Assessment of acute confusion: Use of the NEECHAM confusion scale

Abstract

A CUTE CONFUSIONAL STATE (ACS) is a significant health care problem for the acutely ill hospitalized elderly. Estimates of the incidence of ACS range from 24% to 80% (Foreman, 1989; Ham & Sloane, 1990; Kane & Kurlowicz, 1994; Lipowski, 1989; Neelon, 1990). ACS is largely a disorder of attention with a sudden onset. It is usually secondary to an acute medical condition or a major pathophysiologic change. This multifactoral condition occurs due to an increasing number of accumulated risk factors, including decreased reserve capacity and an increase in physiological and environmental challenges. The downward trajectory into confusion is often viewed as a normal progression of events, and the patient is allowed to pass without intervention into a confusional state. Prompt assessment and intervention by nurses and physicians is essential because of increased morbidity and mortality rates associated with untreated ACS (Francis, Martin, & Kapoor, 1990; Lipowski, 1983; Weddington, 1982; O'Brien, Grisso, Maislin, Chiu, & Evans, 1993). When caring for a patient who is confused, it is assumed that the confusion experienced by the frail elder is the natural outcome of hospitalization. Traditionally, treatment has consisted of restraints and psychotropic medications, with cognitive status assessment nonexistent. The potential exists for the long-term outcomes related to associated morbidity and mortality to improve if signs and symptoms were viewed as a marker of diminished brain reserve and prompt interventions were implemented. Thus, nurses who are skilled at mental status assessment play a crucial role in changing the way ACS is diagnosed and treated (Francis & Kapoor, 1992; Levkoff et al., 1992; Vermeersch, 1990). In response to the inconsistent identification and monitoring of ACS, a study was conducted in which the NEECHAM Confusion Scale was used to assess the cognitive status of elderly, hospitalized patients. The NEECHAM Scale has high internal consistency (Cronbach's c~ = .85) and high interrater (.96) and test-retest reliability (.96) in stable subjects (Neelon, Champagne, McConnell, Carlson & Funk, 1992). Three research questions guided the study. The first question was based on the need for valid and reliable assessment instruments to use for collecting data from which to make patient care decisions. This question measured the reliability coefficient of the NEECHAM in a nonacademic health care setting. The second question was based on beliefs about the physiologic etiology of ACS and changes seen in oxygen saturation levels that lead to hypoxia (Beresin, 1988; Neelon & Champagne, 1992). The third question examined whether a relationship exists