Delirium in Older Adults: A Medical Emergency Families Miss

What delirium is

Delirium is an acute state of confusion that develops over hours to days and fluctuates through the day. Key features:

• Inattention: the person cannot focus, is easily distracted, loses the thread of conversation.
• Disorganised thinking: rambling, illogical speech, confusion about time and place.
• Altered level of awareness: either agitated and restless (hyperactive), or drowsy, slow and withdrawn (hypoactive), or alternating (mixed).
• Fluctuation: better at times, worse at others, often worse in the evening and at night.
• Perceptual changes: misperceptions, hallucinations or delusions, such as seeing insects or believing carers mean harm.
• Sleep-wake reversal, disturbed sleep.
• Emotional changes: fear, anger, tearfulness.

The hypoactive form, quiet and sleepy, is the most commonly missed and carries a worse outlook. Anyone who is "not themselves" suddenly deserves attention.

Delirium, dementia and depression: how to tell

• Onset: delirium starts suddenly, over hours to days; dementia develops over months to years; depression over weeks to months.
• Course: delirium fluctuates through the day; dementia is relatively steady day to day; depression has persistent low mood.
• Attention: poor in delirium; relatively preserved in early dementia.
• Awareness: altered (drowsy or hyper-alert) in delirium; normal in dementia until late.
• Cause: delirium has an acute physical cause; dementia is a brain disease.

People with dementia are at much higher risk of delirium, and delirium may be mistaken for the dementia getting worse. Any sudden change in a person with dementia should be treated as possible delirium. The best clue is the family's own observation: "This is not how she normally is." Tell the doctor exactly what is different and when it started.

Common causes and triggers

Delirium usually has more than one contributor.

• Infections: urinary tract infection, chest infection (pneumonia), skin infections, any fever; also viral illnesses. Sometimes without fever in older people; see urinary tract infections in older adults and pneumonia in older adults.
• Dehydration and poor eating, low sodium or other salt imbalances; see hydration for older adults and diarrhoea and dehydration in seniors.
• Medicines: new medicines, dose changes, stopping medicines suddenly, sedatives, sleeping tablets, strong painkillers, anticholinergic medicines (some bladder, allergy and stomach medicines), steroids and others; also alcohol use or withdrawal; see medicine side effects families should watch and polypharmacy and deprescribing. Never stop a medicine on your own: call the doctor.
• Low or high blood sugar, particularly in diabetes; see diabetes and low-sugar emergencies.
• Low oxygen or breathing problems, heart failure, heart attack; see heart failure at home guide.
• Kidney or liver problems, thyroid disorders, anaemia.
• Constipation, urinary retention (not passing urine), pain.
• Surgery and anaesthesia, hip fracture; see hip fracture recovery at home.
• Hospital stay, unfamiliar surroundings, lack of sleep, immobility, catheters, restraint, noise, no glasses or hearing aids.
• Stroke, head injury, brain bleeds, seizures.
• Sensory loss unaddressed: hearing and vision.
• Sleep deprivation and lack of daylight, emotional stress, bereavement.
• Heat illness; see heat stroke and dehydration in seniors.

What to do if you suspect delirium

1. Act the same day. Call the doctor, or take the person to a doctor or emergency department, today. 2. Call 112 immediately if there is also: sudden weakness or face drooping or slurred speech (possible stroke; see stroke warning signs and the first hour); chest pain; severe breathlessness; a fit; unconsciousness or inability to wake; a head injury; very low sugar not recovering; or a high fever with stiff neck or rash. 3. Describe the change clearly: when it started, how it differs from normal, any fever, pain, fall, cough, burning urine, vomiting, diarrhoea, poor intake, constipation, new or changed medicines, alcohol, recent surgery or illness, and any history of dementia or earlier delirium. 4. Bring all medicines (including herbal and over-the-counter), and a medical summary; see emergency contact card and medical summary. 5. If a glucose meter is available, check blood sugar quickly, and a thermometer for temperature, but do not delay seeking help; see glucometer buying guide and digital thermometer guide. 6. Do not give sedatives or sleeping tablets or leftover medicines to calm the person: they can make delirium worse. 7. Keep the person safe: prevent falls, stay with them, remove hazards.

