Delirium: non-drug and drug management

Management begins by naming active causes and assigning actions. Correct oxygenation, glucose, circulation and metabolic disturbance; treat infection and pain; relieve retention and constipation; manage withdrawal; stop or reduce contributory medicines safely. Re-examine when behaviour changes because agitation can be the first sign of worsening physiology rather than failure of behavioural care.

De-escalation is skilled treatment. Approach from the front, identify yourself, use the person's preferred name and one instruction at a time, allow processing time and avoid arguing with a frightening misperception. Ask what they need, acknowledge emotion and offer food, drink, toilet, pain relief or a quieter space. Familiar carers can explain usual communication, but should never be compelled to provide constant supervision.

Create a therapeutic environment: stable bed space and staff where possible, daylight and ordinary daytime activity, low noise at night, visible clock and calendar, working sensory aids and personal objects. Mobilise with help and avoid bed rails or devices that increase climbing. Use enhanced observation focused on reassurance and needs, not silent surveillance or repeated confrontation.

Assess capacity for the immediate decision and use the least restrictive lawful response. A person may lack capacity to understand an essential infusion during severe delirium yet still express meaningful comfort and relationship preferences. Document why any restraint is necessary, proportionate, time-limited and reviewed. Physical restraint and rapid tranquillisation require local governance and senior oversight.

Medicine is exceptional. NICE advises short-term haloperidol when a delirious person is distressed or considered a risk to self or others and verbal and non-verbal de-escalation has failed or is inappropriate. The aim is the minimum reduction needed for safe essential care, not sleep or suppression of wandering. Explain off-label or protocol aspects and review after every dose.

MHRA advises a baseline ECG and correction of electrolyte disturbance, the lowest dose for the shortest possible time and close review for cardiac and extrapyramidal effects. In a frail adult, a local protocol may start 0.5 mg orally and reassess after one to two hours, avoiding repeated stacking. Oral treatment is preferable when accepted. Stop promptly when risk resolves and do not write routine discharge continuation.

Do not use haloperidol in Parkinson disease or dementia with Lewy bodies. Ask about parkinsonism, cognitive fluctuation, formed visual hallucinations, REM-sleep behaviour and previous severe antipsychotic reactions before prescribing. If medication is unavoidable, involve old-age psychiatry, geriatrics or neurology; low-dose quetiapine is sometimes selected off-label but has limited evidence and important sedation, hypotension and mortality risk.

Benzodiazepines can worsen disinhibition, falls and respiratory depression. Their main delirium roles are alcohol or benzodiazepine withdrawal under a specific symptom-triggered protocol and selected catatonia or palliative situations. Give parenteral sedatives only in a monitored environment with airway, reversal and escalation capability and never combine casually with opioids.

Review at least each shift: cause trajectory, distress, sleep, intake, mobility, bowel and bladder, sensory support, restrictive interventions and any medicine effect. Akathisia, rigidity or oversedation can look like ongoing delirium. If symptoms persist, reopen diagnosis and environmental delivery. Communicate any dose, indication and stop date across transitions.