The sentence not to accept
You visit and she does not know where she is. Or she is drowsy and will not properly wake, or says things that do not hang together, or sees people who are not there. You ask what happened and you are told: "the dementia's progressing."
Most of the time that is not true, and it is the single most damaging sentence said in aged care. Because if this is delirium — and very often it is — it is not a decline to accept. It is a medical emergency with a cause that can usually be found and treated.
How to tell the difference, in one line
- Dementia arrives over months and years and worsens slowly and fairly steadily from one day to the next.
- Delirium arrives over hours or days. And it fluctuates. Nearly herself at eleven in the morning, gone by four in the afternoon, worse again in the evening. That swing within a single day does not belong to dementia.
If something changed within days, and changes again across the day, the question is not "how much worse has she got" but "what has happened to her?"
The standard that is on your side
Here is what makes this more than a general worry in this country. Under the strengthened Quality Standards, providers are expected to recognise and respond to deterioration in a resident's condition — to notice a change, escalate it, and involve the person and their family. Acute confusion is the textbook deterioration.
So two questions are entirely fair, and they are not rude:
- When was the change first noticed, and what was the escalation?
- When was the GP contacted, and when was I told? If you found out by visiting, that is a separate problem from the delirium, and it belongs in writing.
The quiet form that gets missed
Delirium is associated with higher mortality, longer hospital stays and a loss of function that is often not fully regained. And one form is missed far more than the other: hypoactive delirium — not the agitated resident who calls out, but the quiet one, drowsy in a chair, no longer joining in. She troubles nobody, and that is exactly why she can go a week unnoticed. "She's just tired" is the phrase never to take on trust.
The causes, nearly all treatable
- Infection, urinary or chest, often without a fever — in older people fever can be absent entirely.
- Constipation, up to faecal impaction. "When did she last have her bowels open?" should always be asked, and "I'm not sure" is itself a finding.
- Urinary retention — a bladder that is not emptying. A bedside bladder scan settles it in two minutes.
- Dehydration, particularly after a hot spell or a bout of vomiting or diarrhoea.
- Untreated pain, which in someone who can no longer say so presents as confusion or agitation.
- Medicines. Something started in the past fortnight — or stopped abruptly. The easiest cause to correct and the least often looked for.
- Blood abnormalities: low sodium, blood sugar, low oxygen.
What to ask for today
Not tomorrow, not at the next care plan meeting. Ask for a same-day GP review, and ask that it cover these by name:
- When she changed, and whether she fluctuates. Get the last seventy-two hours described.
- When she last had her bowels open.
- Whether her bladder is emptying — a bladder scan.
- How much she has been drinking, from the record rather than from memory.
- What changed in her medicines in the past two weeks, including anything ceased.
- Whether she is in pain, assessed with an observational tool if she cannot say.
One thing worth knowing, because it causes real harm: in older women, bacteria in the urine are extremely common with no infection present. A positive dipstick alone is not enough to conclude a urinary infection is the explanation, and it is not a reason to stop looking for the other causes.
What not to accept
The commonest wrong answer is to give her something to settle her. Sedation does not treat the cause, it raises the risk of falling, and it can deepen and prolong the delirium. And in aged care here it carries its own weight: medication used to sedate rather than to treat is a restrictive practice, with authorisation and reporting requirements attached. If the first suggestion is something for agitation and nobody has yet asked about her bowels, the order of business is wrong and you may say so.
What genuinely helps, and can be asked for immediately: her glasses and hearing aid actually on — being able to see and hear reduces confusion — daylight during the day and darkness at night, a familiar face nearby, a clock and calendar in view, and getting her up and moving as soon as it is safe rather than leaving her in bed.
When to call 000
If the confusion comes with a high fever, breathlessness, chest pain, repeated vomiting, an inability to rouse her, or sudden stroke signs — facial droop, arm weakness, slurred speech — do not wait for a visit. Call 000.
If you get nowhere
Put it in writing to the facility manager, in one sentence: "I am requesting a same-day GP review for acute confusion that began on [date], to exclude infection, constipation, urinary retention and medication causes, and I am asking when the deterioration was escalated." That sentence changes the pace, because it names an expectation rather than a preference.
If that does not resolve it, the Aged Care Quality and Safety Commission takes complaints from family members, including anonymously, and recognising and responding to deterioration is squarely within what it assesses. Free independent advocacy is available through the national aged care advocacy network.
Where to start
If you are reading this because it happened yesterday, do one thing now: ask when she last had her bowels open, and what changed in her medicines in the past fortnight. Two questions, both answerable from the notes — and in a far from small share of cases, the answer is right there.
If you are looking for a home and want to know how they handle this when it happens, we can do that work. For A$109 we take down your mother's situation, look for the homes in your area that answer these questions properly, and report back what they told us, with names and dates. Start here
This article is for information and does not replace a medical assessment. Acute confusion always needs to be assessed by a clinician: do not change or stop any medicine yourself. If there are red flag signs, call 000. Curalune does not allocate beds and does not guarantee availability.