The doctor will examine, check vital signs, look for infection, check blood tests, sugar, salts, kidney function, oxygen levels, medicines and sometimes do scans, then treat the cause. Treatment of the underlying cause is the main treatment. Medicines to calm are used only in specific, severe situations, at the lowest dose for the shortest time, and non-drug measures come first.

Supporting the person during delirium

Non-drug care helps recovery and reduces distress.

• Familiar faces: a family member staying with the person, in hospital too, is among the best measures; have a calm, regular carer.
• Glasses, hearing aids and dentures in place and working; see hearing aid care and batteries.
• Orientation, gently: a clock and calendar, saying the day, place and who you are, without quizzing; see orientation aids for memory loss.
• Calm, quiet environment: low noise, soft light, few visitors at a time, familiar objects and photographs; avoid frequent room changes.
• Day and night cues: bright light and open curtains by day, darkness and quiet by night, to restore sleep rhythm; see sleep problems in older adults.
• Simple, calm communication; do not argue about hallucinations or false beliefs; reassure; see communicating with someone who has dementia.
• Food and fluids: offer drinks and small meals often; help with eating.
• Movement: encourage sitting up and walking with help, as soon as the doctor agrees; avoid bed rest.
• Toileting: regular prompts; check for constipation or retention; avoid catheters where possible.
• Pain control: watch for signs of pain and tell the doctor.
• Avoid restraint and unnecessary tubes or lines.
• Safety: prevent falls; a low bed, mat and supervision; see bed safety for restless sleepers.
• Reassure the family: hallucinations and strange behaviour are part of the illness and can improve.

Recovery

Delirium may clear in days, but can last weeks, and some people take months to return to baseline, particularly those with dementia. Some do not recover fully. After an episode, a person may be fragile, with increased risk of another. Keep follow-up with the doctor, repeat the cognitive assessment once recovered, review medicines and look at causes. Be patient and encouraging. Some people recall frightening experiences; reassure them and listen. See monitoring a parent after hospital discharge.

Preventing delirium

At home and in hospital, the following reduce risk, particularly for older adults with dementia or frailty:

• Treat infections early; do not ignore a UTI or cough.
• Keep hydrated and well fed; see malnutrition in older adults.
• Review medicines regularly, avoiding unnecessary sedatives and those that cloud thinking; never stop or start any without the doctor.
• Keep glasses and hearing aids in use.
• Maintain sleep routine and daylight.
• Keep mobile: walk and exercise; see chair exercises for seniors.
• Manage pain effectively.
• Prevent constipation; see constipation in older adults.
• Treat chronic diseases well.
• Before planned surgery, tell the team about memory problems and previous delirium; ask about measures to reduce risk; see hospital admission and discharge for seniors.
• In hospital, a family member staying, bringing familiar items and being alert to changes helps; speak up early if the person seems different.
• Avoid alcohol and sudden withdrawal.

Delirium and dementia: a two-way risk

Delirium can speed up cognitive decline in people with dementia, and dementia raises the risk of delirium. Prevention and early treatment protect brain health. A person who has had delirium should be checked for dementia once recovered; see mild cognitive impairment and dementia stages and what each needs.

For carers

Seeing a loved one confused and frightened is distressing. Stay calm, accept help, take turns, eat and rest; see caregiver burnout signs and prevention.

When to ask a professional

Ask a doctor or emergency department for any sudden confusion; this is urgent. A geriatrician can advise on delirium and medicines. A pharmacist can review medicines. A nurse can advise on care at home. For senior services, call Elderline 14567. In an emergency, call 112.