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neuro.delirium.v1

Delirium (inpatient/ICU)

neurologyacuteadultgeriatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro expansion (2026-05-14): authored at INTEGRATED tier — manifest file forward-declared (does not yet exist on disk; PRODUCTION promotion requires manifest + RxNav validation + delirium-specific calculator registry entries). 12 phenotype severity_triggers: hyperactive / hypoactive / mixed / CAM+ / CAM-ICU+ / delirium-superimposed-on-dementia / alcohol-withdrawal-DTs / benzo-opioid-withdrawal / anticholinergic-burden / metabolic / sepsis-associated-encephalopathy / drug-induced. 5 setting playbooks span the full delirium journey: home (family recognition + 911) → ed (rule out delirium FIRST in elderly; treat reversible precipitants; non-pharm + minimum sedation) → icu (ABCDEF bundle + dexmedetomidine preferred over benzo per PADIS 2018) → inpatient (HELP bundle + deprescribe per AGS Beers 2023) → outpatient (post-discharge cognitive follow-up at 1-3 mo; ≥30% have lasting cognitive impairment per BRAIN-ICU). Schema-blocked calculators (CAM, CAM-ICU, ICDSC, RASS, 4AT, CIWA-Ar, COWS) NOT in clinical-tools-registry.ts — surfaced in depth bundle as schema-blocked queue items. Currently encoded as plain-English required_inputs and severity_triggers. Same workaround pattern as neuro.status-epilepticus.core.v1 STESS/EMSE/Sheiner-Tozer. Three regimen axes: (1) non-pharm ABCDEF + HELP first-line; (2) pharm last-resort (haloperidol low-dose for safety only, dexmedetomidine for ICU sedation preference, benzo ONLY for withdrawal); (3) anticholinergic deprescribing per AGS Beers 2023. Sibling differentiation: symptom.dementia.v1 (acute vs chronic — CAM positivity distinguishes), id.sepsis.core.v1 (sepsis-associated encephalopathy). Both sibling engines are PRODUCTION-registered. Modern view: non-pharm first-line per SCCM PADIS 2018; antipsychotics have NO ICU benefit per MIND-USA + HOPE-ICU; FDA black-box mortality in elderly with dementia; benzos deliriogenic except for alcohol/benzo withdrawal; dexmedetomidine preferred ICU sedative per PADIS 2018.

Entry points (6)

  • symptom
    Acute (hours-days) onset of inattention + fluctuating course (CAM core feature; Inouye 1990)
    acute_onset_inattention
  • symptom
    Fluctuating level of consciousness or arousal (RASS / GCS variation)
    fluctuating_consciousness
  • symptom
    New agitation or lethargy in elderly inpatient (SCCM PADIS 2018 PMID 30113379)
    agitation_or_lethargy_new
  • symptom
    ICU patient on sedation with altered mental status — CAM-ICU positive (SCCM PADIS 2018)
    icu_altered_mental_status
  • symptom
    Post-operative confusion in elderly (AGS post-op delirium 2015)
    post_operative_confusion
  • symptom
    Acute visual hallucinations + tremor + autonomic instability — alcohol withdrawal DTs (Marcantonio NEJM 2017)
    visual_hallucinations_acute

Required inputs (25)

