7.3 Depression, Anxiety, Confusion, and Delirium Awareness

Mood and Thinking Changes Are Care Findings

A nurse aide does not diagnose depression, anxiety, confusion, or delirium, but the aide is usually the first to notice them. The aide sees whether the resident ate breakfast, slept, cried during care, avoided activities, answered differently, or became suddenly restless. These observations matter because mood and thinking changes affect safety, nutrition, hydration, mobility, skin integrity, and quality of life. On the Texas written test, distinguishing a chronic baseline from an acute change is a recurring theme.

Depression is more than a sad day. It can show as persistent sadness, loss of interest, low energy, poor appetite, weight loss, sleep change, withdrawal, slowed movement, irritability, frequent crying, poor concentration, or statements of guilt, worthlessness, or wanting to die. Some residents deny sadness but quietly stop attending meals or refuse grooming. Depression is not a normal part of aging and should never be shamed away.

Observe, Support, Report Aid

Anxiety may appear as fear, repeated call lights, pacing, trembling, restlessness, rapid speech, shortness of breath, stomach upset, or refusal to be alone. Triggers include pain, unfamiliar caregivers, noise, dementia, trauma history, family conflict, medical procedures, or fear of falling. The aide can lower stimulation, explain what is happening, offer choices, stay briefly if safe, and report symptoms.

Delirium Versus Dementia: The Highest-Yield Distinction

This contrast appears on nearly every CNA exam.

• Dementia develops slowly over months to years, is usually irreversible, and the level of alertness stays stable.
• Delirium develops suddenly over hours to days, fluctuates through the day, and is often reversible when the cause is treated. Causes include infection (urinary tract infection and pneumonia are common in elders), dehydration, low oxygen, medication effects, uncontrolled pain, constipation, urinary retention, and sleep deprivation.

Because delirium signals a possibly serious acute illness, sudden confusion is always urgent. A resident who was oriented yesterday and today does not know where they are needs prompt reporting. By contrast, a resident who is always forgetful but pleasant may simply be at baseline.

The aide's response is safety first. Make sure the resident is not climbing out of bed, pulling tubing, wandering unsafely, or choking. Keep the call light in reach, remove hazards, leave the bed in the care-plan position, and stay calm. Use gentle reorientation: "It is Tuesday morning, you are in your room, and I am here to help you wash up." Do not scold or argue with hallucinations; if the resident is frightened by something they see, acknowledge the fear and report.

Basic needs can worsen mood and confusion. Check whether the resident needs the toilet, has pain cues, is hungry, thirsty, too hot, too cold, overstimulated, or missing glasses, dentures, or hearing aids. Correct what is within the CNA role and report what is not. If the resident has diabetes, oxygen, urinary problems, recent falls, or infection signs, include those facts when reporting.

Documentation must be objective. Instead of writing that the resident was "crazy," report that she tried to climb over the bed rail three times between 0700 and 0730, did not know where she was, and said there were people in the closet. Add what helped, such as lowering noise, toileting, or staying nearby. Objective means observable facts, not opinions or labels; "refused lunch and ate two bites" is objective, while "was uncooperative" is a judgment.

Suicide-Risk Warning Signs the Aide Must Report

Depression in elders can become a safety emergency. Texas requires the aide to report any statement or behavior suggesting self-harm immediately, and there is no permission to keep such a statement secret. Watch for these warning signs and report every one of them to the nurse without delay.

• Statements such as wanting to die, being a burden, or wishing not to wake up
• Giving away prized belongings or saying goodbye in an unusual way
• A sudden calm or improvement after a period of deep depression, which can signal a decision
• Hoarding medication, refusing food and fluids, or refusing all care
• Sudden withdrawal from family, friends, or favorite activities

The aide does not counsel, diagnose, or judge the resident. The aide listens calmly, keeps the resident safe and in sight if asked, and reports the facts so the nurse and care team can act. Anxiety, depression, confusion, and delirium often overlap, and the aide's job is the same in each case: observe carefully, meet basic needs, protect safety, and report.

Urgent Report Triggers

Report immediately if a resident threatens self or others, sees or hears frightening things, becomes suddenly confused, has new severe anxiety, new extreme sleepiness, sudden agitation, a fall, a head injury, fever signs, new weakness, poor intake, or any major change from their usual mood or behavior.