Bed rest is not benign for an older person. Even during necessary hospital treatment, preserve safe movement, transfers and time out of bed when possible. #mobility

You can test attention with nothing but your voice: months backwards, days backwards, serial sevens, spell WORLD backwards, digits reversed. Under a minute, no kit. Alongside subjective assessment of attention, writing cognitive test results down can help to track change/recovery.  #delirium

Mr G, 80, using a fentanyl patch for chronic back pain, developed a fever from a chest infection and, over the same day, became drowsy, pinpoint-pupilled and confused, with a slowing respiratory rate. The infection was real, but the delirium was opioid toxicity. Fever and warm skin had increased the absorption from his patch, and a dose that had been stable for months was suddenly delivering far more. The heat had turned a steady drug into an overdose. We removed the patch, but the point the team almost missed is that removal alone is not enough. The drug already absorbed sits in a depot under the skin and keeps releasing for many hours, so he needed close monitoring for a full day, with naloxone to hand and given in small titrated doses if his breathing worsened. Transdermal opioids deliver more when the patient is hot, whether from fever, a heatwave or a hot pack. In any febrile patient on a fentanyl patch who becomes drowsy and confused, think opioid toxicity, remove the patch, and keep watching well beyond it. #delirium

The quietest patient on the ward is sometimes the sickest. Hypoactive delirium hides in plain sight.

Age & Ageing editorial: make the 4AT routine at the front door for patients 65+, alongside NEWS and frailty scoring. One admission, three assessments. #delirium #4AT academic.oup.com/ageing/arti…

Mrs H, 85, was admitted with a minor illness, corrected, and improving, then became confused on day three. The illness was better, not worse. The clue was on the fluid chart: three days of a hypotonic maintenance drip, run steadily, with no one checking the sodium. It had fallen to 121. This was hospital-acquired hyponatraemia, caused not by her disease but by our fluids, and it had produced a delirium out of a recovering patient. We reviewed the fluids, corrected the sodium carefully, and she cleared. Inappropriate hypotonic IV fluids are a genuine and preventable cause of hyponatraemia and delirium in hospital, especially in older people. If a patient becomes confused while on maintenance fluids, check the sodium and question the bag. We cause this one ourselves. #delirium

Delirium education needs to address understanding the basics, fundamental actions, and the issue of attitudes to delirium, as well as ownership. #delirium #education

Give the family a job. Watching someone you love be confused, with nothing to do, is its own suffering. Hand them a role: bring the glasses, a photo, sit, talk about ordinary things, tell us when he seems himself. It helps everyone. #delirium

Waking from anaesthesia into blur and silence is disorientation by design. Glasses and hearing aids should travel to theatre with the patient and go back on as they wake. Cheap, kind, protective. #periop #delirium

The most important cognitive test in surgery happens before it starts. Without a pre-op baseline, "confused, query baseline" is guesswork. Four minutes at pre-assessment turns it into diagnosis. #periop #delirium