Synopsis
Treat delirium through urgent cause control and skilled non-drug care, de-escalate distress while preserving communication and mobility, and restrict sedating medicine to exceptional short-term safety indications with Parkinson and Lewy-body safeguards.
- Cause treatment and multicomponent non-drug care are first-line delirium management; no medicine cures the syndrome.
- Use one calm communicator, introduce each action, validate fear, offer simple choices, restore glasses and hearing aids and involve familiar people when wanted.
- Meet physical needs: oxygen when indicated, analgesia, hydration, nutrition, toilet, bowel care, temperature comfort, sleep and safe mobilisation.
- Reduce noise, crowding, ward moves, alarms and unnecessary devices while maintaining daylight, clock, calendar and repeated orientation.
- If the person is distressed or risks harm, attempt verbal and non-verbal de-escalation before medicine unless immediate danger makes this inappropriate.
- NICE permits short-term haloperidol, usually one week or less, only when de-escalation fails or is inappropriate and distress or risk remains.
- Before haloperidol, check Parkinson or DLB, cardiac history, QT-prolonging drugs, ECG and electrolytes and use the lowest dose for the shortest time.
- A frail older-adult emergency regimen may begin haloperidol 0.5 mg orally once with reassessment; follow the local typed protocol and avoid automatic repeat dosing.
- Avoid haloperidol in Parkinson disease and DLB. Seek specialist advice; medication alternatives are off-label and still carry sedation, stroke and mortality risk.
- Benzodiazepines usually worsen ordinary delirium; reserve them for alcohol or benzodiazepine withdrawal, catatonia or a specialist indication.
Key red flags
Never sedate agitation before checking oxygenation, glucose, pain, retention, constipation, withdrawal, medication toxicity and new neurological signs.
Parkinson disease or dementia with Lewy bodies creates marked neuroleptic sensitivity; haloperidol can cause rigidity, aspiration, reduced consciousness and death.
QT prolongation, bradycardia, electrolyte disturbance, cardiac disease or interacting medicines increases torsade risk and requires ECG-informed avoidance or correction.
Fever, severe rigidity, reduced consciousness and autonomic instability after an antipsychotic suggests neuroleptic malignant syndrome and requires immediate cessation and emergency care.
Alcohol or benzodiazepine withdrawal needs a specific benzodiazepine regimen and thiamine pathway rather than ordinary delirium sedation.
Restraint, repeated security presence or forced care can amplify fear and injury; any restriction requires immediate necessity, proportionality and frequent review.
Investigation priorities
Detect a new or untreated medical driver.
Management branches
Delirium is recognised with distress, disorientation or unsafe behaviour.
- Correct physiological and medical drivers and provide pain, hydration, nutrition, bowel, bladder and sensory care.
- Use one calm communicator, familiar support, orientation, low-stimulation space, sleep protection and safe mobilisation.
- Review response and capacity frequently and remove unnecessary devices and restrictions.