Delirium (Sudden Confusion)

What it is

Delirium is a sudden disturbance of awareness, attention and thinking that develops quickly, over hours to a few days, and characteristically fluctuates, often worse at night, with the person seeming clearer at some moments and very confused at others. The person may be unable to focus or follow a conversation, become disoriented about time and place, experience muddled thinking, and sometimes have frightening hallucinations or false beliefs.

The single most important thing to understand about delirium is that it is a medical emergency and a sign that something is physically wrong with the body. It is not a mental illness in the usual sense, not madness, and not, as it is sometimes feared, possession or bewitchment. It is the brain's response to a physical insult, and finding and treating that physical cause is both the treatment and, very often, the cure.

What it can look like

There are two main forms, and one is dangerously easy to miss. In hyperactive delirium, the person is agitated, restless, distressed, perhaps hallucinating or trying to pull out drips, which is alarming but at least gets noticed. In hypoactive delirium, the person becomes quiet, drowsy, withdrawn and slow, which is frequently mistaken for tiredness, low mood or simply "going downhill," and so goes unrecognised. Many people fluctuate between the two. A sudden change in an older person's alertness or behaviour, in either direction, should raise the alarm.

Why it matters so much

Delirium is common in unwell older people, especially in hospital, and it is serious. It is associated with longer illness, greater risk of lasting decline, and higher mortality, and it is distressing for the person and the family. Yet because it is so often mistaken for dementia, for ordinary ageing, or for a psychiatric problem, the underlying physical cause can be missed, with serious consequences. Recognising delirium for what it is, an urgent signal of physical illness, can be lifesaving.

What causes it

Delirium is triggered by physical problems, often several at once, particularly in someone who is older or already frail. Common causes include infections (a urinary or chest infection is a classic trigger in older people), dehydration, pain, constipation or urinary retention, low oxygen, disturbances of the body's salts and sugar, medicines and especially new ones or several together, alcohol or sedative withdrawal, and the stress of surgery. Often it is a combination, and the more vulnerable the brain, for example in someone who already has dementia, the smaller the trigger needed.

How it is diagnosed

Delirium is diagnosed clinically by recognising the sudden, fluctuating change in awareness and attention, ideally with an account from family of how quickly it came on, which is the key feature that separates it from dementia. The essential work is then finding the cause: a doctor examines the person and orders tests, looking for infection, checking the body's salts, sugar and oxygen, reviewing all medicines, and considering pain, constipation and other triggers. A new diagnosis of confusion in an older person should always prompt the question "is this delirium?" before it is attributed to dementia or age.

How it is treated

The treatment of delirium is to find and treat the cause: the infection, the dehydration, the offending medicine, the pain, the constipation. As the physical problem is corrected, the delirium usually lifts, though recovery can take days to weeks and is sometimes incomplete in very frail people. Alongside treating the cause, good supportive care helps greatly and can be provided by family: a calm, well-lit environment, familiar faces and objects, glasses and hearing aids in place, gentle reorientation, good hydration and nutrition, undisturbed sleep at night, and avoiding unnecessary moves and restraints. Medication is not the treatment for delirium and can worsen it; sedatives are used only sparingly, for severe distress or danger, and with caution.

Delirium in the African context

Delirium is common and dangerous yet widely unrecognised, and in many settings the sudden confusion, agitation, or hallucinations it causes are mistaken for madness, dementia, or bewitchment rather than the medical emergency they are. This matters greatly, because delirium is usually caused by something treatable, an infection such as malaria, pneumonia, or a urinary infection, dehydration, medication, or alcohol withdrawal, and it often clears when that cause is treated. In an older person especially, sudden confusion should prompt urgent medical care, not a spiritual or behavioural response. Recognising delirium for what it is can save a life.

What families can do

Families are often the first to notice delirium, and quick action matters.

• Treat sudden confusion, especially over hours or days, as a medical emergency and seek urgent care.
• Tell the health team when the change began and what is different, since they may not know the person's normal state.
• Mention all medicines, recent illness, alcohol use, and missed fluids, which help find the cause.
• Keep the person calm, oriented, and safe, with familiar faces, good lighting by day, and quiet at night.
• After recovery, watch for lingering effects, and support the underlying health condition.