Patient handout

Delirium — acute confusional state (DSM-5-TR 2022; SCCM PADIS 2018 PMID 30113379; NICE CG103 2010 reaffirmed 2024; CAM Inouye 2006 PMID 16540616; 4AT Bellelli 2014 PMID 25028342; MIND-USA Girard 2018 PMID 30346242)

PRODUCTION

1. Your condition

This handout is for delirium — acute confusional state (dsm-5-tr 2022; sccm padis 2018 pmid 30113379; nice cg103 2010 reaffirmed 2024; cam inouye 2006 pmid 16540616; 4at bellelli 2014 pmid 25028342; mind-usa girard 2018 pmid 30346242). Your care team identified this based on: acute change in cognition / inattention / fluctuating mental status / altered level of consciousness in any care setting (dsm-5-tr 2022 criterion a+b; cam inouye nejm 2006 pmid 16540616).

Other reasons your team may use this plan: new agitation or new withdrawn / drowsy / low-arousal state in hospitalised older adult — hyperactive ~25 % / hypoactive ~50 % / mixed ~25 % (marcantonio nejm 2017 pmid 29020579); positive cam (feature 1 + 2 and 3 or 4; inouye nejm 2006 pmid 16540616) or 4at ≥ 4 (bellelli age ageing 2014 pmid 25028342) on routine bedside screen; positive cam-icu + rass ≥ -3 in ventilated / non-verbal patient (ely jama 2001 pmid 11730446; sessler ajrccm 2002 pmid 12421743).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
identify_and_treat_underlying_cause	Per cause: infection → empirics + source control (route to id.sepsis or id.geriatric-infection-syndromes); hypoglycaemia → D50; hyperglycaemia / DKA → endo.dka.core.v1; alcohol withdrawal → psych.alcohol_withdrawal.core.v1 with thiamine BEFORE glucose; opioid withdrawal / intoxication → psych.opioid_use_disorder.core.v1; uremia → neph.aki; hepatic encephalopathy → lactulose + treat precipitant; electrolytes → repletion; anticholinergic burden → deprescribe; urinary retention → bladder scan + catheter; faecal impaction → disimpaction; sensory deprivation → glasses + hearing aids	per_cause	per_cause	Cause-directed treatment is the foundation; without addressing the underlying cause, non-pharm + pharm interventions are palliative only (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)
thiamine	100 mg IV / IM × 3-5 d (Wernicke prophylaxis) or 500 mg IV TID × 2-3 d (suspected Wernicke triad)	IV/IM	daily to TID	Royal College of Physicians + NICE CG100 — thiamine BEFORE glucose in alcohol use disorder / Wernicke risk; glucose without thiamine can precipitate or worsen Wernicke. Routinely given in alcohol withdrawal-delirium (Mayo-Smith ASAM 2020 NEEDS_SOURCE_REVIEW)

Plan: Delirium treatment hierarchy — Step 1 identify + treat underlying cause (always first; DELIRIUMS) → Step 2 non-pharmacologic HELP/NICE bundle FIRST → Step 3 antipsychotic SECOND-LINE for severe agitation with safety risk only (haloperidol / risperidone / quetiapine / olanzapine) → Step 4 ICU PADIS A2F bundle (dexmedetomidine sedation-bridge over benzodiazepine) → Step 5 alcohol/benzo withdrawal-delirium exception (lorazepam titrated to CIWA-Ar/RASS; routes to psych.alcohol_withdrawal.core.v1). NO antipsychotic prophylaxis (MIND-USA Girard 2018 PMID 30346242 NEGATIVE; Hope-ICU Page 2013 NEEDS_SOURCE_REVIEW NEGATIVE) (NICE CG103 2010; SCCM PADIS 2018 Devlin PMID 30113379; Marcantonio NEJM 2017 PMID 29020579)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Mental status at baseline — no signs of delirium (NICE CG103 2010)

If you have:

Awake, alert, oriented to person + place + time (or near-baseline if dementia)
Conversation coherent for patient baseline
Sleep-wake cycle near baseline
No new agitation or withdrawn / drowsy behaviour

Do this:

Continue daily non-pharm bundle: reorientation (clock, calendar, name), sensory aids on (glasses, hearing aids, dentures), hydration, daytime activity, family presence (Inouye NEJM 1999 PMID 10089183)
Continue scheduled medications as prescribed; do not add OTC sedating antihistamines / sleep aids (AGS Beers 2023 PMID 36968894)
Maintain regular sleep schedule with daytime light + activity and dim lighting at night
Keep up scheduled follow-up appointments + medication reviews

YELLOW — Caution — early signs of delirium developing (NICE CG103 2010)

If you have:

New confusion, forgetfulness, or trouble paying attention (different from usual)
New restlessness, irritability, withdrawal, or drowsiness
Sleep-wake cycle disruption (sleeping all day, awake all night)
New visual hallucinations or "seeing things"
Difficulty with usual activities (bathing, dressing, eating)
Started a new medication in the last 1-2 weeks
New constipation, urinary symptoms, or feeling unwell

Do this:

