How to manage an elderly patient with confusion who refuses treatment?

From the Guidelines

Managing a confused elderly patient who refuses treatment requires a compassionate, patient-centered approach that prioritizes their autonomy, dignity, and quality of life. When dealing with an elderly patient who is confused and refuses treatment, it is essential to assess their capacity to make decisions and determine if they understand the consequences of refusing treatment 1. This assessment should be guided by the "Geriatric 5Ms" framework, which considers the patient's cognitive and psychological domains, mobility and fall risk, medications, what matters most to the patient, and multicomplexity 1.

To manage the patient's care effectively, try to identify the reason for refusal—it could be fear, confusion, lack of understanding, or a genuine preference. Communicate clearly using simple language, maintain eye contact, and minimize distractions. Involve family members or trusted caregivers who may help reassure the patient. Consider consulting a geriatric psychiatrist or ethics committee if the situation is complex. For patients with dementia or delirium, non-pharmacological approaches should be tried first, including reorientation techniques, maintaining a consistent routine, and creating a calm environment 1.

If the patient lacks decision-making capacity and treatment is urgently needed, legal mechanisms like healthcare proxies or court-appointed guardianship may be necessary. However, it is crucial to respect the patient's autonomy and involve them in the decision-making process as much as possible. Advance care planning, including the identification of care preferences and surrogate decision-makers, is essential in patient-centered care for older adults with complex conditions 1. Remember that forcing treatment can damage trust and increase agitation, so negotiation and compromise are often more effective approaches.

In terms of specific interventions, medications like low-dose haloperidol (0.5-1mg) or quetiapine (25-50mg) may help manage agitation, but should be used cautiously due to increased risk of stroke and mortality in elderly patients. The Mental Capacity Act 2005 and other relevant laws should guide the assessment of capacity and the use of advance decisions, ensuring that the patient's wishes are respected and their best interests are prioritized 1.

Key considerations in managing a confused elderly patient who refuses treatment include:

• Assessing the patient's capacity to make decisions
• Identifying the reason for refusal
• Communicating clearly and involving family members or caregivers
• Using non-pharmacological approaches to manage agitation and confusion
• Respecting the patient's autonomy and involving them in decision-making
• Considering legal mechanisms like healthcare proxies or court-appointed guardianship if necessary
• Prioritizing the patient's quality of life, dignity, and best interests.

From the Research

Assessment and Evaluation

To manage an elderly patient with confusion who refuses treatment, it is essential to assess their decision-making capacity, as refusal of treatment may be due to underlying conditions such as dementia or delirium 2. A comprehensive evaluation, including a complete history, medication review, physical examination, mental status evaluation, and laboratory evaluation, can help identify the cause of confusion 3.

Determining Decision-Making Capacity

Determining decision-making capacity is crucial in cases where patients refuse treatment, especially if the treatment is life-sustaining 4. An algorithm for responding to patient refusals can be used to ensure that the patient's refusal is informed and that their decision-making capacity is assessed.

Nursing Intervention

Nursing assessment of acute confusion should include baseline data on cognition, behavior, and functional status, as well as ongoing systematic assessments during hospitalization 5. This can help identify and manage acute confusion in hospitalized older patients.

Management of Geriatric Patients

In the management of geriatric patients, consultation-liaison psychiatrists should be aware of the unique considerations in elderly patients, including polypharmacy, delirium, dementia, and depression 6. Antipsychotics, antidepressants, and other medications may be used with caution to treat neuropsychologic symptoms, agitation, and hallucinations in the hospital setting. Non-pharmacological interventions, such as melatonin and suvorexant, may also be considered to prevent delirium.

Key Considerations

• Assess decision-making capacity in elderly patients who refuse treatment
• Identify underlying causes of confusion, such as delirium or dementia
• Use a comprehensive evaluation to determine the cause of confusion
• Consider non-pharmacological interventions to prevent delirium
• Be aware of the unique considerations in elderly patients, including polypharmacy and comorbid medical illnesses
• Consultation-liaison psychiatrists can improve the management of elderly patients and prevent unnecessary nursing home placement 6