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geriatrics.delirium.core.v1PRODUCTION
geriatrics.delirium.core.v1

Delirium (older adult)

general_internal_medicineacutegeriatricadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame delirium as an acute brain emergency in a vulnerable (often demented/frail) older adult: predisposing vulnerability x precipitating insult; goal is the reversible-cause hunt, not symptom suppression (NICE CG103 2023)

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Older adult with possible acute cognitive change identified; scope confirmed (NICE CG103 2023)

Patient inputs (14)

Age >=65 is a core predisposing factor; older brain is delirium-vulnerable; affects drug dosing (start low) (NICE CG103 2023)

Baseline dementia / cognitive impairment is the STRONGEST predisposing factor; needed to separate delirium from dementia and detect delirium-superimposed-on-dementia (DSM-5-TR)

Anticholinergic burden, benzodiazepines, opioids, polypharmacy and abrupt withdrawal (alcohol/benzo) are leading precipitants and the most modifiable (NICE CG103 2023)

Acute onset (hours-days) + fluctuating course is the definitional pivot vs chronic dementia (DSM-5-TR; CAM)

Severe hypo/hypernatremia precipitates and mimics delirium; correction must be controlled (osmotic demyelination) (AGS/ADS 2015)

Inattention + altered consciousness are the two CAM cardinal features; drive screening and subtype (Inouye Ann Intern Med 1990)

Point-of-care glucose — hypoglycemia is an immediately reversible life-threatening mimic; check first (AGS/ADS 2015)

Hypoxia / hypercapnia is a rapidly reversible precipitant; bedside SpO2 mandatory in RED_FLAGS (NICE CG103 2023)

Fever signals infection (UTI/pneumonia/sepsis) — the single most common precipitant in the elderly (NICE CG103 2023)

Alcohol/benzodiazepine dependence flags withdrawal delirium (DTs) — the ONE setting where benzodiazepines are correct (AGS/ADS 2015)

Sensory impairment (no glasses/hearing aids) is a predisposing factor and a directly correctable HELP-bundle target (Inouye NEJM 1999)

Hyper/hypocalcemia is a metabolic precipitant on the I WATCH DEATH hunt (AGS/ADS 2015)

Uremia is a metabolic encephalopathy cause; renal function also guides drug dosing (NICE CG103 2023)

Focal deficit / new seizure / meningism redirects to stroke/ICH/NCSE/meningitis pathway and CT/LP/EEG (NICE CG103 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateninghypoglycemia_immediate
    Point-of-care glucose low in a confused older adult — immediately reversible life-threatening cause (AGS/ADS 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghypoxia_hypercapnia_immediate
    SpO2 low or hypercapnia in delirious older adult — rapidly reversible precipitant (NICE CG103 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningwernicke_risk_thiamine_now
    Confusion with alcohol use disorder or malnutrition — possible Wernicke encephalopathy (AGS/ADS 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningncse_suspected
    Fluctuating/depressed consciousness with subtle motor signs and no other cause — non-convulsive status epilepticus suspected (AGS/ADS 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsepsis_precipitant
    Delirium with fever / qSOFA >=2 / NEWS2 escalation — sepsis as precipitant (Sepsis-3 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningalcohol_benzo_withdrawal_delirium
    Delirium attributable to alcohol or benzodiazepine withdrawal (delirium tremens / withdrawal seizure) (ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredangerous_agitation_endangering_care
    Severe agitation posing danger to self/others or preventing essential care, refractory to non-pharmacologic measures and deprescribing (NICE CG103 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypoactive_delirium_missed
    Lethargy / withdrawal / reduced responsiveness in an older inpatient — hypoactive delirium (most common in elderly, worst prognosis, frequently missed) (NICE CG103 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Delirium — cause-first ladder (treat precipitant -> HELP non-pharm FIRST -> deprescribe -> targeted pharmacologic ONLY for dangerous agitation -> withdrawal/Wernicke -> ICU dexmedetomidine)
axis: delirium_cause_first_bundlestep 1 - Step 1 — Treat the reversible cause(s) (DELIRIUM / I WATCH DEATH)
Selected step "Step 1 — Treat the reversible cause(s) (DELIRIUM / I WATCH DEATH)" — Every delirium — precipitant hunt is the definitive treatment
  • treat_precipitant_infection_metabolic_hypoxia_retention_pain
    first line
    cause_directed_therapy
    triggers: UTI_or_pneumonia_or_sepsis, hypoxia_or_hypercapnia, electrolyte_derangement, urinary_or_fecal_retention, uncontrolled_pain
    NICE CG103 2023 — delirium is the surface sign of an acute insult; targeted treatment of infection, metabolic derangement, hypoxia, retention and pain is the definitive therapy and outperforms any drug
  • empiric_thiamine_before_glucose
    rescue
    cause_directed_therapy
    triggers: alcohol_use_disorder, malnutrition, suspected_wernicke
    AGS/ADS 2015 — IV thiamine 500 mg before any glucose load when Wernicke is possible; glucose without thiamine can precipitate irreversible Wernicke-Korsakoff

ed playbook — drug actions (6)

