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Acute confusion is a significant problem among elderly surgical patients, and it can impair the older adult's ability to localize, interpret, or communicate discomfort to care-givers. Discomfort is a common experience for hospitalized older adults, especially those recovering from trauma or surgery. In this study, 36 (78%) of the elderly (>74 yrs.) patients on an orthopedic/trauma unit were found to be at risk for or acutely confused. Three measures of discomfort were administered to these 36 confused patients by research assistants during routine postoperative nursing activities, such as turning, transfers, or bathing. Acute confusion needs to be viewed as a priority problem for nurses working with elderly surgical patients. Self-report is not a reliable indicator of discomfort in elderly confused patients. It is recommended that health care providers focus on discomfort as they provide care to these elders, and intervene in a preventive fashion.