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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. Hypoactive delirium can lead to prolonged suffering, functional decline, reduced quality of life, and all too frequently, death. Unlike the more obvious agitated form of delirium, hypoactive delirium works quietly, its symptoms subtle and easily overlooked. Despite being a common presentation of delirium in hospitalised patients, hypoactive delirium is often dismissed or misinterpreted because its symptoms—lethargy, disorientation, and reduced responsiveness—are easily attributed to other causes (Falk et al. 2023; Hosker and Ward 2017). Therefore, the condition may go untreated, leaving people in a fog of lethargy and confusion, unable to meaningfully connect with the world around them. The importance of identifying and addressing this condition early cannot be overstated—it is a serious condition that steals the life force, leaving people in a state of helplessness and isolation. Recognising hypoactive delirium for what it is and responding promptly is essential to supporting overall recovery. There is no definitive cure for hypoactive delirium (Falk et al. 2023) and no direct treatment beyond identifying the condition, supporting the person and addressing its precipitating causes. Supportive care such as a calm environment, adequate nutrition and hydration, reorientation, presence of family, and careful attention to avoid sedative medications are commonly initiated, and a period of watchful waiting for the resolution of the delirium begins. The lack of a cure makes the issue of prevention through the use of established protocols very important (NICE 2023). Identifying risk factors for delirium is crucial, as is creating clinical environments that prevent or minimise its occurrence. This can be achieved through measures that help maintain patients' orientation, such as ensuring proper lighting and distinguishing between day and night, turning off lights at night, promoting restful sleep during night-time hours, avoiding unnecessary room changes, minimising staff changes and encouraging family involvement in care (NICE 2023). Though there is increasing interest in the lived experience of delirium, there is limited evidence on the lived experience of hypoactive delirium. The literature that exists reveals the complexity and difficulty associated with hypoactive delirium. In a qualitative study, patients who experienced hypoactive symptoms of delirium following cardiac surgery described being trapped in a distorted reality, unable to differentiate between real and illusory experiences, with vivid and emotionally charged hallucinations (Falk et al. 2023). They reported cognitive and emotional challenges, including confusion, memory loss, nightmares, and a profound sense of disconnection, compounded by difficulty communicating and feeling isolated from both healthcare providers and loved ones (Falk et al. 2023). Literature reviews of patient experiences and recollections of delirium, reveal perceptual disturbances, psychological distress and recurring themes, such as confusing experiences, distorted perceptions of time and place, communication challenges, vivid memories, and intense emotions like fear, anxiety, and anger (Fuller 2016; Kuusisto-Gussmann et al. 2021). Participants frequently reported a sense of imminent danger, including fears for their own or their family's safety, feelings of confinement or restraint, and misinterpreting nursing interventions, such as injections, as aggressive actions (Fuller 2016). Although these reviews do not differentiate types of delirium, one study included in Fuller's (2016) review found that hypoactive delirium is just as distressing as the hyperactive forms of delirium. Family and friends of those experiencing hypoactive delirium can experience high levels of distress (Hosker and Ward 2017; Oya et al. 2022). They may become concerned and even alarmed as they see their loved one being overtaken by lethargy, unable to express their needs or find the energy to participate in essential activities such as eating, drinking, or mobilising. Family and friends are often the first to detect delirium. They may initially attribute the changes in the person's behaviour to the aftermath of surgery, the side effects of medications or treatments. Still, as time passes, the realisation sets in that something more insidious is possibly at play. The decline becomes impossible to ignore, with family and friends unable to help or even reach the person. Watching a loved one slip further away can create an overwhelming sense of helplessness, distress and grief—emotions that may not be acknowledged or actioned by the treating multidisciplinary health team. The long-term implications of hypoactive delirium can be profound, not just for affected individuals, but for their loved ones as well. Survivors may experience permanent harm, robbing them of confidence and leaving them with reduced independence, unable to carry out daily activities or even engage in meaningful conversation. The emotional weight of this can be overwhelming, particularly where families feel that had the condition been