  • agerequired
    demographic • used at CONTEXT
    Age ≥65 is the largest single risk factor; pre-existing cognitive impairment + comorbidity increase further (Inouye Lancet 2014; AGS post-op delirium 2015)
  • baseline_cognitionrequired
    history • used at CONTEXT
    Pre-existing dementia is the strongest predisposing factor; DSD (delirium superimposed on dementia) drives prognosis (Marcantonio NEJM 2017 PMID 21075055)
  • cam_assessmentrequired
    symptom • used at INITIAL_WORKUP
    CAM (acute onset + inattention + (disorganized thinking OR altered LOC)) is gold-standard bedside screen (Inouye Ann Intern Med 1990)
  • cam_icu_or_icdsc_assessment
    symptom • used at INITIAL_WORKUP
    CAM-ICU OR ICDSC for ventilated/non-verbal ICU patients (SCCM PADIS 2018 PMID 30113379)
  • rass_or_richmond
    symptom • used at CONTEXT
    RASS −5 to +4 quantifies arousal; pairs with CAM-ICU; mandatory in PADIS 2018 sedation protocols
  • current_meds_full_listrequired
    medication • used at CONTEXT
    Anticholinergic / benzodiazepine / opioid / sedating antihistamine / corticosteroid / sympathomimetic load drives drug-induced delirium (AGS Beers 2023; NICE CG103)
  • recent_med_changesrequired
    medication • used at CONTEXT
    New start / dose change / abrupt stop within 7 d frequently precipitates delirium (NICE CG103)
  • alcohol_or_benzo_userequired
    history • used at CONTEXT
    Withdrawal delirium has distinct Rx (benzo per CIWA-Ar, not antipsychotic); chronic alcohol → thiamine FIRST
  • recent_surgery_anesthesia
    history • used at CONTEXT
    Post-op delirium incidence 15-50% in elderly; specific RFs: hip fracture, cardiac, prolonged surgery (AGS post-op delirium 2015)
  • temperaturerequired
    vital • used at RED_FLAGS
    Fever → infection (UTI / pneumonia / line / CNS) as precipitant; sepsis-associated encephalopathy (id.sepsis.core.v1)
  • sbp_hr_rr_spo2required
    vital • used at RED_FLAGS
    Hemodynamic + respiratory instability supports SAE / hypoxic / hypercapnic encephalopathy (SCCM PADIS 2018)
  • glucoserequired
    lab • used at RED_FLAGS
    Hypo/hyperglycemia is the most-missed reversible cause; correct FIRST (NICE CG103)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hypo/hypernatremia drives confusion; correction rate matters per electrolyte engine (NICE CG103)
  • calciumrequired
    lab • used at INITIAL_WORKUP
    Hypercalcemia (malignancy / hyperparathyroid) and hypocalcemia can present as delirium
  • bun_creatininerequired
    lab • used at INITIAL_WORKUP
    Uremic encephalopathy at advanced CKD/AKI; consider HD timing (AGS Beers 2023; KDIGO)
  • lft_ammonia
    lab • used at INITIAL_WORKUP
    Hepatic encephalopathy with hyperammonemia → lactulose / rifaximin (AASLD HE 2014)
  • tsh
    lab • used at INITIAL_WORKUP
    Hypothyroidism (myxedema) / hyperthyroidism (apathetic hyperthyroid in elderly) can present as delirium
  • b12_folate
    lab • used at INITIAL_WORKUP
    Severe B12 deficiency may cause acute confusion in elderly (AAN 2018)
  • urinalysis_culturesrequired
    lab • used at INITIAL_WORKUP
    UTI is most common infectious precipitant in elderly delirium (Inouye Lancet 2014 PMID 21796639)
  • abg_or_capnography
    lab • used at INITIAL_WORKUP
    Hypoxia + hypercapnia drive delirium; PADIS 2018 routine in ICU
  • tox_screen_ethanol
    lab • used at BRANCHING_WORKUP
    Substance intoxication / withdrawal — alcohol level + UDS in unexplained delirium (NICE CG103)
  • ct_head_if_focal_or_trauma
    imaging • used at BRANCHING_WORKUP
    CT head if focal neuro deficit, head trauma, anticoagulated fall, or rapid decline (NICE CG103); routine CT NOT indicated otherwise
  • eeg_if_subclinical_seizure_suspected
    imaging • used at BRANCHING_WORKUP
    NCSE can mimic delirium — cEEG within 60 min if persistent unexplained AMS especially post-cardiac-arrest (NCS 2012)
  • sleep_wake_environment_factors
    history • used at CONTEXT
    Disrupted sleep, ICU noise, restraints, indwelling devices are modifiable contributors (HELP bundle; Inouye Lancet 2014)
  • pain_assessmentrequired
    history • used at CONTEXT
    Untreated pain is a common precipitant; ABCDEF "A" = Assess pain (SCCM PADIS 2018 PMID 30113379)

12-phase flow (12)

