In home care, we often hear: “They’re just more confused today.”
But a sudden change in confusion should never automatically be put down to dementia or ageing.
A client who is normally settled but suddenly becomes confused, drowsy, agitated, withdrawn or simply “not themselves” may be experiencing delirium.
Delirium can be a sign that something else is medically wrong, and the underlying cause needs to be identified.
What Is Delirium?
Delirium is a sudden change in a person’s thinking, attention and awareness.
It can develop over hours or days and may fluctuate throughout the day. A client may appear relatively well in the morning and be significantly confused later that afternoon.
Delirium is not a normal part of ageing.
Common causes or contributing factors can include:
- infection, including urinary or chest infections
- constipation or faecal impaction
- urinary retention
- dehydration
- pain
- medication changes or side effects
- low oxygen levels
- fever
- electrolyte or metabolic disturbances
- low or high blood glucose
- recent surgery or hospitalisation
- poor sleep or sleep deprivation
- alcohol or medication withdrawal.
Don’t Forget the Basics
Sometimes the cause is not immediately obvious.
In home care, think about the simple things too:
- When did the client last open their bowels?
- Are they passing urine normally?
- Are they drinking enough?
- Are they eating?
- Are they in pain?
- Has anything changed with their medications?
Constipation, particularly severe constipation or faecal impaction, can cause considerable pain and distress and may contribute to delirium in an older or vulnerable person.
A change in bowel habits can therefore be an important piece of clinical information.
What About Dementia?
Dementia usually develops much more gradually.
Changes typically occur over months or years, rather than suddenly over a few hours or days.
A person living with dementia may progressively experience difficulties with:
- memory
- communication
- problem solving
- judgement
- orientation
- behaviour
- completing familiar tasks.
Their abilities can change over time, but a sudden or significant change from their usual behaviour still needs attention.
Delirium and Dementia Can Occur Together
This is particularly important in home care.
A person who already has dementia can also develop delirium.
In fact, people living with dementia can be particularly vulnerable to delirium.
So if someone with dementia suddenly becomes dramatically more confused, don’t simply assume: “That’s just their dementia getting worse.”
Ask yourself: Is this normal for this person, or is something different today?
Knowing your client’s normal behaviour and level of functioning is extremely important.
What Might You Notice?
A client experiencing delirium may suddenly:
- become much more confused
- not recognise familiar people or surroundings
- become unusually sleepy or difficult to wake
- become agitated, restless or frightened
- behave very differently from normal
- have difficulty following a conversation
- lose concentration easily
- see or hear things that are not there
- become suspicious or paranoid
- stop or significantly reduce eating and drinking
- become suddenly incontinent
- have a change in mobility
- become much weaker
- experience falls or near falls.
Delirium Isn’t Always Agitation
Some people with delirium become restless, noisy or agitated. Others become very quiet, sleepy and withdrawn.
This quieter form can be much easier to miss.
If a normally chatty client suddenly becomes sleepy, disengaged or unusually quiet, that change can be just as important as agitation.
Delirium vs Dementia – A Quick Guide
| Delirium | Dementia |
|---|---|
|
|
“They just don’t seem right”
This is one of the most valuable observations a nurse or carer can make. You might not know exactly what is wrong, but you know the client.
You may find yourself saying:
“She is much sleepier than usual.”
“He isn’t making sense today.”
“Normally she knows exactly who I am.”
“He’s hardly eaten or drunk anything today.”
“She hasn’t opened her bowels for several days.”
“He keeps trying to get out of bed and he never normally does that.”
These observations matter.
A change from the client’s normal baseline is important clinical information.
You do not need to know the diagnosis before reporting the change.
What should you do?
- If you notice a sudden change:
- Stay with the client and assess what you can within your role and scope of practice.
- Report the change promptly to the RN, Clinical Manager or appropriate healthcare professional in accordance with the client’s care plan.
- Consider what else has changed – bowel movements, urine output, fluid and food intake, pain, temperature, breathing, mobility, sleep and medications.
- Document what you have observed, when it started and what action you took.
- Escalate urgently if the client appears seriously unwell.
If there is severe deterioration, reduced consciousness, significant breathing difficulty, signs of stroke, severe chest pain or another medical emergency, call 000.
Good documentation matters
Avoid simply writing: “Client confused today.”
It doesn’t tell the next nurse or carer very much.
A better note would be: “At approximately 1400, client appeared significantly more confused than usual baseline. Client normally recognises regular staff and is orientated to her home. Today she repeatedly asked where she was and did not recognise her regular carer. Reduced oral intake noted. Client has also not opened bowels for three days. RN notified at 1415.”
That gives the clinical team useful information to act on.
Carers – your observations are important
Carers are often the people who spend the most time with a client.
You may notice a subtle change before the family, GP or visiting nurse does.
Never think: “I’m only the carer.”
Knowing what is normal for that individual – how they talk, walk, eat, drink, toilet, sleep and behave – makes your observations extremely valuable.
You are not expected to diagnose delirium.
Your job is to recognise that something has changed and escalate it.
The Take-Home Message
A person with dementia can certainly have good days and bad days.
But a sudden or significant change should never automatically be blamed on dementia.
Think:
- What has changed?
- When did it start?
- When did they last open their bowels?
- Are they eating, drinking and passing urine normally?
- Are they in pain?
- What else am I noticing?
Then report it.
Sometimes the first and most important clinical observation is simply: “They are just not themselves today.” Recognising that change and acting on it early can make a very significant difference.