recognised and treated earlier, their loved ones might have retained some of their independence, cognitive abilities and dignity. Prompt recognition and intervention are crucial not only for recovery but also for preserving relationships and connections, alleviating suffering, and mitigating long-term consequences that can have lasting emotional and physical effects. The stealth of hypoactive delirium can make it incredibly difficult to recognise. Symptoms of hypoactive delirium may overlap with other conditions, such as dementia or frailty, and can be mistakenly attributed to normal aging or depression. When in care, due to their proximity to patients, nurses are key to identifying hypoactive delirium either by recognising changes in the patient's condition or delving deeper into the patient's longitudinal history. Unlike its hyperactive counterpart, which can be more easily identified through agitation or confusion, hypoactive delirium is subtle. It can easily be dismissed as simple fatigue or apathy or attributed to a chronic condition like dementia by those unfamiliar with the person. This makes diagnosis elusive, and delays in treatment are not uncommon. To improve early recognition, it is crucial for nurses and health professionals to effectively and authentically engage with family members, value their insights and involve them in identifying any signs of hypoactive delirium at the earliest opportunity. Evidence suggests that there is considerable inconsistency in how delirium is identified and addressed by health professionals, particularly among older adults (Bianchi, Harris, and Fitzpatrick 2024). To mitigate negative outcomes, Bianchi, Harris, and Fitzpatrick (2024) highlight the need to establish and widely distribute best practice guidelines for delirium screening, diagnosis and management. An integrated approach that supports healthcare professionals, including effective communication with patients and their loved ones, is vital. Additionally, health services should implement clear policies for delirium recognition and management, with infrastructure that ensures assessments and care plans are integrated into electronic records and accessible across all care settings (Bianchi, Harris, and Fitzpatrick 2024). There is a critical need for more research specifically focused on hypoactive delirium, particularly in the areas of prevention, early recognition, and intervention strategies. Key areas requiring research include: (1) identification of early biomarkers for hypoactive delirium, (2) a stronger evidence-base around the efficacy of family-based interventions in early identification, and (3) better understanding of long-term cognitive outcomes following hypoactive delirium. Understanding the mechanisms of hypoactive delirium is essential to developing more effective clinical practices that can reduce its impact. Additionally, it is vital to explore the lived experiences of individuals who have experienced hypoactive delirium, focusing on their emotional and psychological needs both during the delirium episode and in the recovery phase. This includes examining the long-term consequences and cognitive sequelae that may persist long after the delirium resolves. Equally important is increasing awareness of the challenges faced by family and friends of those experiencing hypoactive delirium. Family and friends may feel helpless and distressed as they witness their loved ones undergo this disorienting and frightening experience, and their needs for support and guidance during and after the episode must be recognised and better understood. Research addressing these gaps can potentially improve patient care, enhance carer support systems, and guide the development of effective interventions, ultimately reducing hypoactive delirium's negative impact on patients and their loved ones. Prioritising these areas of research could help ensure better outcomes for individuals affected by hypoactive delirium and those who care for them. Hypoactive delirium is not only a major and serious clinical challenge but also a highly distressing experience for patients and their support network. Nurses and the multidisciplinary team play an essential role in the early recognition of hypoactive delirium by taking family and friends' concerns seriously and through regular screening and vigilant monitoring of the person's cognitive status, especially those in high-risk populations. It is essential to collaborate effectively with family and friends and to listen to their insights and concerns to help identify any signs of delirium as early as possible. The importance of a truly collaborative, respectful, and inclusive approach by the multidisciplinary team, working alongside families and loved ones to prevent, identify, and care for individuals impacted by hypoactive delirium, cannot be overstated. As healthcare providers, it is our collective responsibility to not only recognise the signs of hypoactive delirium but to advocate for its early identification and to work collaboratively to ensure the best possible outcomes for people affected by this serious, insidious condition.
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