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 has 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 care homes. 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
The distinction is sharp enough that you can spot it without being a clinician:
- Dementia arrives over months and years. It worsens slowly and fairly steadily from one day to the next.
- Delirium arrives over hours or days. And it fluctuates. This is the giveaway: 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?"
Why this matters more than it sounds
Delirium is not only frightening to watch. It is associated with higher mortality, longer hospital stays and a loss of function that is often not fully regained. National clinical guidance treats it as something to be actively identified and acted on, not observed. Every day the cause goes unlooked-for counts.
And one form is missed far more than the other: hypoactive delirium. Not the agitated resident who shouts, but the quiet one, drowsy, sitting in a chair, not 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 temperature — in older people fever can be absent entirely.
- Constipation, up to faecal impaction. An ugly cause and an uglily neglected one. "When did she last open her bowels?" should always be asked, and "I'm not sure" is itself a finding.
- Urinary retention — a bladder that is not emptying. A bladder scan at the bedside 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 something 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 review. Ask the home to arrange a same-day medical review, and ask that it covers these by name:
- When she changed, and whether she fluctuates. Get the last seventy-two hours described.
- When she last opened her bowels.
- 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 stopped.
- 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 without any infection being present. UK guidance is explicit that a positive urine dipstick alone should not be used to diagnose a urinary infection in over-65s. A dipstick is not a reason to stop looking for the other causes — and it is not, on its own, a reason for antibiotics.
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 itself. If the first suggestion is medication for agitation and nobody has yet asked when she last opened 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 a calendar in view, and getting her up and moving as soon as it is safe rather than leaving her in bed.
When to call 999
If the confusion comes with a high temperature, 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 999.
If you get nowhere
Put it in writing to the manager, in one sentence: "I am asking for a same-day medical review for acute confusion that began on [date], to exclude infection, constipation, urinary retention and medication causes." That sentence, in writing, changes the pace of the response. The GP practice covering the home is the clinical route, and NHS 111 exists out of hours. If the home will not act on a resident who has become acutely confused, that is a safety issue for the Care Quality Commission.
Where to start
If you are reading this because it happened yesterday, do one thing now: ask when she last opened her bowels, 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 £69 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 999. Curalune does not allocate beds and does not guarantee availability.
