Confusion, Hallucinations and Sudden Change: When to Call

Delirium versus dementia versus other causes

| | Delirium | Dementia | Other (for example, depression, psychosis) | |---|---|---|---| | Onset | Sudden, over hours to days | Gradual, over months to years | Variable | | Course | Fluctuates, often worse at night | Slowly progressive | Variable | | Attention | Poor, easily distracted, drowsy or agitated | Usually preserved until later stages | Variable | | Awareness | Altered, may sleep by day and be awake at night | Usually alert | Usually alert | | Cause | Almost always a physical trigger | Brain disease | Mental health condition |

A person with dementia can also develop delirium on top, and this is common. Any sudden worsening in someone with dementia should be treated as possible delirium; see delirium in older adults, delirium and dementia and dementia sundowning.

Signs of sudden change

• New confusion about time, place or people.
• Difficulty paying attention or following conversation; rambling or nonsensical speech.
• Drowsiness, difficulty waking, or the opposite: restlessness, agitation, picking at clothes or bedding, shouting.
• Fear, suspicion, delusions (fixed false beliefs) or hallucinations (seeing, hearing or feeling things that are not there).
• Sleep reversal: awake at night, sleepy by day.
• Sudden change in behaviour, appetite or mood.
• Loss of ability to do things they could do the day before: walking, feeding, speaking, using the toilet.
• Falls, incontinence or withdrawal that is new.

Common causes to think about

Doctors use a checklist of physical triggers; families can help look for them.

• Infections: urine infection, chest infection or pneumonia, skin or wound infection, a tooth abscess, flu, covid, or other illnesses; older people may have no fever; see urinary tract infections in older adults, pneumonia in older adults: prevention and recovery and fever in older adults: why it can be subtle and when to call.
• Dehydration and poor intake: see hydration for older adults: how much and how to remember and heat stroke and dehydration in older adults.
• Blood sugar problems: very low or very high sugar in diabetes; see hypoglycaemia in older adults and diabetes and low sugar emergencies.
• Medicines: new or changed medicines, too many medicines, sedatives, sleeping tablets, strong painkillers, anticholinergic-type medicines, and sudden stopping of some medicines or alcohol; see medicine side effects families should watch for and polypharmacy and deprescribing: taking fewer, better medicines. Never stop or change prescribed medicines on your own; call the doctor for advice.
• Pain, constipation and urinary retention: untreated pain, a full bowel or bladder; see constipation in older adults: fibre, fluids and movement and prostate problems and urinary symptoms in older men.
• Low oxygen or high carbon dioxide: from heart or lung disease; see when oxygen saturation is low: what to do.
• Stroke or bleeding in the brain, especially after a fall or head injury.
• Kidney or liver problems, electrolyte imbalance (such as low sodium).
• Thyroid disease and vitamin deficiencies; see thyroid problems in older adults.
• Alcohol intoxication or withdrawal; see alcohol and medicines in older adults.
• Sensory loss: missing glasses or hearing aids; see dual sensory loss in older adults.
• Carbon monoxide or poisoning, where several people feel unwell with headache and drowsiness; see smoke and gas safety for older adults.

Hallucinations: some specific patterns

• Delirium: frightening, changing visions, often at night, with confusion.
• Lewy body dementia and Parkinson's disease: well-formed, detailed visual hallucinations, such as people or animals, may occur early, with fluctuating alertness; see parkinson's disease at home: a practical guide. Some medicines can trigger or worsen them; the doctor may adjust treatment. Do not change Parkinson's medicines without the doctor.
• Alzheimer's and other dementias: misperceptions and false beliefs (for example, accusing others of theft) are common; see dementia challenging behaviours.
• Charles Bonnet syndrome: in people with serious loss of vision, the brain "fills in" the gaps with vivid images (patterns, faces, scenes). The person usually knows they are not real and is not otherwise confused. It is harmless but can be frightening; see an eye doctor, improve lighting and reassure; see glaucoma and macular degeneration at home and low vision home safety.
• Medicines and withdrawal: see above.