  1. 1. thiamine (before glucose if at risk)
    500 mg • IV • once now
    trigger: Alcohol use / malnutrition / suspected Wernicke
    Prevent Wernicke before any glucose load
  2. 2. dextrose
    25 g (D50 50 mL) • IV • once
    trigger: POC glucose low
    Reverse hypoglycemia immediately
  3. 3. naloxone
    0.04-0.4 mg titrated • IV • titrate to ventilation
    trigger: Opioid toxicity (miosis/hypopnea)
    Reverse opioid-induced obtundation
  4. 4. cause-directed therapy (antibiotics / O2 / electrolyte correction / relieve retention)
    per precipitant • per precipitant • per precipitant
    trigger: Precipitant identified
    Definitive treatment is treating the cause
  5. 5. haloperidol (ONLY if dangerous agitation refractory to non-pharm)
    0.25-0.5 mg • PO/IM/IV • q4-6h PRN, lowest dose
    trigger: Agitation endangering self/others or preventing essential care
    Symptom control only; avoid in Lewy body/Parkinson; QTc caution
  6. 6. lorazepam (ONLY for alcohol/benzo withdrawal or seizure)
    1-2 mg symptom-triggered (CIWA-Ar) • IV/PO • symptom-triggered
    trigger: Withdrawal delirium / seizure
    The single benzodiazepine exception

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute confusion / new disorientation / "not themselves" reported by family or staff (NICE CG103 2023); Fluctuating attention or level of consciousness — positive CAM / 4AT screen (Inouye Ann Intern Med 1990); New agitation (hyperactive) OR new lethargy/withdrawal/somnolence (hypoactive — most missed) in older inpatient (DSM-5-TR).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Delirium (older adult)** (geriatrics.delirium.core.v1).
Phenotype framing: Resolve etiology and subtype: motor subtype (hyperactive vs HYPOACTIVE — most common in elderly, worst prognosis, frequently missed; vs mixed); precipitant(s) via DELIRIUM / I WATCH DEATH (Infection, Withdrawal, Acute metabolic, Trauma/Toxins, CNS, Hypoxia, Deficiencies, Endocrine, Acute vascular/MI, Heavy metals/drugs); distinguish from dementia, depression (pseudodementia), primary psychiatric disease, and non-convulsive status (DSM-5-TR)
Scope: Frame delirium as an acute brain emergency in a vulnerable (often demented/frail) older adult: predisposing vulnerability x precipitating insult; goal is the reversible-cause hunt, not symptom suppression (NICE CG103 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Delirium — cause-first ladder (treat precipitant -> HELP non-pharm FIRST -> deprescribe -> targeted pharmacologic ONLY for dangerous agitation -> withdrawal/Wernicke -> ICU dexmedetomidine)** — step "Step 1 — Treat the reversible cause(s) (DELIRIUM / I WATCH DEATH)".
1. treat_precipitant_infection_metabolic_hypoxia_retention_pain (cause_directed_therapy, first line) — NICE CG103 2023 — delirium is the surface sign of an acute insult; targeted treatment of infection, metabolic derangement, hypoxia, retention and pain is the definitive therapy and outperforms any drug
2. empiric_thiamine_before_glucose (cause_directed_therapy, rescue) — AGS/ADS 2015 — IV thiamine 500 mg before any glucose load when Wernicke is possible; glucose without thiamine can precipitate irreversible Wernicke-Korsakoff

Setting playbook (ed) — Confirm delirium (CAM/4AT), rule out and treat immediately reversible life-threatening causes, start cause-directed therapy + HELP bundle, and disposition by precipitant acuity
3. thiamine (before glucose if at risk) 500 mg IV once now — Alcohol use / malnutrition / suspected Wernicke (Prevent Wernicke before any glucose load)
4. dextrose 25 g (D50 50 mL) IV once — POC glucose low (Reverse hypoglycemia immediately)
5. naloxone 0.04-0.4 mg titrated IV titrate to ventilation — Opioid toxicity (miosis/hypopnea) (Reverse opioid-induced obtundation)
6. cause-directed therapy (antibiotics / O2 / electrolyte correction / relieve retention) per precipitant per precipitant per precipitant — Precipitant identified (Definitive treatment is treating the cause)
7. haloperidol (ONLY if dangerous agitation refractory to non-pharm) 0.25-0.5 mg PO/IM/IV q4-6h PRN, lowest dose — Agitation endangering self/others or preventing essential care (Symptom control only; avoid in Lewy body/Parkinson; QTc caution)
8. lorazepam (ONLY for alcohol/benzo withdrawal or seizure) 1-2 mg symptom-triggered (CIWA-Ar) IV/PO symptom-triggered — Withdrawal delirium / seizure (The single benzodiazepine exception)

Non-pharmacologic actions:
- Start HELP bundle immediately: reorientation, glasses/hearing aids, family presence, calm low-stimulus area
- Remove unnecessary lines/catheters; avoid physical restraints
- Treat pain (scheduled acetaminophen), constipation, urinary retention
- Continuous SpO2 + cardiac monitor; fall precautions
- CT head if focal deficit / trauma / anticoagulated / no cause found; LP if meningism/unexplained fever; EEG if NCSE suspected

