DPDoctor's PassportEducation
Palliative and end-of-life care indexPassport
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Textbook/Palliative and end-of-life care/Delirium and agitation/Rapid
RapidMLAMSRAFoundationGP

Delirium and agitation

Essential points for quick revision.

2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
!
Agitation with immediate danger

Violence, repeated line removal, wandering into danger, severe distress, seizure, hypoxia, shock, hypoglycaemia or suspected intracranial catastrophe requires urgent medical and safety intervention.

Action: Use ABCDE assessment, check glucose and oxygenation, call trained help and reduce environmental threat. Treat pain and the likely reversible cause, use verbal de-escalation and familiar support, and apply the least restrictive proportionate medicine or restraint only when immediate risk persists; document capacity, rationale and review.

Synopsis

Recognise fluctuating inattention and altered arousal, identify reversible contributors proportionately, protect the patient and others with least-restrictive care, and use antipsychotic or sedative treatment only for defined distress or risk with close review.

  • Delirium is an acute or subacute fluctuating disturbance of attention, awareness and cognition caused by one or more physical or medication factors.
  • Look actively for hypoactive delirium: drowsiness, reduced speech, poor intake, withdrawal and slowed movement are easily mistaken for fatigue or depression.
  • First-line screening uses the 4AT or another locally validated tool, followed by clinical diagnosis, collateral baseline and focused examination.

Key red flags

New inattention, altered arousal or fluctuating cognition is delirium until assessed, including quiet withdrawal and reduced intake.

Immediate safety risk

Violence, falls, airway compromise, line removal or inability to deliver essential care requires urgent least-restrictive safety intervention.

Investigation priorities

01
First-line 4AT and clinical assessmentFirst stepFirst line

Screen alertness, orientation, attention and acute fluctuation and establish a bedside delirium diagnosis.

Management branches

Initial deliriumRecognise, protect and find contributors

A person develops acute or fluctuating inattention, altered arousal, cognition or behaviour.

  1. Use 4AT and clinical assessment, obtain collateral baseline and perform ABCDE, glucose, pain, bladder, bowel, neurological and medication review.
  2. Treat urgent hypoxia, infection, metabolic change, retention, impaction or toxicity and institute orientation, sensory, sleep and mobility measures.

Key medicines

Haloperidol for severe distress or riskIn a frail palliative adult, start 500 micrograms to 1 mg orally or subcutaneously as a patient-specific dose under the local delirium protocol, repeat only after reviewed response and keep the total and duration as low and short as possible.
Levomepromazine for refractory terminal deliriumSpecialist palliative protocols may use 6.25 to 12.5 mg subcutaneously as rescue and a patient-specific 24-hour infusion, often beginning around 25 mg, with cautious titration to relief.
Open full textbook →Answer 2 questions
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom