Subtle Signs of Delirium Among People with Dementia That Family Caregivers Sometimes Miss

Similar Manifestations: Delirium and dementia share common symptoms like confusion, disorientation, and agitation. However, delirium is treatable. If the underlying cause of delirium is treated, the symptoms of delirium will often disappear. A common example is antibiotic treatment of an undiagnosed urinary tract infection or UTI (one of the common causes of delirium for older adults) with antibiotics, often will also treat their delirium. Knowing the person’s history and record of baseline behaviour is therefore important in recognizing unusual levels of agitation, sleepiness, confusion and other symptoms.

Type of Dementia: Individuals with Lewy-Body Dementia who may be experiencing a delirium episode have a higher risk of being undiagnosed as individuals with this type of dementia are more prone to delusions and hallucinations. In addition, they could fluctuate drastically from baseline to erratic behaviour several times a day which mimic mixed-type of delirium.

Co-morbidities and Polypharmacy: Delirium can also be caused by other conditions such as clinical depression and other mental disorders that can mimic symptoms of delirium (e.g., fluctuating moods). In addition, individuals with dementia may be taking multiple medications and/or be introduced to new medications or dosage changes that can trigger a delirium episode, and for this reason, would be harder to recognize even by their primary caregivers. It is therefore important for their primary caregivers to pay attention to their loved ones when new medications are introduced or whenever alterations in medication dosages and timing of medication administration are introduced in their loved one’s care plan.

Limited Awareness and Education: Last but not least, healthcare professionals, caregivers, and even individuals themselves may not be adequately educated about delirium. Lack of awareness can lead to underestimating its prevalence and impact, resulting in oversight.

Fluctuating Levels of Consciousness: Delirium often manifests as sudden changes in consciousness. Individuals with dementia may experience periods of increased alertness followed by confusion and drowsiness.

Impaired Attention: A hallmark of delirium is impaired attention and focus. If a person with dementia, “all of a sudden” struggles to stay engaged in conversations or activities, suspect delirium and seek medical attention immediately.

Fluctuating Levels of Agitation: Agitation is a common symptom of delirium. Individuals with dementia who are usually calm may exhibit increased restlessness, irritability, or even aggression during episodes of delirium.

Disturbed Sleep Patterns: Delirium often disrupts normal sleep-wake cycles. Individuals with dementia may experience insomnia, increased daytime sleepiness, or frequent awakenings during the night. Alternatively, they may exhibit “more than usual sleepiness” and unwillingness to get out of bed.

Fluctuating Psychomotor Activity: Changes in motor activity, such as restlessness or slowed movements, are common in delirium. If an individual with dementia can usually move around on their own and get dressed and “suddenly” unable to stand or walk steadily, they may be experiencing a delirium episode.

A good mnemonic to remember when trying to figure out the cause of a delirium episode is PINCHME. (Source: “End of Life Care in Frailty: Delirium.” British Geriatrics Society. 12 May 2020)

P: Could the person be experiencing pain?

I: Is it possible they have some sort of infection (e.g., UTI)

N: Consider nutritional needs. Are they hungry? Is it a chemical imbalance (e.g., low sodium, potassium, glucose)

C: Are they constipated?

H: Are they properly hydrated? Are they drinking enough water?

M: Have they been prescribed a new medication? Dosage change?

E: Is there unusual noise, distractions from the environment or changes in their room?

Untreated delirium can significantly impact the overall quality of life for individuals with dementia, leading to increased distress, discomfort, and a diminished sense of well-being. Therefore, recognizing the signs of delirium, especially in individuals with dementia, is crucial for timely intervention and improved outcomes.

Even after treating the delirium episode, individuals with dementia may experience an irreversible decline in cognitive function. This decline can manifest as a loss of abilities in activities of daily living, memory, and overall cognitive function. An individual with dementia who can independently dress and feed themselves, can experience a diminished capacity to perform these activities and in extreme cases, may lose these abilities altogether, especially if their delirium was left untreated. This can lead to increased care needs requiring more intensive care and support and dependence on their caregivers.

When it comes to the person you are caring for, YOU are the EXPERT. You know their likes, dislikes, their habits, moods and behaviour. Trust your instincts and your observations. Your loved one may no longer be able to communicate verbally, but they are still able to let you know what’s going on with them. Their behaviour, their gait, their eating and sleeping patterns – everything they do or don’t do is a form of communication.

As their family caregiver, you will be the first one to notice these changes. The members of the healthcare team will need you to assist with making the best and most appropriate care decisions for your loved one. A care plan will need to change and will need to be updated regularly and as needed, depending on your loved one’s condition.

It has happened where healthcare professionals, nurses and even physicians may not be aware or fully educated on delirium and may miss it altogether. Do not be afraid to remind them. You are a crucial and key member of your loved one’s Healthcare Team. The intimate knowledge of your loved one is relevant information they need in their clinical management. Trust your area of expertise!