Confusion

Causes of delirium

Serious illness causes a burden on the entire body – including the brain. The brain can cope with many different stresses related to illness, but there is a point at which all the different stresses add up and become too much to handle.

In advanced illness, there are often many factors which can make someone vulnerable to developing delirium. Delirium is particularly common near the end of life.

• infection
• medications
• low levels of oxygen in the blood (hypoxia)
• increased pressure on the brain from tumour or injury
• chemical imbalances in the bloodstream, such as a high level of calcium caused by a tumour
• withdrawal from alcohol or drugs
• pain
• person’s general medical condition
• constipation or urinary retention

Signs of delirium

Trouble sleeping
Commonly, the first sign of delirium is trouble sleeping, often with disturbing, vivid dreams. The patient may describe the dreams as very strange yet very real.

Increased confusion at night
Sometimes people are sleepy during the day, and restless and confused at night, as their day/night cycles become switched around. The term 'sundowning' describes worsening of confusion and behaviour in the evening. During the day, there may be no obvious problems, or there may be fluctuations in the degree of confusion.

Feeling threatened
It is not unusual for confused patients to feel threatened by other people or by changes in their surroundings. They may be reluctant to trust family, friends, and caregivers, and may believe that people bringing their medications are trying to poison them – this is called being paranoid. In a way, paranoia might be considered a practical method of self-protection – if it is not possible to sort out the world any longer, it is safest to consider everything a threat.

Inappropriate or hurtful comments
People who are confused, particularly if they have become paranoid, may say things that are hurtful to family members. They may accuse family members of wanting to steal their money, or of not being loving or faithful to them. This behaviour is common in confused people across different settings and cultures, and seems to be a basic reaction of a brain experiencing problems. Family members should be aware that people who are delirious cannot control what they are saying and their thoughts are not rational. In a fully alert state, they would be very unlikely to think or say the same things.

Loss of memory
Memory is poor in a delirium.

Poor ability to concentrate
Confused people have difficulty paying attention and following what people are saying to them.

Hallucinations and illusions
Sometimes confused people will misinterpret things that really are there, such as thinking that a coat rack is a person, or a piece of clothing on the floor is a cat or dog. This is called an illusion. 

A hallucination occurs when people see or hear things when there is nothing there at all. They may feel as though their skin is being touched when it is not, or see insects crawling on the bed or walls.

Sorting out symptoms

Confusion can be caused by many different things. To find out what is causing the confusion the health care team will often ask questions, conduct a physical examination, or order some tests. This will help them to make decisions about how best to manage the confusion. 

Questions from the health care team

The medical team may ask some of the following questions in order to understand to the extent of the patient's confusion and what may be causing it:

• When did the confusion start?
  • Did it come on suddenly?
  • Has it been increasing slowly over the past few days?
  • Did it begin in the morning, evening, bed time?
• Have there been previous episodes of confusion, such as after surgery?
• Is there a history of dementia?
• How bad is the confusion?
  • Mild, moderate, or severe?
  • Rating confusion on a scale from 0 to 10 is helpful. Zero means no confusion, while 10 means the worst possible confusion.
• How does the person behave when confused?
  • Picks at the air or the sheets on the bed?
  • Loud voice, yelling, hitting?
  • Talks in ways that don't seem to make much sense?
  • Talks very quickly? Mumbles softly?
  • Seems frightened or distressed?
• Does the person see, feel, or hear things that other people don't?
• What makes the confusion worse? Is it worse at certain times of the day or night?
• What makes the confusion better?
• What medications is the person currently taking?
  • When are they taken?
  • How long has the person been taking them?
  • Have there been any side effects experienced from taking this medication?
• Does the confusion affect the person's safety?
• Does the confusion affect the safety of anyone in the home?
• What are the goals and expectations of care?
  • Is there a health care directive?
  • Is there a desire to have tests and treatments for problems that might be treatable?

Physical examination

The health care team may want to do a general physical exam in order to understand what might be causing the confusion. The exam may include asking the person some simple questions to check memory, judgment, and ways of thinking.

