Off the Charts

By Shawn Kennedy, AJN interim editor-in-chief

A recent post on our blog highlighted the experience of AJN’s associate editor Amy Collins in trying to get someone to diagnose the underlying reason for acute confusion in her grandmother. Over a two-week period, Amy’s grandmother was seen by various private and ED physicians, none of whom seemed to have an adequate diagnosis or a suggestion for treatment. Finally, nurses suggested that a urinary tract infection (UTI), fecal impaction, or some other infection might be a factor. It was a fecal impaction and yet none of the five physicians who previously evaluated Amy’s grandmother had thought about or assessed for it.

What the nurses said. Amy’s post generated many comments, both on the blog and on our Facebook page. What was interesting to me was how many nurses knew to first check for a UTI, electrolyte disturbance, or fecal impaction as a reason for confusion. Here are a few samples:

“Though not conclusive, in every case I have seen a change in cognition or behavior it was either a UTI or fecal impaction. I work in home health as a CNA and I am a nursing student.”

“The first thing I think to check is infection (UTI) with elderly, confused patients.”

“I’m a senior nursing student…and this material is on our exam that we are taking Friday. With acute confusion, always check for UTI and constipation.”

“Possible UTI. Possible dehydration &/or  constipation. Poor nutrition. All can (and do) manifest as “altered mental status.” Think I’d start with those, and then evaluate further for more complex issues.”

“I would check for fecal impaction, that tends to be a common tendency especially in long term care facilities and a urine sample for UTI.”

So why did none of the physicians who saw Amy’s grandmother think of those potential causes? Is it that none were astute in geriatric medicine, or is it that it’s easier to dismiss the rantings of an older woman as dementia and move on to a “more interesting” case? Was it a case of what one commenter suggested—“simply lazy health care”?

Some resources. Or might it perhaps be that nurses are ahead of physicians in working with the aged?  The John A. Hartford Foundation, which is “dedicated to improving health care for older Americans,” has funded educational programs for nurses through the Hartford Institute of Geriatric Nursing at New York University College of Nursing (you may be familiar with the Nurses Improving Care for Healthsystem Elders [NICHE] program); has fostered leadership building through the Building Academic Geriatric Nursing Capacity initiative with the American Academy of Nursing; and also supports nine Hartford Centers for Geriatric Nursing Excellence. And AJN was pleased to be a partner in the How to Try This series on geriatric assessment (a practical series of articles and videos on recognizing and treating common conditions among the elderly). There are also programs for physicians and social workers. Let’s hope people take advantage of them—it’s painfully apparent that the need is urgent.