Hospital Delirium in Elderly Patients
Your parent was fine before hospitalization, but now they're confused, agitated, or seeing things. This is likely delirium - a common, serious, but often reversible condition that caregivers must understand.
Sudden confusion in an elderly person is always a medical emergency, whether in the hospital or at home. It's a sign that something is seriously wrong with the body - an infection, medication reaction, dehydration, or other treatable condition. Never assume it's "just dementia" or "normal for their age."
What Is Delirium?
Delirium is a sudden, severe change in mental status caused by a medical condition. Key characteristics:
- Sudden onset: Develops over hours or days, not gradually
- Fluctuating: May be better in the morning, worse at night, or vary throughout the day
- Attention problems: Can't focus, easily distracted, drifts off
- Disorganized thinking: Rambling speech, illogical conversations
- Altered consciousness: May be hyperalert or drowsy
- Potentially reversible: Often improves when the underlying cause is treated
Delirium vs. Dementia
| Feature | Delirium | Dementia |
|---|---|---|
| Onset | Sudden (hours to days) | Gradual (months to years) |
| Attention | Severely impaired | Usually normal until late stages |
| Fluctuation | Changes throughout the day | Relatively stable day-to-day |
| Consciousness | Altered (drowsy or hyperalert) | Usually normal |
| Hallucinations | Common, often visual | Less common (except in Lewy body) |
| Reversibility | Usually reversible if cause treated | Progressive, not reversible |
| Duration | Days to weeks | Years |
People with dementia are MORE likely to develop delirium, not less. If your parent has dementia and suddenly gets much worse, don't assume it's "just the dementia progressing." Sudden worsening in someone with dementia should always be evaluated for delirium.
Types of Delirium
Hyperactive Delirium
Agitation, restlessness, trying to get out of bed, pulling at lines and tubes, hallucinations, combativeness. This type is obvious and usually gets attention.
Hypoactive Delirium
Drowsy, withdrawn, quiet, decreased movement, slow responses. This type is often MISSED because the patient isn't causing problems. It's actually more dangerous and associated with worse outcomes.
Mixed Delirium
Fluctuates between hyperactive and hypoactive states. May be calm in the morning and agitated at night.
What Causes Hospital Delirium?
Infections
UTI, pneumonia, sepsis - the most common triggers in elderly
Medications
Anesthesia, pain meds, sedatives, antihistamines, many others
Dehydration
Common in hospitalized patients, especially those on NPO status
Sleep Deprivation
Constant interruptions, unfamiliar environment, noise
Pain
Undertreated or unrecognized pain
Constipation
Often overlooked cause of confusion in elderly
Urinary Retention
Unable to empty bladder, especially after surgery
Metabolic Issues
Electrolyte imbalances, low blood sugar, kidney problems
Oxygen Levels
Low oxygen (hypoxia) from lung problems
Withdrawal
From alcohol, sedatives, or other substances
Risk Factors
Some patients are more likely to develop delirium:
- Age over 65 (risk increases with age)
- Pre-existing dementia (strongest risk factor)
- History of delirium
- Multiple medical conditions
- Taking many medications
- Vision or hearing impairment
- Malnutrition
- Alcohol use
- Depression
- Type of surgery: hip fracture, cardiac surgery, ICU stays
What You Can Do to Prevent Delirium
Family involvement can significantly reduce delirium risk:
Be Present
Having a familiar face in the room is protective. Consider rotating family members to provide consistent presence, especially in evening hours when delirium worsens.
Bring Orienting Items
Family photos, a clock, a calendar, familiar objects from home. These help maintain connection to reality.
Ensure Glasses and Hearing Aids
Sensory deprivation increases delirium risk. Make sure they have their glasses and hearing aids, and that they work. This is often overlooked in hospitals.
Advocate for Sleep
Ask staff to cluster care activities and minimize nighttime interruptions when possible. Close the door, dim lights, maintain normal sleep-wake cycles.
Encourage Fluids
Help them drink water regularly. Dehydration is a common trigger. Track intake if staff isn't closely monitoring.
Promote Mobility
Ask about getting them out of bed and walking. Immobility increases risk. Even sitting in a chair helps.
Keep Them Oriented
Remind them where they are, what day it is, why they're in the hospital. Gently reorient throughout the day.
What to Do If Delirium Develops
If you notice sudden confusion, tell the nurse right away. Say: "This is not my parent's baseline. This is a sudden change. I'm concerned about delirium." Don't accept "They're just confused from being in the hospital" as an answer.
Your Advocacy Role
- Report baseline: Tell staff what they were like before hospitalization
- Document timeline: When did changes start? What did you notice?
- Ask about causes: Request workup for infection, medication review, labs
- Question medications: Ask if any medications could be contributing
- Stay present: Your familiar face is calming
- Don't argue with delusions: Redirect gently
- Avoid restraints: Ask about alternatives - they worsen delirium
Calming Strategies
- Speak calmly and simply
- Maintain eye contact
- Use their name frequently
- Don't correct or argue - redirect
- Soft lighting, reduced noise
- Gentle touch if they find it comforting
- Familiar music at low volume
- Reassurance that they're safe
Recovery from Delirium
Even after the underlying cause is treated, delirium may take days to weeks to fully resolve. Some patients, especially those with prior dementia, may never fully return to baseline. Don't expect immediate improvement once the infection is treated or medication stopped.
Long-Term Implications
Delirium is not just a temporary inconvenience:
- Increased mortality: Higher risk of death in hospital and after discharge
- Longer hospital stays: Average 8 extra days
- Cognitive decline: May accelerate dementia or unmask previously hidden cognitive problems
- Functional decline: May not regain previous abilities
- Increased nursing home placement: Many can't return to previous living situation
- Recurrence risk: Previous delirium increases risk of future episodes
After Discharge
Delirium often persists after hospital discharge:
- Expect recovery to take weeks, not days
- Monitor for recurring symptoms
- Follow up with doctor within 1-2 weeks
- Continue orienting strategies at home
- Ensure adequate sleep and hydration
- Review all medications with doctor
- Watch for signs of depression
- Consider cognitive rehabilitation
If your parent experienced hospital delirium, document it for future reference. Make sure it's in their medical record. This information is crucial if they're hospitalized again - providers should know they're at high risk for delirium and take extra precautions.
Questions to Ask the Medical Team
- Has my parent been screened for delirium?
- What's being done to prevent delirium?
- Can unnecessary medications be reduced?
- How can we minimize sleep interruptions?
- When can they get out of bed?
- Are there alternatives to a urinary catheter?
- If delirium develops: What's the suspected cause? What tests are being done?
Be Prepared for Hospitalizations
Our Care Coordination Binder includes hospital advocacy checklists and medication lists to help prevent complications.
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