Masking in Hospitals and Nursing Homes as a Major Causative Agent for “Confusion” in the Elderly

Masks are likely a major source of increased confusion for older adults & their caregivers in nursing homes - and are still mandatory.

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As a longtime geriatrician with a career that’s been almost exclusively spent in the long-term care space, I’m acutely aware of how disruptive and potentially harmful to care it is when my older adult patients become more confused, for whatever reason.

Bad things can happen! When confused, older adults are more prone to miscommunications and misunderstandings with their care providers, suffer from more frustration, are diagnosed with cognitive deficits and dementia more readily – and by virtue of their confused state – are more likely to exhibit what we colloquially refer to as “behavior problems” in our field.

So - what is “confusion” or being “confused”?

From Confusion | definition of confusion by Medical dictionary (thefreedictionary.com)

I think this is a pretty good working definition. The fact is – as we tend to use the term in geriatrics, it’s really a pretty general, descriptive term – one that’s not particularly specific to any one particular chronic or acute disease entity, state, or condition.

But, obviously, like I said – a confused older adult or nursing home patient is a much more difficult patient to work with. They are less able to understand patient education. They get frustrated easier and may “check out” during conversations with doctors or nurses. They may even get ‘written off’ as being “senile” or “demented” by some helpers or clinicians, which can lead to all sorts of additional problems if such a label is prematurely affixed.

What Can Cause “Confusion”?

What can cause an older adult to be “bewildered, perplexed, or unable to orientate herself or himself?” The fact is there’s any number of potential causes. Dementia (like from Alzheimer’s disease), delirium, alcohol use, medication side effects, poor oxygenation (like due to asthma), poor sleep…. And that’s not even an exhaustive list!

While any number of the above issues can be corrected medically, by addressing the underlying medical causes – the fact is in my line of work we start with the interventions that are the safest and easiest to effectively executive first before we move up the chain.

So, for example, while poor sleep may be contributing to an older adult’s confusion, and certainly should be addressed, it’s not always easy to make the lifestyle changes (better sleep hygiene, etc.) needed to improve sleep quality quickly, and moreover, medications to treat insomnia, particularly for older people, have significant downsides.

So before we start tackling the proverbial higher-hanging fruit in the tree when in comes to tackling the issue of a confused older adult, what should come first?

If it’s a new patient, the best thing to do is start simple.

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We Correct for Sensory Issues First

Has their eyeglass prescription been updated recently? Has their eyesight changed? Good to get them a new vision test if so. How about hearing aids? If they have them, do they need to be checked / recalibrated? If they don’t, maybe they need some? The idea here is that sensory issues are potentially a major source of “confusion” in older adults (e.g., poor vision, poor hearing) and are often easily correctible.

I can speak of any number of situations where simply making sure patients had a current eyeglass prescription and ready access to effective hearing aids significantly reduced reports of a patient seeming confused, befuddled, or even “we suspect he / she’s got dementia.”

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The Forever Masking Craze as an Underappreciated Source of “Confusion” in Older Adults

You knew I would get to this. So at my nursing home, for the last 2+ years now, we’ve had a “universal masking” policy (like all nursing homes & hospitals in the US) which means that staff and patients are required to mask on the premises.

Obviously, for our residents who don’t comply with masks due to dementia – we don’t force them. But for everyone else, and for staff, masks (and for staff, face shields – a plastic covering that goes over the mask) is required as a condition of employment.

As Schroeter et al (2021) note in their article in Frontiers in Psychology, the source of the confusion in older adults caused by masking may be much more than just the muffling of voices that masks achieve (and it’s true – they do that as well – see Nienke et al 2022): masking is a full-fledged “mass disabling event” on older adults’ ability to engage in social cognition.

That is to say, the act of physically preventing the perception and processing of social cues (not just language) in older adults - this very likely causes all sorts of significant downstream problems for residents in nursing homes – particularly (but not exclusively) those with pre-existing dementia and cognitive impairment. Such as:

• Masks impair older adults’ ability to hear and process auditory speech. This alone is a significant source of increased confusion.

• Masks (if simultaneously worn by older adults) impair their ability to be understood (and this is not insignificant – as many older adults already have problems with dysphasia / dysarthria (e.g., problems with articulating and producing speech).

• Masks also block the visual perception of facial expressions. Some have argued (most famously and currently Mark Changizi and Tim Barber, in their new book “Expressly Human”) that facial expressions, in fact, are some of the most foundational methods of communication we have have as a species.

Regarding that last point – it’s very, very important to recognize that in dementia, one of the deficits that often go first is deficits in spoken language (e.g., aphasia, anomina) – often leaving the sufferer disproportionately reliant on reading facial cues (particularly mouth cues) and expressions in order to understand others. Which we take away with masks.

That’s right - masks are almost like a double gut-punch to the social functioning of older adults, to both their ability to verbally community as well as their ability to read facial expressions and decode evolutionarily important facial expressions if they suffer from cognitive impairment and poor hearing (which very frequently co-occur).

Why do I Keep Harping About Masks?

I keep talking about masks because my patients & residents are people. I very much take seriously their whole health as people.

The most important thing to remember is that despite how one feels about vaccination, for older adults in nursing homes, it’s clearly the best defense there is against COVID from a risk-reward perspective. Depending on what data you consult, it’s made COVID infection for many vaxxed / boosted seniors less serious than infection with a seasonal flu.

Moreover, the ubiquity of rapid testing (we in the nursing home biz are used to regular COVID swabbing – I am tested 3x a week) makes the probably-rather-exaggerated bugaboo of “asymptomatic transmission” less of an issue as well.

I personally believe that we are rapidly hurtling towards a situation where the remaining NPIs (that’s short for Non Pharmaceutical Interventions) that exist in hospitals and nursing homes now border on ongoing abuse – particularly for my population of older adult nursing home patients.

Outside of active outbreak situations, my opinion is masks for older adults in nursing homes should be stopped entirely. We should revert largely back to how we treated localized outbreaks prior to COVID, such as when we had flu outbreaks – stop visitations, initiate quarantines or sequestered units, gown, glove, and use N95s, and then when the outbreak clears – remove all of this and allow residents and staff to go back to life as before.

The stupid plastic barriers at nursing stations should be removed as well.

Keep the testing regime at the door, the temperature screenings, and of course keep up with vaccinations.

To be perfectly honest, the masking, banning / hugely restricting visitations, banning conjugal dining, restricting recreational therapy activities and etc. – all of that stuff – it has only marginal effectiveness on preventing infections in my patients, and at this point, I think the harms to my patients have far outstripped, net-net, the benefits. We have a much more sad, confused, agitated and likely debilitated population of older adults because of the persisting use of masks in our nursing homes (as well as a number of any other lingering NPIs that we just can’t seem to quit).

Just one geriatric doc’s opinion.

References

Nienke C. Homans & Jantien L. Vroegop (2022) The impact of face masks on the communication of adults with hearing loss during COVID-19 in a clinical setting, International Journal of Audiology, 61:5, 365-370, DOI: 10.1080/14992027.2021.1952490

Schroeter, M. L., Kynast, J., Villringer, A., & Baron-Cohen, S. (2021). Face masks protect from infection but may impair social cognition in older adults and people with dementia. Frontiers in Psychology, 3460.

Changizi, M., & Barber, T. P. (2022). Expressly human: Decoding the language of emotion. BenBella Books, Inc.