Delirium

Symptoms

Symptoms of delirium usually begin over a few hours or a few days. They typically happen along with another medical condition or in addition to other symptoms, such as pain or fever. Delirium symptoms often come and go. There may be times when symptoms disappear. Symptoms tend to be worse in dark or unfamiliar settings, such as at night or in a hospital room.

The main symptoms of delirium fall into several broad categories.

Less awareness of surroundings

This may lead to:

• Trouble focusing on a conversation topic or a following a change in topics.
• Getting stuck on an idea rather than responding to questions.
• Being easily distracted.
• Being withdrawn, with little or no activity or little response to surroundings.

Poor thinking skills

This may appear as:

• Poor memory, such as forgetting recent events.
• Not knowing where they are or who they are.
• Trouble with speech or remembering words.
• Rambling speech or speech that's hard to understand.
• Trouble understanding what others are saying.
• Trouble reading or writing.

Behavior and emotional changes

These may include:

• Anxiety, fear or distrust of others.
• Depression.
• A short temper or anger.
• A sense of feeling very happy or elated.
• Lack of interest and emotion.
• Quick changes in mood.
• Personality changes.
• Seeing things that others don't see.
• Being restless or anxious.
• Being quick to argue.
• Calling out, moaning or making other sounds.
• Being quiet and withdrawn.
• Slowed movement or being sluggish.
• Changes in sleep habits.
• Being awake at night and sleeping during the day.

Types of delirium

There are three types of delirium:

• Hyperactive delirium. This may be the easiest type of delirium to recognize. People with this type may be restless and pace the room. They also may be anxious, have quick mood swings or see things that aren't there. They may cry out or become agitated. People with hyperactive delirium may resist medical care or be unable to cooperate with medical care due to the change in their mental state.
• Hypoactive delirium. People with this type of delirium may have a low level of activity. They tend to be sluggish or drowsy. They might seem to be in a daze. They tend not to interact with other people.
• Mixed delirium. Symptoms of mixed delirium include symptoms of both of the other types of delirium. People with mixed delirium may quickly switch back and forth from being restless and anxious to being sluggish and drowsy.

Delirium and dementia

Delirium and dementia may be hard to tell apart. Some people may have both. Someone with dementia has a slow decline of memory and other thinking skills. This is due to damage or loss of brain cells. The most common cause of dementia is Alzheimer's disease, which comes on slowly over months or years.

Delirium often happens in people with dementia. But having an episode of delirium doesn't always mean a person has dementia. Tests for and a diagnosis of dementia shouldn't be made during a delirium episode because test results may not be accurate.

Some differences between the symptoms of delirium and dementia include:

• How quickly symptoms start. Symptoms of delirium appear quickly, typically over a day or two. Dementia begins with minor symptoms that get worse over time.
• Attention. It's hard for people with delirium to stay focused. In contrast, people in the early stages of dementia generally stay alert. Someone with dementia often isn't sluggish or agitated.
• Rapid changes in symptoms. Delirium symptoms can come and go several times during a day. While people with dementia have better and worse times of day, their memory and thinking skills typically stay at a constant level.

When to see a doctor

If a family member, friend or someone you support shows symptoms of delirium, talk to that person's healthcare professional as soon as possible, especially if there are symptoms of an infection, such as a cough or urinary concerns. Your input about a person's symptoms, typical thinking and other abilities will be important for a diagnosis. Telling the team about changes you've seen also can help find the cause of delirium.

If you notice symptoms of delirium in someone in the hospital or in a long-term care center, tell the nursing staff or another member of the healthcare team right away. Older adults who are in the hospital, especially those in intensive care, and people living in a long-term care center are at higher risk of delirium.

Risk factors

Any condition that leads to a hospital stay raises the risk of delirium. This is especially true when someone is recovering from surgery or is in intensive care. Delirium is more common in older adults who are in the hospital and in people who live in long-term care centers.

