Harold came into the skilled nursing facility, admitted from the local hospital. Harold lives at Pleasant Meadows, an assisted living community where he has been independent. The problem arises when the nurse from the skilled facility  calls the nurse from Pleasant Meadows. The Harold that the nurse now describes in not the man the Pleasant Meadows nurse has know for the last 6 month, before he went to the hospital. Harold?  Uncooperative, disoriented, unsteady on his feet, falling, with generalized weakness? No, no the nurse from Pleasant Meadows insists that they (the skilled facility) don’t know what they are doing and don’t know how to take care of Harold.

Sadly this scenario is not unusual, for one healthcare facility to accuse another of not knowing what they are doing. Doesn’t the fact that because Harold already has the diagnosis of Alzheimer’s disease mean that it is understood that he is confused? Yes, Harold is always confused, but this new Harold is in an altered mental state. He was admitted to the hospital with pneumonia. Infections in the elderly many times can cause confusion. This infection caused Harold to experience a rapid decline in his mental functioning and an increase in his confusion.

Sudden increase in confusion can result in very vague symptoms. The family member might say he is “not acting right”, has different behavior, is either more sleepy or more agitated, is extremely distracted,  has recent inappropriate behavior. These sudden changes can come within days or even hours of onset. The great difficulty comes in diagnosing why the individual is suddenly more confused. As well as realizing that it is going to take much more time for the problem to resolve compared to the fast onset.

Harold will continue to have increased confusion even after he has recovered from his pneumonia. And Harold is likely not to return to his previous level of mental functioning.  This infection has tragically caused him to lose some mental clarity  and has resulted in progression of his dementia. Right now Harold needs one on one care, with people who explain the environment and what is going on, as well as protecting him from unsafe activities. All the while giving his mind the time to heal as well as his body.

Yes, it is not only possible for someone with Alzheimer’s disease to suddenly become more confused, it is more than likely when there is an infection involved. A sudden increase in confusion, or delirium continues to be misunderstood.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing



Mr. Frank is a 76 year old man who has been admitted to the hospital for a hip fracture. Mr. Frank had fallen at home and when he was admitted he was very alert, friendly, quiet and pleasant. Yes, he was in some pain before his surgery, but it was well controlled with medication. Now that he has come out of anesthesia, after his successful surgery, he is yelling, throwing his bed sheets as well as everything on his bedside table, on the floor. He is very agitated, and keeps trying to climb out of bed, even though the staff instruct him to use the call light for assistance. Mr. Frank is suddenly a completely different patient. A very difficult patient.

The hospital staff are sure that Mr. Frank has delirium because of the suddenness of his change in mental status. Having delirium following a bone fracture and surgery isn’t all that uncommon for the older patient. Studies show that physical or mental illness affects 15-53% of older surgical patients. Delirium is more common in the older patient than younger patients. And the person with delirium is also more likely to have other complications as well. Actually 48% of patients older than 65 years are shown to have had acute confusion before and after surgery.

Delirium before surgery can be related to pain or sleep disturbances due to pain. Or an electrolyte imbalance, medications the patient has been taking, or possibly an infection that was related to the fall in the first place. All of the possibilities require extensive evaluation of current medications, lab work for complete blood count, urinalysis and serum electrolytes. After consulting with the physician, many other tests may be ordered to assess the source of the delirium and  create a treatment plan.

Care of this older, confused patient will include being very present for Mr. Frank. Making good eye contact when staff speak to him, as well as using soft reassuring words. If Mr. Frank is having hallucinations giving him one-on-one care to reassure him that what he is experiencing is not real. Making sure that if Mr. Frank uses glasses, that they are clean and on when he is awake. If Mr. Frank uses a hearing aid that the battery is working and that the hearing aid is in and turned on when he is awake.

Maintain a quiet and peaceful environment while decreasing noise as much as possible. This is the time to also reassure the family, while you educate them on the subject and course of delirium. While teaching them how to be involved with the patient, to assure a positive outcome. Watching a loved one struggling with anxiety and agitation is very difficult on the family as well as the patient.

It is reported that post operative delirium in the older patient, is costing 164 billion annually. While that is certainly an impressive number, it doesn’t even touch on the real cost to the elderly patient and his family.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing


I receive emails from families who can’t understand what has happened to Mom, Dad, Uncle Charlie and so on. You see this person was just fine a couple of weeks age, driving, shopping, living alone, balancing their check book, and now the doctor says Mom has Alzheimer’s disease and needs to live in a nursing home. What usually happened is that Mom had an infection, an accident, change in medication or surgery and this put Mom into a state of delirium

Synonyms for delirium are; irrational, raving, deranged, and yes even demented. Once the stress is over, the elder returns to their previous state of cognition. But what if Mom is in the hospital when she becomes delirious? The hospital personnel don’t know Mom and  don’t recognize her delirium. Mom will be labelled a confused, demented elder and medicated to keep her under control and “safe.” This will only lead to increased confusion making Mom appear even more confused.

The presence of delirium can indicate that the elder’s brain has a decrease in capacity and may indicate an increased risk of developing dementia. The healthcare community sees delirium frequently with the elderly and infrequently with the young. The same person can have had no history of delirium, even though they have experienced several hospitalizations, yet when they are old, they become confused and disoriented every time they are admitted.

Whenever there is a sudden change in an elder’s ability to think, focus, reason, and remember, look back to whatever stress could have caused the change. The longer the person suffers from delirium, the more chance it will not be resolved.

Remember Alzheimer’s Disease is slow, delirium is fast and doesn’t have to be permanent.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing