Clinical Commander

Back to dossier
neuro.delirium.v1PRODUCTION
neuro.delirium.v1

Delirium (inpatient/ICU)

neurologyacuteadultgeriatric
Hard-required inputs
0 / 14
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Acute / fluctuating attentional disturbance in vulnerable patient — distinguish from chronic dementia or coma (DSM-5; SCCM PADIS 2018 PMID 30113379)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Acute onset + fluctuating course confirmed by collateral history

Patient inputs (25)

Age ≥65 is the largest single risk factor; pre-existing cognitive impairment + comorbidity increase further (Inouye Lancet 2014; AGS post-op delirium 2015)

Pre-existing dementia is the strongest predisposing factor; DSD (delirium superimposed on dementia) drives prognosis (Marcantonio NEJM 2017 PMID 21075055)

Anticholinergic / benzodiazepine / opioid / sedating antihistamine / corticosteroid / sympathomimetic load drives drug-induced delirium (AGS Beers 2023; NICE CG103)

New start / dose change / abrupt stop within 7 d frequently precipitates delirium (NICE CG103)

Withdrawal delirium has distinct Rx (benzo per CIWA-Ar, not antipsychotic); chronic alcohol → thiamine FIRST

Untreated pain is a common precipitant; ABCDEF "A" = Assess pain (SCCM PADIS 2018 PMID 30113379)

CAM (acute onset + inattention + (disorganized thinking OR altered LOC)) is gold-standard bedside screen (Inouye Ann Intern Med 1990)

Hypo/hypernatremia drives confusion; correction rate matters per electrolyte engine (NICE CG103)

Hypercalcemia (malignancy / hyperparathyroid) and hypocalcemia can present as delirium

Uremic encephalopathy at advanced CKD/AKI; consider HD timing (AGS Beers 2023; KDIGO)

UTI is most common infectious precipitant in elderly delirium (Inouye Lancet 2014 PMID 21796639)

Fever → infection (UTI / pneumonia / line / CNS) as precipitant; sepsis-associated encephalopathy (id.sepsis.core.v1)

Hemodynamic + respiratory instability supports SAE / hypoxic / hypercapnic encephalopathy (SCCM PADIS 2018)

Hypo/hyperglycemia is the most-missed reversible cause; correct FIRST (NICE CG103)

Substance intoxication / withdrawal — alcohol level + UDS in unexplained delirium (NICE CG103)

CT head if focal neuro deficit, head trauma, anticoagulated fall, or rapid decline (NICE CG103); routine CT NOT indicated otherwise

NCSE can mimic delirium — cEEG within 60 min if persistent unexplained AMS especially post-cardiac-arrest (NCS 2012)

RASS −5 to +4 quantifies arousal; pairs with CAM-ICU; mandatory in PADIS 2018 sedation protocols

Post-op delirium incidence 15-50% in elderly; specific RFs: hip fracture, cardiac, prolonged surgery (AGS post-op delirium 2015)

Disrupted sleep, ICU noise, restraints, indwelling devices are modifiable contributors (HELP bundle; Inouye Lancet 2014)

CAM-ICU OR ICDSC for ventilated/non-verbal ICU patients (SCCM PADIS 2018 PMID 30113379)

Hepatic encephalopathy with hyperammonemia → lactulose / rifaximin (AASLD HE 2014)

Hypothyroidism (myxedema) / hyperthyroidism (apathetic hyperthyroid in elderly) can present as delirium

Severe B12 deficiency may cause acute confusion in elderly (AAN 2018)

Hypoxia + hypercapnia drive delirium; PADIS 2018 routine in ICU

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

Severity triggers (12)

