Delirium is usually worse in the late afternoon, evening and night. A clear morning does not mean it has gone.
Delirium comes and goes through the day. The same person can hold a reasonable conversation at eleven in the morning and not know where she is by eight in the evening.
This is a common reason delirium gets missed. If the doctor sees her during a good hour, everything looks fine.
Why evenings are worse
Nobody can fully explain it. Tiredness builds up through the day. The light goes, and with it many of the cues that show you where you are.
Wards get busy when staff change shifts and pass on information, then suddenly quiet. Visitors leave and familiar faces go home. Sleep is broken by noise, lights and routine health checks. Illness disturbs the body’s own day and night rhythm.
Probably all of these contribute. None of them alone explains it.
Sundowning
You may hear staff or family call this sundowning. That word is usually used about dementia rather than delirium.
The two are worth keeping apart. In dementia, evening restlessness is a long-standing pattern in someone who is confused all day. In delirium the confusion is new. It came on over hours or days, and a medical cause needs to be found.
If the evening confusion is new, do not let the word sundowning end the conversation. Say what has changed and ask: could it be delirium?
What helps
- open the curtains in the morning
- ask whether the lights over the bed can be dimmed at night
- glasses on and hearing aids in during the day
- visit in the late afternoon rather than at midday
- keep a clock and a calendar in view
Tell the staff what the evenings are like. If they only see her in the morning, they are seeing the best hour of her day.
When to get help
New sudden confusion is a medical emergency. Outside a care setting, phone the local emergency number now. In a hospital or care home, tell staff immediately. Say what has changed and ask whether it could be delirium.