Hypoactive Delirium: The Critical Need for Collaboration Between Families and Nurses in Prevention, Recognition and Care

Abstract

Delirium is a common and serious clinical condition that is associated with several adverse, and sometimes permanent outcomes. There are three primary types of delirium: hyperactive, hypoactive, and mixed. All three are characterised by a new acute onset of symptoms and changes in the person's normal behaviour (Hosker and Ward 2017). Hyperactive delirium involves restlessness, agitation, and heightened alertness. Individuals may be visibly agitated and distressed, displaying behaviours such as aggression, hallucinations, or incoherent speech. In contrast, hypoactive delirium is far more subtle and insidious. It presents as lethargy, drowsiness, and reduced responsiveness, with the person appearing disengaged and uninterested in their surroundings. While these symptoms may be a red flag for family and close friends who recognise the change in the patient's behaviour, hypoactive delirium can easily be mistaken for depression, fatigue or dementia, making it difficult to recognise and treat (Hosker and Ward 2017). Mixed delirium is a combination of both hyperactive and hypoactive symptoms, with the person alternating between periods of agitation and lethargy.

Delirium in any form represents a serious medical condition that requires immediate attention, and hypoactive delirium is particularly challenging due to its subtle and insidious nature. Hypoactive delirium occurs more frequently than hyperactive or mixed delirium and is associated with worse outcomes, particularly among older people, and is responsible for the high rates of morbidity and mortality among hospitalised patients (Falk et al. 2023; Hosker and Ward 2017). Affecting those with underlying medical conditions or undergoing surgery or with high frailty, hypoactive delirium can result in distress, longer hospital stays, higher rates of hospital readmission, and increased vulnerability to complications (Bianchi, Harris, and Fitzpatrick 2024; Falk et al. 2023). In post-operative patients, delirium is linked to a higher risk of death (Falk et al. 2023). Despite its widespread impact, because hypoactive delirium is easily mistaken for other conditions many patients may not receive the timely recognition and intervention they need. The longer hypoactive delirium remains unrecognised, the worse the long-term outcome (Hosker and Ward 2017).

Hypoactive delirium not only robs affected people of their energy and vitality, but also their connection to the world around them because it significantly disrupts a person's cognitive and emotional connections, leading to isolation and disorientation. The mental fog that envelops them leaves them unable to articulate their distress, leaving them trapped in a reality they cannot independently escape.

Family members, or close friends, are crucial in the early detection and care of people with delirium—it is often family/friends who are the first to notice subtle and acute changes in the person (Greindl et al. 2022). In this commentary, we discuss hypoactive delirium and the need for the multidisciplinary team to work authentically, respectfully and with genuine inclusion with families and significant others to identify and care for people affected by hypoactive delirium.