concern was raised and what needs reassessment.

Before the encounter ends, we aim for nursing to have a clear plan and actionable orders: what to monitor, when to report further changes to our team and what findings require urgent escalation. Center leadership and the primary practice group team are made aware of all consultations that take place during our coverage hours.

As clinical leaders, we can support this work by making it easy for staff to raise concerns and by responding with curiosity. When someone says, “This is different for her,” our next question should help them explain what they are seeing.

Recognizing an acute change often starts with someone who knows the patient well, and we want that knowledge to become part of the assessment.

How does your team communicate a patient’s baseline, and how do you make sure subtle changes get timely attention?

See how Third Eye Health helps skilled nursing teams respond to after-hours changes in condition. Request a demo.