One night I was called by a concerned nurse to see one of the inpatients. The nurse was alarmed to find the elderly woman trying to eat the ornamental plant on her nightstand. On my arrival I observed the patient starting to eat a styrofoam coffee cup. After I took the cup away I asked her what she was doing. She said she was hungry so she decided to have some of the “candy”. She was obviously confused, she didn’t understand that she was trying to eat non-edible items.
This patient had previously shown no indication of mental health issues or dementia. She was in the hospital for treatment of cellulitis which was resolving, and it was expected she would be discharged soon. Her vital signs were within normal limits, she was afebrile, her blood sugar was normal and her O₂ sat on room air was 97%.
Reviewing her chart, I saw she had been given Triazolam for the first time that night to help her sleep. I suspected the medication was causing her to be delusional. This is a transient side effect of this type of medication, which is more likely to occur when people delay going to bed to sleep after taking it. In this case, she did not go to sleep immediately but sat up reading in bed for some time after she was given the medication.
The three most common causes of altered mental status in otherwise healthy elderly patients are: medications, infection, and metabolic abnormalities. In this case, it was the medication. I have seen younger patients also develop confusion from this medication, especially if they delay going to bed after taking it. It can be quite alarming for the patient’s family and sometimes can lead to accidents as the patient tries to act out the fantasies of their dreams, especially if they try to drive a car.
Triazolam is a short-acting benzodiazepine primarily used as a short-term treatment for insomnia. Like other drugs in the benzodiazepine class, Triazolam acts by enhancing the activity of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits activity in the brain, resulting in sedative, hypnotic, and anxiolytic effects.
By enhancing the effects of GABA, Triazolam can cause excessive inhibition of brain activity. In some individuals, this disruption in normal brain function can lead to cognitive and perceptual disturbances, such as delusions—false beliefs that are resistant to reasoning or contrary evidence.
Drugs in the benzodiazepine class can also be associated with memory disturbances, particularly anterograde amnesia—the inability to form new memories after taking the drug. This memory impairment can contribute to delusional thinking because gaps in memory may lead individuals to create false narratives or interpretations to make sense of their experiences. Essentially, the brain attempts to “fill in the blanks,” which can result in delusional beliefs.
Triazolam is primarily used for treating insomnia but, paradoxically, it can cause abnormal sleep behaviors such as sleepwalking, sleep-talking, or engaging in activities without full awareness (e.g., sleep-driving). These altered states of consciousness can lead to confusion upon awakening and, in some cases, cause individuals to develop false beliefs about reality, feeding into delusions.
These effects are more likely in individuals who have a history of mental illness, are elderly (due to decreased drug metabolism and increased sensitivity), or use the drug at higher doses or for an extended period.
Additionally, a small number of individuals may experience paradoxical reactions to benzodiazepines where, instead of calming effects, they experience agitation, aggression, or psychotic symptoms. In such cases, delusions could emerge as part of a heightened state of confusion and mental disturbance.
In the case of our elderly patient, after some warm milk (in a hard plastic cup) and some crackers, the patient went to sleep. In the morning her mental status was back to normal and she had no recollection of her bizarre behavior the night before.
