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CNA Training & Classes | September 7, 2019

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Why is My Patient Confused?

While a little forgetfulness is a normal part of aging, confusion, and disorientation are not.

But is all confusion dementia?  And why do people with dementia seem to suddenly get worse at certain times – usually the end of the day?

As a CNA you are used to dealing with confused patients but navigating the causes for this confusion can be difficult.

There are many reasons why your patient may be confused.  While some of the causes are chronic, others are short-term and preventable.  Some are benign, and others can signal a serious medical condition.

Understanding it’s causes can help you weed out the reason for your patient’s confusion, and it will fall into one of the 3 D’s:

  • Dementia
  • Delirium
  • Depression


You are probably very familiar with the concept of dementia.  Dementia is a syndrome of cognitive defects or declines.  It causes progressive memory loss and loss of day to day functioning.  It is a progressive disease which means it worsens over time.

The one crucial factor to remember if you think your patient may be developing dementia is that the changes are never sudden.  They are very gradual, worsening over months or years.  No one will be fine one day, then wake up the next with dementia.


In direct contrast to dementia, delirium is a sudden change in your patient’s mental and functional abilities.  Like dementia, it causes confusion and a loss of daily functioning. It also creates a decrease in the awareness of the patient’s environment.  People in delirium tend to lose their ability to focus on an activity or task, and their thinking is very disorganized.  They may have suddenly lost the ability to perform tasks that were previously easy for them, like dialing a telephone.

The hallmark of delirium, however, is its rapid progression.  Onset can be as fast as a few hours to over several days.  It is so quick that people are often not able to tell that something is happening to them, by the time it starts they are already deep into delirium.

Types of Delirium

There are three types of delirium:

  • Hypoactive – where the patient is suddenly more sleeping and sluggish, uninterested in everything, and have slow speech or mumbling.
  • Hyperactive – where the patient is restless, irritable, combative, angry, uncooperative, and easily distracted.
  • Mixed – where the patient shifts between the other two states.

One of the most common forms of delirium is known as “sundowning,” which is merely a hyperactive delirium.  Many nurses and healthcare workers see delirium as a regular part of dementia, but that couldn’t be farther from the truth.  Sundowning is entirely abnormal and is entirely preventable.

The other common delirium misunderstanding is the patient who is labeled as having “behavioral outbursts.”  These patients are merely showing signs of a mixed delirium, where they are quiet and easy to manage one minute (hypoactive delirium) and angry and combative the next (hyperactive delirium.)


Delirium can be caused by many things, some dangerous and others benign.

The more dangerous causes of dementia are:

  • Dehydration
  • Malnutrition
  • Imbalanced electrolytes – especially sodium levels
  • Medications – particularly sedatives and narcotics
  • Infections – most commonly urinary tract infections and pneumonia
  • Alcohol and drug withdrawal

The benign causes of delirium are:

  • Recent surgery
  • Advanced age
  • History of dementia
  • History of stroke falls, or gait disorders
  • Immobilization
  • Sensory impairment
  • Emotional Stress
  • Untreated pain
  • Environmental overstimulation

Delirium is easily preventable if you get to know your patients well and be alert for potential risk factors.  Preventing the dreaded “sundowning” can be as simple as making sure your patient gets a little exercise every day or encouraging them to participate in activities.


Rounding out the trio is depression, which has an onset somewhere in between dementia and depression.  While people might associate depression with a younger demographic, it is alarmingly common in older adults, particularly in those with underlying dementia.  It often goes under-recognized or misdiagnosed, and therefore is undertreated.

While depression occurs in only 3% of older adults, people with underlying dementia have a 30% risk of developing the disorder.  Quite alarmingly, older people with depression are at a much higher risk of suicide, especially older men.  In fact, older men have the highest rates of suicide when compared to any other demographic worldwide.

Symptoms of Depression in Older Adults

The symptoms of depression mimic many aspects of both dementia and delirium.

They include:

  • Sleep disturbances
  • Fatigue
  • Lack of energy
  • Slower movement
  • Weight loss
  • Loss of appetite
  • Unexplained aches and pains
  • Memory problems
  • Irritability
  • Neglecting personal care (e., Skipping meals, not bathing, forgetting medications)

Link Between Depression and Dementia

People with dementia have a significantly higher risk of developing depression.  The cause for this is unclear, but research has shown that it is much more complicated than just being upset about their condition.  There is some convincing evidence that having depression in their younger years puts people at risk for developing dementia later in life.  There are also similarities in neurobiology between the two conditions including a similar pattern of change and damage to the brain.

This new research brings to light this unique connection between the two conditions and can help caregivers and health workers to be aware who would be at increased risk both for developing depression and dementia.

Why is My Patient Confused?

Determining the cause for your patient’s confusion can be difficult, but understanding the three main causes and their respective signs can help you solve this mystery.

As a CNA your frequent interaction and observations with your patients play a vital role in recognizing the onset and cause of these three conditions: dementia, delirium, and depression.  Your close relationships with your patients will mean that you may observe very subtle clues or trends that can help the nurses and doctors identify an issue earlier.  Always be on the lookout for these changes, document, and communicate your findings with the nurse immediately, you could save a life!