Any new hallucination needs a doctor's review, particularly if sudden or distressing.

What to do at home: first steps

1. Stay calm and safe. Keep your voice low; keep the person from hazards (stairs, kitchen, doors, open flame); do not argue; do not restrain unless there is immediate danger. 2. Check the basics: Are they in pain? Do they need the toilet? Hungry or thirsty? Too hot or cold? Wearing their glasses and hearing aids? Is the room well lit? 3. Check vital signs: temperature, pulse, blood pressure, breathing, and blood sugar if diabetic; see digital thermometers: choosing and using them for older people, how to measure blood pressure at home accurately, how to test blood sugar at home and monitoring an older adult during an acute illness at home. 4. If blood sugar is low and the person can swallow safely, give a quick sugar source, and call for help; see hypoglycaemia in older adults. 5. Note recent changes: new medicines, falls, illness, alcohol, poor intake, bowel and bladder habits, when it began and how it varies. 6. Call the doctor the same day, or sooner if signs below apply. 7. Gather medicines and a summary to show the doctor; see emergency contact card and medical summary. 8. Do not give sleeping tablets, sedatives or leftover medicines to "calm" the person, as these can worsen delirium and cause falls.

Responding to confusion and hallucinations

• Approach calmly from the front, say your name, and speak slowly in short, simple sentences.
• Do not argue or correct harshly. If your parent sees a person in the corner, acknowledge the fear ("I can see that you are frightened") rather than agreeing or denying; reassure that you are there; gently draw attention elsewhere; turn on the light; check if shadows or reflections could be misunderstood; see dementia communication tips and a better way of communicating with someone who has dementia.
• Reorient gently: a clock, a calendar and familiar objects help; see orientation aids for memory loss and consider a talking clock; see talking clock guide.
• Light and sound: bright, even lighting by day, a dim light at night, and no flickering shadows; reduce noise and clutter; see reading lamp and lighting for older eyes.
• Encourage fluids, food and gentle movement; see loss of appetite in older adults: causes and practical fixes.
• Keep glasses, hearing aids and dentures in.
• Watch for wandering, and secure doors and exits; a door sensor can alert you; see wandering and dementia safety, door sensor guide and lock and door safety for seniors.

When to call the doctor, and when it is an emergency

Call 112 or go to hospital at once for: - Sudden confusion or drowsiness with stroke signs: face droop, arm or leg weakness, speech difficulty; see stroke warning signs and the first hour. - Confusion after a fall or blow to the head. - Difficulty waking, unresponsiveness, fits. - Severe breathlessness, blue lips, chest pain. - Very low sugar that does not improve, or a sugar reading that is dangerously high with vomiting. - High fever with stiff neck, rash or severe headache. - Suspected overdose, poisoning or carbon monoxide; get everyone into fresh air. - Signs of shock: cold clammy skin, fast weak pulse, fainting.

Call the doctor the same day for: any new or worsening confusion, new hallucinations or suspiciousness, a marked change in sleep or behaviour, or if your parent is not drinking, not passing urine, or has new pain. If you cannot reach the doctor, go to the nearest emergency department.

Afterwards: recovery and prevention

• Treat the cause. Delirium can take days or weeks to clear, and some people do not return fully to their previous level, so early treatment matters.
• Continue gentle orientation, movement, nutrition and sleep routines.
• Review medicines with the doctor; reduce unnecessary ones.
• Plan for future risk: a person who has had delirium is at higher risk again, and may have an underlying memory problem; ask for a memory assessment after recovery; see mild cognitive impairment: what it is and what families can do and dementia stages and what each needs.
• Mood: fear and low mood may follow; see depression in older adults. If your parent speaks of not wanting to live, stay with them and seek help the same day; Tele-MANAS (14416) is India's national mental health helpline (check the current number).

When to ask a professional

Ask the doctor for urgent review of any sudden change; a geriatrician or psychiatrist for hallucinations, dementia or repeated episodes; an eye doctor for Charles Bonnet syndrome; a pharmacist for a medicine review. Seek emergency help for the signs above.