He's Suddenly Much More Confused Than Usual

The distinction that matters is speed. Dementia progresses over months and years, unevenly, with bad weeks, but it does not turn a person who could follow a conversation on Tuesday into a person who cannot follow one on Thursday. When the change arrives in hours or days rather than seasons, it is usually something layered on top of the dementia rather than the dementia itself, and the name for that layer is delirium.

It gets missed constantly, by families and by professionals, since new confusion in someone who already has dementia looks like more of the same. If you have spent two days wondering whether this is anything, that is what nearly everyone does, and calling now is the whole fix. Caught early, this usually turns around, though recovery is slower than families expect, days to weeks rather than overnight. Left alone, it can leave a person further back than they started.

The causes are ordinary.

• Infection. Infection is common, and pneumonia, a skin infection or a urinary infection can each show up as confusion rather than fever. Urine is worth checking, though bacteria in the urine are so common in frail older adults without causing symptoms that a positive test does not by itself explain new confusion, so ask the clinician to keep looking.
• Dehydration, constipation, retention. Dehydration, constipation, and urinary retention, meaning a bladder that feels full but will not empty, all belong on the list.
• A medication. So does a new medication, a dose increase, or one recently stopped, including over-the-counter sleep aids, since Benadryl and Tylenol PM are far more disorienting in an older brain than the packaging suggests.
• Pain, blood sugar, a fall. Untreated pain, low blood sugar, and an unwitnessed fall with a head strike round it out.
• Withdrawal. Withdrawal deserves its own line, since the timing surprises people. Alcohol withdrawal usually begins within six to twenty-four hours of the last drink and worsens over the following days, and benzodiazepine withdrawal, from lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium) or clonazepam (Klonopin), can start within a day or take a week. Say out loud on the phone if a dose has been missed, reduced, or run out.

A few signs separate delirium from a bad day. It fluctuates, so someone can be nearly themselves at ten in the morning and unreachable by four. Attention goes first, so the person loses the thread mid-sentence or cannot hold a question long enough to answer it. And it runs in two directions. The agitated version gets noticed, while the quiet version, where someone becomes drowsy, withdrawn and hard to rouse, gets missed far more often, since a person who has gone still does not look like an emergency. It carries the same risk.

One exception is worth knowing. In Lewy body dementia and Parkinson's disease dementia, alertness genuinely swings from day to day as part of the illness. That is not a reason to wait, since a change this fast still needs same-day eyes on it, but it is a reason to tell the clinician which kind of dementia the person has, and to say it before anything is given, since people with Lewy body dementia can react badly to antipsychotics.

Make the call, gather what the clinician will ask for while you wait, then quiet the room.

1. None of this should delay the phone. Make the call first and gather the rest while you wait for the callback or the ride. Say in the first sentence of the call whether he takes insulin or a diabetes pill, because low blood sugar looks exactly like this and gets worse by the minute, and the clinician will tell you what to do about it while you are on the line. If his diabetes plan tells you how to check and treat a low, follow it, and call anyway.
2. When the change started and how fast. "Fine at lunch, not fine by dinner" is worth more than "the last few days."
3. Put every bottle into a grocery bag, prescription, over-the-counter and vitamins, and set it by the phone. Do not try to write a list.
4. Temperature, when he last urinated and had a bowel movement, how much he has had to drink, and any fall in the past week, especially on a blood thinner such as warfarin, Eliquis or Xarelto. A normal temperature does not rule out infection in an older adult.

1. Reduce the load. One person talking, television off, lamps rather than overhead glare, glasses and hearing aids on, no visitors today.
2. Say where he is and who you are once, calmly, and then let it go, since repeating it asks the same impaired attention to do the same work again.
3. Offer small sips of water only while he is fully awake and sitting fully upright. Stop and give nothing more by mouth if he coughs on drinks, sounds wet afterward, or is too drowsy to sit up, and say so in the first minute of your call.
4. Add nothing new tonight, no sleep aid and no as-needed medication, but keep the usual prescriptions going unless the clinician says otherwise.

Write down times. Delirium fluctuates, which means the clinician who sees him at two in the afternoon may see something quite different from what you saw at four in the morning. Your written record of the swing is often the most useful piece of information in the room.

Print the emergency room handoff sheet before you go, no email needed, so the person at triage hears the baseline before the symptoms.

If you are weighing whether this is worth a phone call, that hesitation is the answer, and nobody is going to tell you that you called too soon.

This is what the tracking is for. Dates, times and specifics turn "something's off" into something a clinician can act on in a ten-minute appointment.