Medical student experience of an encounter with a patient with delirium - "Mrs. P was 83. She was in a bay of 4 patients on a medical ward. Two of them were noisy - one was calling out repeatedly, another had a loud TV. Mrs. P was quiet. Eyes open, staring at the ceiling. Looked unhappy and puzzled. Not eating the lunch tray in front of her. Not pressing her call bell. Not moving much. In a busy ward, quiet patients are 'settled' patients. Nobody seemed worried about Mrs. P. I was taking histories as part of my clinical attachment. I sat down next to her and said hello and introduced myself. She looked at me briefly but didn't answer. She looked away. I asked her name. She did not answer. I asked her again and she gave her name. I asked where she was. She looked surprised by the question then said, 'at home'. She had no idea she was in hospital. I mentioned this to the ward doctor. He came and assessed her. She was profoundly inattentive, disoriented in time and place, and had been like this for at least two days based on the nursing observations - which had documented 'settled' and 'comfortable' because she wasn't causing any problems, though two entries also mentioned 'confused' ? baseline - though no additional mental status assessments had been done. She had pneumonia and constipation that were already being treated, but nobody had formally recognised that her quietness was delirium. Hypoactive delirium. The subtype where patients don't shout, don't climb out of bed, don't pull out their lines. They just... go quiet. And going quiet, in a hospital, can make you less visible. Hypoactive delirium is more common than the hyperactive form, and it carries a worse prognosis. Patients with hypoactive delirium have higher mortality rates, and longer hospital stays. Yet it's detected even less often, because it doesn't trigger alarms. It doesn't create workload. It doesn't disrupt the ward. The noisiest patients get the most attention but the quietest patients may be sicker. Since that day, I make a point of doing a delirium assessment on the quiet ones."