AVOID / contraindication checks:
- Benzodiazepines worsen and prolong delirium — AVOID except alcohol/benzodiazepine withdrawal or seizure (AGS/ADS 2015)
- Antipsychotics contraindicated in Lewy body dementia and Parkinson disease (severe neuroleptic sensitivity) — use quetiapine cautiously (AGS/ADS 2015)
- Antipsychotic only for dangerous agitation refractory to non pharm; lowest dose, shortest duration; do not continue at discharge (NICE CG103 2023)
- Check baseline and on treatment QTc before/with antipsychotic; avoid with other QT prolonging agents (NICE CG103 2023)
- Give IV thiamine before any glucose load in at risk patients to avoid precipitating Wernicke (AGS/ADS 2015)
- Do not use antipsychotics or sedatives for hypoactive delirium or to treat the delirium itself — they do not shorten it or reduce mortality (NICE CG103 2023)

Monitoring

Regimen monitoring:
- CAM or 4AT at least once per shift; more often if pharmacologically treated (NICE CG103 2023)
- RASS / agitation level continuous when antipsychotic or ICU sedation in use (SCCM PADIS 2018)
- QTc ECG at baseline and on antipsychotic therapy (NICE CG103 2023)
- Cause-resolution tracking: repeat electrolytes/infection markers/oxygenation until corrected (AGS/ADS 2015)
- CIWA-Ar cadence if alcohol withdrawal delirium (ASAM 2020)
- Daily antipsychotic de-escalation review; document deprescribing on discharge (AGS/ADS 2015)

Setting (ed) monitoring:
- POC glucose recheck after dextrose (AGS/ADS 2015)
- SpO2 + mental status continuous (NICE CG103 2023)
- CAM/4AT reassessment + RASS if treated (NICE CG103 2023)
- QTc if antipsychotic given (NICE CG103 2023)

Follow-up plan: Document the delirium episode and resolution status; explicit cognitive follow-up because delirium predicts new/accelerated dementia, functional decline and mortality; medication reconciliation with deprescribing carried forward; carer education + return precautions; outpatient cognitive (MoCA) reassessment once acute illness resolved (AGS/ADS 2015)
- Close-out criterion: Episode documented, cognitive follow-up arranged, deprescribing plan handed off, carer educated (AGS/ADS 2015)

Monitoring phase: Reassess CAM/4AT and RASS/agitation at least once per shift (more often if pharmacologically treated); track cause-resolution (repeat electrolytes, infection markers, oxygenation); QTc on any antipsychotic; daily review to deprescribe sedatives and stop antipsychotic as soon as agitation resolves; CIWA-Ar cadence if withdrawal (NICE CG103 2023)

Disposition

Current setting: ed — Confirm delirium (CAM/4AT), rule out and treat immediately reversible life-threatening causes, start cause-directed therapy + HELP bundle, and disposition by precipitant acuity

Disposition criteria:
- Admit all delirium with an acute precipitant requiring inpatient treatment (NICE CG103 2023)
- ICU if airway/sepsis/NCSE/severe metabolic derangement (NICE CG103 2023)
- Do NOT discharge active delirium without resolution and a safe supervised environment (AGS/ADS 2015)

Escalation triggers (move to higher acuity):
- Refractory hypoxia / airway compromise / depressed consciousness -> ICU + airway (NICE CG103 2023)
- Septic shock or qSOFA >=2 with hypotension -> ICU + sepsis bundle (Sepsis-3 2016)
- Non-convulsive status epilepticus on EEG -> ICU + neurology + antiseizure therapy (AGS/ADS 2015)
- Severe symptomatic hypo/hypernatremia -> ICU + controlled correction (AGS/ADS 2015)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Point-of-care glucose low in a confused older adult — immediately reversible life-threatening cause (AGS/ADS 2015)
- [LIFE_THREATENING] SpO2 low or hypercapnia in delirious older adult — rapidly reversible precipitant (NICE CG103 2023)
- [LIFE_THREATENING] Confusion with alcohol use disorder or malnutrition — possible Wernicke encephalopathy (AGS/ADS 2015)

Citations

- NICE CG103 Delirium (2023 update) + 2024-2025 delirium reviews; AGS/American Delirium Society; DSM-5-TR [PMID:2240918](https://pubmed.ncbi.nlm.nih.gov/2240918/)
- Cited evidence (PMID 10053175) [PMID:10053175](https://pubmed.ncbi.nlm.nih.gov/10053175/)
- Cited evidence (PMID 25379948) [PMID:25379948](https://pubmed.ncbi.nlm.nih.gov/25379948/)
- Cited evidence (PMID 30346242) [PMID:30346242](https://pubmed.ncbi.nlm.nih.gov/30346242/)
- Cited evidence (PMID 31504171) [PMID:31504171](https://pubmed.ncbi.nlm.nih.gov/31504171/)

Last reconciled with current guidelines: 2026-05-16.
References