12 need judgement
  • informationallife_threateningalcohol_withdrawal_dts
    Alcohol-withdrawal delirium (DTs) — autonomic instability + tremor + hallucinations + tachycardia + diaphoresis 72-96 h after last drink; CIWA-Ar ≥15 (NICE CG100; ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsepsis_associated_encephalopathy
    Sepsis-associated encephalopathy (SAE) — delirium with concurrent infection meeting qSOFA ≥2 or Sepsis-3 criteria; cytokine-driven CNS dysfunction (Surviving Sepsis 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecam_icu_positive
    CAM-ICU positive in ventilated / non-verbal ICU patient — Ely 2001 Crit Care Med original; SCCM PADIS 2018 standard
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredelirium_superimposed_on_dementia
    Delirium superimposed on pre-existing dementia (DSD) — both diagnoses present; CAM positive against known cognitive baseline (Marcantonio NEJM 2017 PMID 21075055)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebenzo_or_opioid_withdrawal
    Benzodiazepine or opioid withdrawal precipitating delirium — abrupt discontinuation in chronic user (COWS for opioid, CIWA-B for benzo)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetabolic_induced
    Metabolic-induced delirium — hyponatremia (<125), hypernatremia (>155), hypoglycemia (<70), uremia (BUN >100 or Cr >5), hypercapnia (PCO2 >60), hepatic encephalopathy (ammonia >100), hypercalcemia (>13)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperactive_delirium
    Hyperactive phenotype — agitation + hallucinations + restlessness + heightened arousal (RASS +1 to +4); less common but more visible
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehypoactive_delirium
    Hypoactive phenotype — lethargy + slowed responses + decreased arousal (RASS −3 to −1); most common in elderly + ICU; under-diagnosed; worse outcomes (Inouye Lancet 2014 PMID 21796639)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemixed_delirium
    Mixed phenotype — alternating hyperactive + hypoactive features over hours-days; most common overall
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecam_positive
    Standard CAM positive (acute onset + inattention + (disorganized thinking OR altered LOC)) in non-intubated patient — Inouye 1990 Ann Intern Med original
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanticholinergic_burden
    High anticholinergic burden (ACB score ≥3) precipitating delirium — first-generation antihistamines, OAB anticholinergics, TCAs, paroxetine, oxybutynin (AGS Beers 2023; Inouye Lancet 2024 review)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedrug_induced_delirium
    Drug-induced delirium — new psychoactive medication / dose change / interaction within 7 d (opioids, benzodiazepines, anticholinergics, corticosteroids, fluoroquinolones, antiepileptics, sympathomimetics) (NICE CG103; AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Non-pharm ABCDEF (ICU) + HELP (inpatient non-ICU) — first-line for ALL delirium per SCCM PADIS 2018 PMID 30113379 + Inouye Lancet 2014
axis: delirium_non_pharm_abcdef_help
Selected axis "Non-pharm ABCDEF (ICU) + HELP (inpatient non-ICU) — first-line for ALL delirium per SCCM PADIS 2018 PMID 30113379 + Inouye Lancet 2014" by default fallback (first axis)
  • ABCDEF bundle
    first line
    non_pharmacologic
    triggers: delirium_in_ICU, all_phenotypes
    SCCM PADIS 2018 — Assess + treat pain; Both SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial); Choice of analgesia + sedation (avoid benzo); Delirium assess (CAM-ICU); Early mobility/exercise; Family engagement. Largest evidence base for prevention + reducing duration
  • HELP bundle (Hospital Elder Life Program)
    first line
    non_pharmacologic
    triggers: delirium_inpatient_non_ICU, prevention
    Inouye Lancet 2014 PMID 21796639 + HELP meta — orientation, sleep hygiene, early mobility, hearing/vision aids, hydration, no restraints, deprescribe; reduces delirium incidence ~40%
  • Discontinue offending medications
    first line
    deprescribe
    triggers: anticholinergic_burden_present, benzo_chronic, opioid_high_dose
    AGS Beers 2023 — taper anticholinergic load (diphenhydramine, oxybutynin, scopolamine, paroxetine, TCAs); reduce benzo; switch sedating antihistamines to non-sedating; switch opioids to multimodal (SCCM PADIS 2018)
  • Treat precipitant
    first line
    targeted_therapy
    triggers: uti_treat, dehydration_correct, hypoxia_correct, pain_treat, constipation_treat
    NICE CG103 + Marcantonio NEJM 2017 PMID 21075055 — single most effective intervention is treating the precipitant; UTI most common in elderly (Inouye Lancet 2014)
  • Sleep / day-night cycle restoration
    first line
    environmental
    triggers: icu_environment, inpatient_night_disruption
    SCCM PADIS 2018 — minimise nighttime interventions, dim lights, avoid daytime naps, melatonin 3 mg HS off-label evidence weak
  • Early mobility / PT/OT
    first line
    rehabilitation
    triggers: icu_immobile, post_op_immobile
    SCCM PADIS 2018 PMID 30113379 — early mobility reduces delirium duration and ICU LOS

outpatient playbook — drug actions (4)

