My elderly uncle recently had to be hospitalized following a severe fall which caused him to fracture his hip. The fall occurred while he was mentally fighting with fellow Marines in a battle on our street. There was no battle, and there were no other Marines, but it was real to him.
Was he hallucinating? Or having delusions? Or was it delirium? At the hospital it took a while for me to recognize that I was calling his mental state delusional but that was inappropriate. I had to change from delusions and hallucinations to delirium with hallucinations as the best descriptive words of his acute mental incapacity when I talked with the medical experts.
My uncle has mild, very mild, dementia surfacing in morning confusion, but clarity abounds as the hours pass. We have learned to not get concerned by his cloudy sunrise thinking.
Then he started to talk to people who were not there when it was any hour of the day. During the day, his thoughts were non-threatening to himself or others; at night, though, his thoughts surfaced in paranoid attempts to describe people who were not real, plots that were non-existent, and an enhanced fear of darkness. His agitation and anxiety were maxing out! So was mine.
I used the word “delusions” when trying to describe his thought-processing issues with the paramedics and with the ER staff. One doctor wanted to assign a psychiatrist to his list of inpatient hospital providers. No! He has never been in need of mental health care, not after the Korean War, nor two tours of duty in Vietnam, and he certainly didn’t need that now. Was I using the wrong word? Yes!
Delusions are an uncommon problem. Delusion would not typically include hallucinations though and he was having those. He had no classic delusions of grandeur or jealousy, for example, but he did believe that someone meant to do him harm which no doubt is why he “called in” his fellow Marines to fight the battle with him.
So, he had hallucinations, but not delusions. I could have told the medical staff he was having hallucinations, but that really only described a small part of his dilemma.
A nurse suggested to me that he was suffering from delirium. So I used her word; no psychiatrist needed anymore. Delirium is an acute or sudden onset confusion. By the time he was hospitalized, he had suffered from delirium and hallucinations for several hours, sporadically, rising, ebbing, and ending and then restarting by the time of day more than any other concrete observation. So what is delirium?
Delirium is serious confusion which arises fairly suddenly and can be combined with hallucinations and hyperactivity. Normal attention spans for communication are shortened greatly or almost non-existent. Agreed. In his case we learned he had a urinary tract infection which likely caused the delirium. One morning his normal confusion and intense concentration skills abated when he thought he saw an imaginary person by my computer and when he saw bugs. By afternoon, he was his sweet and normal elderly self. About 8 pm he was certain we were going to have a break in and talked adamantly about some conspiracy by foul-mouthed men just outside his window; they were up to no good. We got him quieted and to bed, but by 3:30 am he was secretly fighting the front yard military battle.
He mental concerns fit with the definition of rapid onset, serious attention issues, and an altered sleep cycle as he was not able to sleep beyond minutes, if that. He was having very vivid auditory, visual and tactile hallucinations too. He had a set of symptoms, a likely cause that had a definable onset, and which gratefully are beginning to lessen as I write this article.
The first step of treatment was eliminating the antibiotic tablets to which he could have had a reaction causing this issue; it was a few days before the staff realized that he could have delirium from a small urinary tract infection. Realizing he was now suffering a fractured hip, it was necessary to prevent any further falls or delirious behaviors that could negatively impact his physical recovery. In his delirium he pulled at nearby tubes such as his IV, and wadded and tossed sheets and towels across the room. He was lightly restrained to keep him safe. Finally he slept with a newly prescribed drug, but his agitation was still so mammoth that after essentially two days of being awake, he slept only a few short hours at best. Sleep deprivation was likely adding to his delirium and hallucinations. Now the delirium is more sporadic, and much gentler. Good. Surgery is just ahead.
Reviewing my new understanding of these terms, I conclude:
1) Delusions are manifestations of the magnitude of the person with society; i.e. grandeur, jealousy, etc.
2) Hallucinations are a mental condition that allows the individual to perceive vividly that something or someone is present that is not. They can be realized by visual sightings, smells, hearing, or tactile sensations of reality, when not real.
3) Delirium is with some sudden onset and has a core beginning such as medication reactions. Hallucinations can be combined with the delirium, adding to the issues of mental well-being. This diagnosis is typically short-term.
Yesterday two doctors called him an advanced dementia patient! No! I used the correct words and described briefly its onset and we all got to the same page, quickly. Whew.
Common language is good.