Examples of other conditions that may raise the risk of delirium include:

• Brain disorders such as dementia, stroke or Parkinson's disease.
• Past delirium episodes.
• Vision or hearing loss.
• Substance use or withdrawal, including alcohol and other drugs.
• Having multiple medical conditions.

Prevention

Some steps can help prevent delirium or make it less serious if it happens. Those steps include:

• Getting good sleep.
• Staying calm and aware of surroundings.
• Preventing or quickly treating medical concerns.
• Avoiding medicines used for sleep, such as diphenhydramine (Benadryl Allergy, Unisom, others).

Taking these steps may be hard when someone is in the hospital. That's because hospital stays often include room changes, invasive procedures, loud noises and poor lighting. And lack of natural light and lack of sleep can make confusion worse. If you're worried that someone in the hospital may be at risk of delirium, talk to a member of the healthcare team.

Treatment

Treating delirium first involves addressing anything that could have caused delirium. That may include stopping some medicines, treating an infection or treating a lack of nutrients in the body. After that, treatment of delirium focuses on creating the best setting for healing the body and calming the brain. That may include a range of measures.

Supportive care

The goal of supportive care is to prevent a person from developing other health issues as a result of delirium. To do that, the healthcare team likely will take the following steps:

• Provide fluids and nutrition.
• Assist with movement.
• Treat pain.
• Make sure the person can breathe easily.
• Address any issues with bladder control.
• Treat constipation.
• Avoid using IV lines or bladder tubes if possible.
• Avoid changes in surroundings and caregivers when possible.
• Include family members or other familiar people in care.

Medicine

If you're a family member or caregiver of someone who has delirium, talk with a member of the healthcare team about medicines that may trigger symptoms. The person with delirium may need to stop taking those medicines or take them at a lower dose.

Sometimes pain may cause delirium. In those situations, medicine may be prescribed to manage pain. Other medicines may help calm a person who is agitated or confused. Or medicines may be needed if the person is showing distrust of others, is fearful or is seeing things that others don't see. These medicines may be needed when symptoms:

• Make it hard to do a medical exam or provide treatment.
• Put the person in danger or threaten the safety of others.
• Don't lessen with other treatments.

When symptoms go away, the medicines are usually stopped or are given in lower doses.

Preparing for an appointment

If you're a family member or primary caregiver of a person with delirium, you'll likely play a role in making an appointment or giving information to the healthcare team. Here's some information to help you get ready for the appointment and know what to expect.

What you can do

Before the appointment, make a list of:

• All medicines the person takes. That includes all prescriptions, medicines available without a prescription and supplements. Include the doses and note any recent medicine changes.
• Names and contact information of any person who provides care for the person with delirium.
• Symptoms and when they started. Describe all symptoms and any changes in behavior that began before the delirium symptoms. These might include pain, fever or coughing.
• Questions you want to ask the healthcare professional.

What to expect from the doctor

A healthcare professional is likely to ask questions about the person with delirium. The questions may include:

• What are the symptoms and when did they begin?
• Has there been a recent fever, cough or urinary tract infection or any sign of pain?
• Was there a recent head injury or other trauma?
• What were the person's memory and other thinking skills like before the symptoms started?
• How well did the person perform everyday activities before symptoms started?
• Can the person usually function independently?
• What other medical conditions have been diagnosed?
• Are prescription medicines taken as directed? When did the person take the most recent dose of each?
• Are there any new medicines or supplements?
• Do you know if the person recently used drugs or alcohol? Does the person have a history of problematic alcohol or drug use? Is there any change in the pattern of use, such as increasing or stopping use?
• Has the person recently seemed depressed, very sad or withdrawn?
• Has the person shown signs of not feeling safe?
• Has the person recently seemed distrustful, suspicious or afraid of other people?
• Has the person seen or heard things that no one else does?
• Are there any new physical symptoms, such as chest or stomach pain?