  1. 1. Continue deprescribing per AGS Beers 2023
    titrated taper • PO • daily
    trigger: Persistent anticholinergic / benzo / opioid load
    AGS Beers 2023 + Inouye Lancet 2024 review — sustained deprescribing reduces recurrence
  2. 2. sertraline for post-delirium depression
    25 mg PO daily → titrate to 50-100 mg • PO • daily
    trigger: PHQ-9 ≥10 + persistent low mood
    APA 2024 — preferred SSRI safety profile in elderly
  3. 3. taper any antipsychotic started in hospital
    slow taper q1-2 wk • PO • as outlined
    trigger: Antipsychotic still on board at discharge
    APA 2024 + AGS Beers 2023 — discontinue when behavioural symptoms resolved; q3 mo reassessment if maintained
  4. 4. thiamine maintenance if AUD
    100 mg PO daily • PO • daily
    trigger: Alcohol use disorder maintenance
    ASAM 2020

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute (hours-days) onset of inattention + fluctuating course (CAM core feature; Inouye 1990); Fluctuating level of consciousness or arousal (RASS / GCS variation); New agitation or lethargy in elderly inpatient (SCCM PADIS 2018 PMID 30113379).

Objective

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

Assessment

**Delirium (inpatient/ICU)** (neuro.delirium.v1).
Phenotype framing: 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)
Scope: Acute / fluctuating attentional disturbance in vulnerable patient — distinguish from chronic dementia or coma (DSM-5; SCCM PADIS 2018 PMID 30113379)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Non-pharm ABCDEF (ICU) + HELP (inpatient non-ICU) — first-line for ALL delirium per SCCM PADIS 2018 PMID 30113379 + Inouye Lancet 2014**.
1. ABCDEF bundle (non_pharmacologic, first line) — SCCM PADIS 2018 — Assess + treat pain; Both SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial); Choice of analgesia + sedation (avoid benzo); Delirium assess (CAM-ICU); Early mobility/exercise; Family engagement. Largest evidence base for prevention + reducing duration
2. HELP bundle (Hospital Elder Life Program) (non_pharmacologic, first line) — Inouye Lancet 2014 PMID 21796639 + HELP meta — orientation, sleep hygiene, early mobility, hearing/vision aids, hydration, no restraints, deprescribe; reduces delirium incidence ~40%
3. Discontinue offending medications (deprescribe, first line) — AGS Beers 2023 — taper anticholinergic load (diphenhydramine, oxybutynin, scopolamine, paroxetine, TCAs); reduce benzo; switch sedating antihistamines to non-sedating; switch opioids to multimodal (SCCM PADIS 2018)
4. Treat precipitant (targeted_therapy, first line) — NICE CG103 + Marcantonio NEJM 2017 PMID 21075055 — single most effective intervention is treating the precipitant; UTI most common in elderly (Inouye Lancet 2014)
5. Sleep / day-night cycle restoration (environmental, first line) — SCCM PADIS 2018 — minimise nighttime interventions, dim lights, avoid daytime naps, melatonin 3 mg HS off-label evidence weak
6. Early mobility / PT/OT (rehabilitation, first line) — SCCM PADIS 2018 PMID 30113379 — early mobility reduces delirium duration and ICU LOS

Setting playbook (outpatient) — Post-discharge cognitive follow-up + medication reconciliation + geriatric assessment if persistent symptoms; ≥30% of post-ICU delirium patients have long-term cognitive impairment per BRAIN-ICU (Inouye Lancet 2014 PMID 21796639)
7. Continue deprescribing per AGS Beers 2023 titrated taper PO daily — Persistent anticholinergic / benzo / opioid load (AGS Beers 2023 + Inouye Lancet 2024 review — sustained deprescribing reduces recurrence)
8. sertraline for post-delirium depression 25 mg PO daily → titrate to 50-100 mg PO daily — PHQ-9 ≥10 + persistent low mood (APA 2024 — preferred SSRI safety profile in elderly)
9. taper any antipsychotic started in hospital slow taper q1-2 wk PO as outlined — Antipsychotic still on board at discharge (APA 2024 + AGS Beers 2023 — discontinue when behavioural symptoms resolved; q3 mo reassessment if maintained)
10. thiamine maintenance if AUD 100 mg PO daily PO daily — Alcohol use disorder maintenance (ASAM 2020)

Non-pharmacologic actions:
- Geriatric / ACE clinic referral if available
- Post-discharge HELP / outpatient delirium-recovery program if available
- Cognitive rehabilitation referral if persistent deficits
- Caregiver education + respite resources
- Driving evaluation per state law
- Advance directives + POLST review
- Hearing + vision aid optimisation
- Falls prevention assessment + home safety check
- Addiction medicine if AUD
- Sleep study if STOP-BANG ≥3