  1. 1FRAME
    Acute / fluctuating attentional disturbance in vulnerable patient — distinguish from chronic dementia or coma (DSM-5; SCCM PADIS 2018 PMID 30113379)
    inputs: age, baseline_cognition
    advance: Acute onset + fluctuating course confirmed by collateral history
  2. 2ENTRY
    Trigger from CAM/CAM-ICU/ICDSC screen, RASS shift, family/staff concern, post-op confusion, ICU sedation off (SCCM PADIS 2018; AGS post-op delirium 2015)
    inputs: cam_assessment
    advance: Entry pattern recognized + delirium screen positive
  3. 3CONTEXT
    Baseline cognition + meds (anticholinergic / benzo / opioid load) + alcohol/benzo use + sleep/environment + pain + recent procedures (AGS Beers 2023; NICE CG103)
    inputs: current_meds_full_list, recent_med_changes, alcohol_or_benzo_use, pain_assessment
    advance: Predisposing + precipitating factors captured
  4. 4RED_FLAGS
    Hypoxia / hypercapnia / hypoglycemia / hypotension / sepsis / NMS / serotonin syndrome / Wernicke encephalopathy / NCSE / opioid overdose — STAT correction before non-pharm bundle (NICE CG103; SCCM PADIS 2018)
    inputs: temperature, sbp_hr_rr_spo2, glucose
    actions: workup.delirium, workup.hypoglycemia, workup.encephalopathy
    advance: Reversible life-threats addressed + airway/circulation stable
  5. 5INITIAL_WORKUP
    CAM / CAM-ICU / ICDSC + RASS; CBC, BMP, Ca, Mg, Phos, glucose, LFT, TSH, urinalysis + cultures, ABG, lactate; tox screen + ethanol if unexplained (Inouye Lancet 2014 PMID 21796639)
    inputs: sodium, calcium, bun_creatinine, urinalysis_cultures
    actions: panel.cbc, panel.renal, panel.thyroid, panel.lft
    advance: Reversible metabolic + infectious causes screened
  6. 6BRANCHING_WORKUP
    CT head only if focal deficit / trauma / anticoag fall / unexplained rapid decline; cEEG if NCSE suspected; LP if febrile + meningismus + immunosuppressed (NICE CG103; SCCM PADIS 2018; NCS 2012)
    inputs: ct_head_if_focal_or_trauma, eeg_if_subclinical_seizure_suspected, tox_screen_ethanol
    advance: Imaging + cEEG / LP indications determined
  7. 7DIFFERENTIAL
    Hyperactive vs hypoactive vs mixed delirium; DSD (delirium superimposed on dementia); SAE (sepsis-associated encephalopathy); alcohol / benzo / opioid withdrawal; drug-induced; metabolic; NCSE; psychiatric mimic (Marcantonio NEJM 2017 PMID 21075055; Inouye Lancet 2014 PMID 21796639)
    advance: Phenotype + precipitants assigned
  8. 8RISK_STRATIFICATION
    Predisposing × precipitating model (Inouye Lancet 2014); ICU sedation protocol determination (SCCM PADIS 2018); CIWA-Ar if alcohol withdrawal; opioid withdrawal COWS
    advance: Severity + duration risk documented
  9. 9TREATMENT
    Non-pharm ABCDEF bundle FIRST (SCCM PADIS 2018 PMID 30113379); treat precipitants (UTI / dehydration / pain / hypoxia); HELP bundle inpatient; deprescribe per AGS Beers 2023; antipsychotic last-resort time-limited only for severe agitation/safety (MIND-USA NEJM 2018 PMID 30346242 — no benefit; HOPE-ICU Lancet Resp 2013 PMID 23818095); benzo ONLY for alcohol/benzo withdrawal or NMS / serotonin syndrome
    inputs: current_meds_full_list, pain_assessment
    advance: Bundle + precipitant Rx active; pharm reserved for safety only
  10. 10DISPOSITION
    ICU for SAE, post-cardiac-arrest, severe withdrawal DTs requiring high-dose IV benzo, NCSE — otherwise ward with HELP bundle; geriatric/ACE unit if available (NICE CG103)
    advance: Level of care matched to phenotype + precipitant severity
  11. 11MONITORING
    CAM / CAM-ICU q-shift in ICU and q-shift on floor for at-risk patients (SCCM PADIS 2018); RASS continuous in ICU; reassess deprescribing weekly; pain/sleep/mobility documented daily (HELP)
    inputs: cam_assessment
    advance: Monitoring plan documented + bundle adherence audited
  12. 12FOLLOWUP
    Post-discharge cognitive follow-up (≥30% of post-ICU delirium patients have long-term cognitive impairment per BRAIN-ICU); medication reconciliation; geriatric clinic if persistent cognitive complaints; ACP / driving discussion (Inouye Lancet 2014 PMID 21796639)
    advance: Post-discharge cognitive plan documented + family education