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.
- Check pain, oxygenation, glucose, infection, bladder, bowel, hydration, renal and hepatic function, calcium, medicines and withdrawal according to the clinical context.
- Use glasses, hearing aids, daylight, orientation, sleep protection, familiar people, mobility, hydration and calm repeated explanation before medicine when safe.
- Treat a reversible cause when likely benefit matches goals; near death, use only investigations and interventions that can improve comfort or an agreed outcome.
- If severe distress or risk persists despite de-escalation, use short-term low-dose haloperidol only after Parkinson, Lewy-body, cardiac and interaction review.
- For refractory terminal agitation, specialist palliative care may use levomepromazine, midazolam or both with explicit proportional-sedation goals and frequent review.
- The gold-standard record describes attention and fluctuation, precipitant assessment, capacity, non-drug measures, target behaviour, medicine response and stop or review point.
Key red flags
New inattention, altered arousal or fluctuating cognition is delirium until assessed, including quiet withdrawal and reduced intake.
Focal neurology, severe headache, seizure, meningism, trauma or anticoagulation raises intracranial emergency and imaging need.
Hypoxia, hypotension, fever, hypoglycaemia, retention, impaction or uncontrolled pain requires prompt treatment rather than sedation alone.
Myoclonus, hallucinations, allodynia and drowsiness during opioid therapy suggests neurotoxicity, particularly after renal decline.
Haloperidol can cause serious extrapyramidal and cardiac harm and is especially hazardous in Parkinson's disease and dementia with Lewy bodies.
Benzodiazepines can worsen ordinary delirium but may be required for alcohol or benzodiazepine withdrawal, seizure, or refractory terminal agitation under a defined plan.
Covert medicine, restraint or deprivation of liberty requires necessity, proportionality, best-interests reasoning and the relevant legal safeguards.
Violence, falls, airway compromise, line removal or inability to deliver essential care requires urgent least-restrictive safety intervention.
Investigation priorities
Screen alertness, orientation, attention and acute fluctuation and establish a bedside delirium diagnosis.
Management branches
A person develops acute or fluctuating inattention, altered arousal, cognition or behaviour.
- Use 4AT and clinical assessment, obtain collateral baseline and perform ABCDE, glucose, pain, bladder, bowel, neurological and medication review.
- Treat urgent hypoxia, infection, metabolic change, retention, impaction or toxicity and institute orientation, sensory, sleep and mobility measures.
- Assess capacity and risk, explain the syndrome to family and review repeatedly because cause, arousal and decision ability fluctuate.