Tests

Blood tests and x-rays may be ordered to see if the cause or causes can be identified, particularly if there is a possibility of improving the delirium, and this is what the patient/family wants.

Treatment

When someone is confused, very upset and at risk of hurting themselves or others, medication will likely be given to help the confused person feel less anxious and more calm.

The treatment plan will depend on the cause of the confusion, and on the goals of care. For example, if the confusion is due to an infection, then antibiotics may be ordered. Alternatively, if the confusion is due to the side-effects of pain medications, then the medication may be changed, the dose may be decreased, or the person may be given fluids to help clear the medication from the body.

Sometimes the health care team and family members will agree not to do tests or try treatments, even if the problems causing the delirium might be treatable. They may make this decision when:

• An advance directive requests no further tests. The patient may have prepared a health care directive that requests no further tests (even blood tests), and no treatment for any life-threatening problems.
• The patient does not wish to return to hospital. Some people have a strong desire to remain in their homes, avoiding a return to hospital no matter what the circumstances. If treating a specific cause of delirium requires hospitalization, then the treatment would not be possible.
• Death is very near. If it is thought that death is very near (hours or perhaps a day or two), there may not be enough time for tests to be done, or for treatments to have enough time to work.

See also: Health Care Directives
 

About sedation

Families are often asked to participate in decisions about whether to sedate a person who is confused. Sedating medications keep patients calm and comfortable. However, making the decision to sedate a loved one can be very difficult for family members. It may be helpful to imagine the confused person looking in on themselves from when they were well – how would they guide their own care knowing their current circumstances? If they had the choice, most people would feel that confusion and paranoid behaviour causes an unacceptable loss of dignity, and would prefer to be kept calm and comfortable rather than be restless and agitated.

Confusion near death

It is very common for people to become confused in the final hours or days of life.
See also: When Death Is Near

What you can do

It can be upsetting to see people become confused, particularly if they also become uncooperative or aggressive. If you are caring for someone when this occurs, these tips may help. Your health care team may also have additional suggestions.

• Try to remain calm yourself. Speak slowly and calmly to the person.
• Try to remind the person of where they are, and who you are.
• Avoid contradicting the (sometimes bizarre) statements of a confused person. Disagreeing or arguing with the person may simply increase the feeling of being threatened. It is generally best to acknowledge the distress they must be feeling, and to promise to try to sort things out.
• If the confused person usually wears a hearing aid, or glasses, make sure that these are available. This may help to minimize distortions in what the person sees and hears.
• Minimize challenges and tasks that will frustrate the person. Try to subtly help with things that will be too difficult or complex.
• The lighting in the room should be bright enough to lessen the chance of having shadows misinterpreted as threatening people or animals, but not so bright that the person cannot rest if needed.
• Try having a clock or calendar nearby. These may help remind the person of the time of day, date, month, year, etc.
• It may be helpful to limit the number of different people that the confused person comes in contact with, particularly if visits increase their feelings of anxiety or cause their behaviour to become more aggressive.

When people who have an advanced serious illness develop delirium, it often indicates a significant complication that may be life-threatening. Sometimes the cause can be easily and quickly sorted out and treated, but sometimes there are too many problems going on at once. Family and friends should be aware that while efforts to find and treat possible causes of delirium may be ongoing, the individual with the illness may not respond to treatment.

Hope for the best, but plan for the worst

When there are life-threatening complications of advanced serious illness, people have different reactions. Some families and friends hang on to hope and will not “give up” on the person, while other families prepare to let go. There is nothing wrong with remaining hopeful, but families should begin to consider the possibility that the person might die from the complication.

In times of uncertainty, families sometimes find it helpful to 'hope for the best, but plan for the worst'.  If there are things that are important to say or do, take advantage of the time you have. There may be other friends and family members who live out of town who need to be notified of the change, and of the possibility that death might occur. Making the most of time that you have may help reduce feelings of regret in the future.

Even if the cause of the delirium cannot be treated, it is possible to maintain comfort and dignity by using medications to keep the person calm and relaxed.

Content reviewed January 2023