Spotting hyperactive, hypoactive and mixed delirium

NICE advises staff to check people at risk for recent changes or fluctuations in thinking, perception, movement or social behaviour. These signs can be obvious or subtle and easy to miss.

Recent changes may include poorer concentration, slow or delayed responses, confusion, hallucinations, reduced mobility or movement, restlessness, agitation, disturbed sleep, appetite change, withdrawal, mood changes or difficulty following requests.

What different presentations may look like

• Hyperactive delirium: pacing, trying to climb out of bed, fear, agitation, shouting, suspicious behaviour or hallucinations.
• Hypoactive delirium: sleeping more, responding less, reduced appetite, less movement, staring, slow speech or unusual quietness.
• Mixed delirium: calm and drowsy at one time, then frightened and agitated at another.
• Fluctuation: the person may seem better for a while and then worse again, often later in the day or overnight.

Manager focus: do not reward quiet deterioration

Delirium can be loud, quiet or both. Hypoactive change is easy to miss and should not be assumed harmless.