AVOID / contraindication checks:
- Non_pharm_first_line_for_all_delirium (SCCM PADIS 2018; NICE CG103)
- Do_NOT_use_benzo_except_for_alcohol_or_benzo_withdrawal (AGS Beers 2023; SCCM PADIS 2018)
- Do_NOT_use_antipsychotic_for_prevention_in_ICU (MIND USA NEJM 2018 PMID 30346242; HOPE ICU Lancet Resp 2013 PMID 23818095)
- Avoid_physical_restraints_increases_agitation (NICE CG103; SCCM PADIS 2018)
- Treat_pain_before_sedation_per_PADIS_2018 (SCCM PADIS 2018)

Monitoring

Regimen monitoring:
- CAM / CAM-ICU q-shift in ICU; q-shift floor in at-risk patients (SCCM PADIS 2018)
- RASS target −2 to 0 in ICU; avoid deep sedation (SCCM PADIS 2018)
- Daily deprescribing review (AGS Beers 2023)
- Daily sleep / mobility / family-presence audit (HELP; PADIS 2018)
- Pain reassessment q4-6 h (PADIS 2018 ABCDEF "A")

Setting (outpatient) monitoring:
- MoCA at 1-3 mo + 6 mo + 12 mo post-discharge
- PHQ-9 at each visit
- Functional reassessment quarterly first year
- Medication review quarterly with AGS Beers 2023 audit

Follow-up plan: 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)
- Close-out criterion: Post-discharge cognitive plan documented + family education

Monitoring phase: 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)

Disposition

Current setting: outpatient — Post-discharge cognitive follow-up + medication reconciliation + geriatric assessment if persistent symptoms; ≥30% of post-ICU delirium patients have long-term cognitive impairment per BRAIN-ICU (Inouye Lancet 2014 PMID 21796639)

Disposition criteria:
- Continue outpatient cognitive follow-up indefinitely if any residual deficit
- Transition to primary care + annual geriatric review when stable
- Hospice if frail elderly with poor functional trajectory + appropriate goals

Escalation triggers (move to higher acuity):
- Recurrent acute confusion → ED for repeat workup
- Persistent cognitive decline → outpatient dementia workup (symptom.dementia.v1)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral
- Falls recurring → comprehensive fall prevention + home safety
- Caregiver burnout → respite + adult protective services if concerns

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Alcohol-withdrawal delirium (DTs) — autonomic instability + tremor + hallucinations + tachycardia + diaphoresis 72-96 h after last drink; CIWA-Ar ≥15 (NICE CG100; ASAM 2020)
- [LIFE_THREATENING] Sepsis-associated encephalopathy (SAE) — delirium with concurrent infection meeting qSOFA ≥2 or Sepsis-3 criteria; cytokine-driven CNS dysfunction (Surviving Sepsis 2026)
- [SEVERE] CAM-ICU positive in ventilated / non-verbal ICU patient — Ely 2001 Crit Care Med original; SCCM PADIS 2018 standard

Citations

- 2018 SCCM PADIS Guidelines + 2019 NICE CG103 Delirium + AGS Beers 2023 + APA 2024 BPSD + 2026 Surviving Sepsis (for SAE) [PMID:30113379](https://pubmed.ncbi.nlm.nih.gov/30113379/)
- Cited evidence (PMID 30346242) [PMID:30346242](https://pubmed.ncbi.nlm.nih.gov/30346242/)
- Cited evidence (PMID 23818095) [PMID:23818095](https://pubmed.ncbi.nlm.nih.gov/23818095/)
- Cited evidence (PMID 21796639) [PMID:21796639](https://pubmed.ncbi.nlm.nih.gov/21796639/)
- Cited evidence (PMID 21075055) [PMID:21075055](https://pubmed.ncbi.nlm.nih.gov/21075055/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2018 SCCM PADIS Guidelines + 2019 NICE CG103 Delirium + AGS Beers 2023 + APA 2024 BPSD + 2026 Surviving Sepsis (for SAE) — PMID:30113379
  • Cited evidence (PMID 30346242) — PMID:30346242
  • Cited evidence (PMID 23818095) — PMID:23818095
  • Cited evidence (PMID 21796639) — PMID:21796639
  • Cited evidence (PMID 21075055) — PMID:21075055