Call the primary care provider TODAY for evaluation
Check for and treat constipation / urinary retention / dehydration
Check that glasses + hearing aids + dentures are in use and working
Review all medications with the provider — anything new in the last 1-2 weeks? Any sleep aids, allergy meds, pain meds?
Maintain reorientation: clock + calendar + name + day; family presence; familiar objects + photos
Avoid alcohol; if usually heavy drinker, do NOT stop suddenly without medical supervision (risk of withdrawal-delirium)
Provide hydration unless restricted; offer regular meals
Keep daytime light + activity; dim lights at night

Call your provider if:

Symptoms worsening over 24-48 h
New fever, urinary symptoms, cough, shortness of breath
Falls or near-falls
New severe agitation or aggression
Patient cannot keep down food/fluids

RED — Medical alert — severe delirium / safety risk (NICE CG103 2010; Marcantonio NEJM 2017 PMID 29020579)

If you have:

Severe agitation: combative, trying to leave, removing IV lines or catheters
Severe withdrawal: tremor, sweating, racing heart in someone who stopped alcohol/benzo in last 72-96 h
Hallucinating + frightened, unable to be calmed
New thoughts of self-harm or wanting to die
Sudden weakness on one side, trouble speaking, severe headache, vomiting (possible stroke)
Seizure
Cannot stay awake to drink or take medications
Blood sugar very high or very low (if known)
Fever ≥ 38 °C with confusion
Cannot be safely managed at home

Do this:

Call 911 / your local emergency services NOW for severe agitation, suspected withdrawal-delirium, suicidal thoughts, stroke symptoms, seizure, or inability to manage safely at home
Go to the nearest emergency department; do not be alone with the patient if they are aggressive
Bring complete medication list, allergy list, advance directive if available
Tell the ED about: all medications (prescription + OTC + supplements), alcohol use, recent surgery, baseline cognition, recent medication changes
Hand any means of self-harm (firearms, large quantities of pills) to a trusted person before leaving home
If the patient has dementia + new severe confusion → this is likely delirium ON TOP of dementia and is a medical emergency (NICE CG103 2010)

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (NICE CG103 2010)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Severe hyperactive delirium with safety risk — falls / self-extubation / aggression / inability to deliver essential care; ~ 25 % of all delirium subtypes
Hypoactive delirium (~ 50 % of all delirium) — withdrawn, drowsy, low-arousal; MOST COMMONLY missed; under-detection 60-80 % in routine care; high mortality
Withdrawal-delirium (delirium tremens in alcohol withdrawal) — fever + tachycardia + diaphoresis + tremor + hallucinations + autonomic instability + altered mental status in patient with alcohol or benzodiazepine cessation 72-96 h prior; life-threatening — mortality 1-5 % treated, up to 35 % untreated (ASAM 2020 NEEDS_SOURCE_REVIEW)(life-threatening)
Delirium in older adult with high anticholinergic burden (ACB score ≥ 3 OR Drug Burden Index elevated) — diphenhydramine, scopolamine, oxybutynin, TCAs, antihistamines, antipsychotics with high anticholinergic activity, antispasmodics, paroxetine; common precipitant of delirium in older adults
Post-operative delirium > 65 yr (incidence 15-40 %) — multifactorial pain + meds (especially benzodiazepines + opioids + anticholinergics) + sleep disruption + electrolytes + dehydration + immobility
ICU delirium (incidence 40-80 %) — apply SCCM PADIS 2018 A2F bundle (Assess pain + Both SAT/SBT + Choice of analgesia + Delirium monitor + Early mobility + Family presence); NO antipsychotic prophylaxis (MIND-USA 2018 NEGATIVE)
Delirium with infection as underlying cause (UTI, pneumonia, cellulitis, sepsis) — especially in older adult where atypical infection presentation is common (delirium-as-sepsis); blunted fever response in frail elderly does not rule out infection
Post-discharge persistent cognitive features after delirium episode — 30-50 % of survivors have persistent features; 40-60 % progress to dementia within 1 yr; high re-hospitalisation + mortality risk

5. Follow-up

Post-discharge cognitive assessment 4-6 wk + 3 mo + 6 mo (persistent features in 30-50 %); caregiver support / education; may unmask dementia (40-60 % of survivors progress within 1 yr; Marcantonio NEJM 2017 PMID 29020579); functional rehabilitation referral; primary-care + geriatrics follow-up; advance care planning revisit

6. Sources

Guideline: DSM-5-TR 2022 Delirium Criteria + SCCM PADIS 2018 (Devlin Crit Care Med 2018 PMID 30113379) + NICE CG103 Delirium 2010 reaffirmed 2024 + APA Practice Guideline for Delirium 1999 (historical anchor) + CAM Inouye NEJM 2006 PMID 16540616 + 4AT Bellelli 2014 PMID 25028342 + CAM-ICU Ely 2001 PMID 11730446 + RASS Sessler 2002 PMID 12421743 + HELP Inouye NEJM 1999 PMID 10089183 + MIND-USA Girard NEJM 2018 PMID 30346242 + Marcantonio NEJM 2017 PMID 29020579 + CAPD Traube 2014 PMID 24717459 + AGS Beers 2023 PMID 36968894