psych.delirium.core.v1PRODUCTION

psych.delirium.core.v1

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)

psychiatryacutesyndromeadultgeriatricpediatric

Hard-required inputs

0 / 18

Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 delirium criteria (A: disturbance of attention + awareness; B: develops over short time + fluctuates; C: additional cognitive disturbance; D: not better explained by pre-existing/established neurocognitive disorder + not in context of severely reduced arousal/coma; E: evidence of medical cause / intoxication / withdrawal / multiple etiologies). CAM 4-feature bedside screen anchor (Inouye NEJM 2006 PMID 16540616)

Inputs

Actions

Advance rule

Set

Advance when

DSM-5-TR criteria met + change-from-baseline cognition documented + dementia / primary psychiatric diagnosis ruled out as sole explanation

Severity triggers (10)

10 need judgement

informationallife_threateningdelirium_with_alcohol_or_benzo_withdrawal (ASAM 2020 NEEDS_SOURCE_REVIEW; Mayo-Smith)
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)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehyperactive_delirium_with_safety_risk (NICE CG103 2010; Marcantonio NEJM 2017 PMID 29020579)
Severe hyperactive delirium with safety risk — falls / self-extubation / aggression / inability to deliver essential care; ~ 25 % of all delirium subtypes
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehypoactive_delirium_missed_diagnosis (Marcantonio NEJM 2017 PMID 29020579; Inouye CAM NEJM 2006 PMID 16540616)
Hypoactive delirium (~ 50 % of all delirium) — withdrawn, drowsy, low-arousal; MOST COMMONLY missed; under-detection 60-80 % in routine care; high mortality
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveredelirium_with_anticholinergic_burden (AGS Beers 2023 PMID 36968894; STOPP/START v3 2023 NEEDS_SOURCE_REVIEW)
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
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverepost_operative_delirium (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)
Post-operative delirium > 65 yr (incidence 15-40 %) — multifactorial pain + meds (especially benzodiazepines + opioids + anticholinergics) + sleep disruption + electrolytes + dehydration + immobility
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereicu_delirium_with_padis_bundle (PADIS 2018 Devlin Crit Care Med 2018 PMID 30113379; MIND-USA Girard NEJM 2018 PMID 30346242)
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)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveredelirium_due_to_infection_underlying (Marcantonio NEJM 2017 PMID 29020579; SSC 2026; Norman J Am Geriatr Soc 2000 NEEDS_SOURCE_REVIEW)
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
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveredelirium_with_persistent_features_after_discharge (Marcantonio NEJM 2017 PMID 29020579; Helfand 2021 NEEDS_SOURCE_REVIEW)
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
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateend_of_life_terminal_delirium (NICE CG103 2010; EAPC palliative)
Terminal delirium in advanced illness / palliative care — multifactorial; goals-of-care alignment + symptom-targeted comfort + family support; aggressive cause-workup may not be aligned with goals
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatedelirium_in_pediatric_setting (Traube CAPD Crit Care Med 2014 PMID 24717459)
Pediatric delirium in PICU / pediatric ward — incidence ~ 25-30 % in PICU; CAPD for pre-verbal / non-verbal children; p-CAM-ICU for verbal children; same hierarchy as adult (identify cause + non-pharm bundle + family presence + sleep + sensory aids first; antipsychotic dose pediatric-weight-based with specialty consultation)
Trigger could not be auto-evaluated — needs clinician judgement.

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CONTEXToptionalDrives screening

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Recommended regimen

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)

axis: delirium_treatment_hierarchystep 1 - Step 1 — Identify + treat underlying cause (always first; DELIRIUMS mnemonic) (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)

Selected step "Step 1 — Identify + treat underlying cause (always first; DELIRIUMS mnemonic) (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)" — Every confirmed delirium — cause workup mandatory; Drugs / Electrolytes / Lack-of-meds / Infection / Reduced-sensory-input / Intracranial / Urinary-retention / Metabolic / Substances (DELIRIUMS)

identify_and_treat_underlying_cause
first line
cause_directed_intervention
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
triggers: every_confirmed_delirium
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
first line
vitamin_B1
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
triggers: suspected_alcohol_withdrawal, suspected_wernicke_encephalopathy, malnutrition_or_hyperemesis, before_glucose_in_alcohol_use_disorder
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)
rxcui 10454

outpatient playbook — drug actions (3)

1. identify and treat underlying cause first
Per cause: infection → outpatient or admit; medication → deprescribe anticholinergic / sedative / opioid; metabolic → repletion; goals of care • per_cause • per_cause
trigger: Every confirmed delirium
NICE CG103 2010 / Marcantonio NEJM 2017 PMID 29020579 — cause-directed treatment foundation
2. AVOID antipsychotic prescription at outpatient discharge unless independent indication
NA • NA • NA
trigger: Patient discharged on antipsychotic for inpatient delirium agitation
NICE CG103 2010 + AGS Beers 2023 PMID 36968894 — antipsychotic should taper within 24-48 h of agitation resolution; should NOT continue at outpatient discharge unless indication independent of delirium
3. caregiver education on non-pharm bundle if managing at home
NA • environmental_behavioural • daily
trigger: Home management of mild delirium
Inouye NEJM 1999 PMID 10089183 — HELP bundle principles transferable to home setting: reorientation, sleep, sensory aids, hydration, family presence, minimise PIMs

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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.

Objective

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

Assessment

**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)** (psych.delirium.core.v1).
Phenotype framing: Delirium (DSM-5-TR) vs major neurocognitive disorder (dementia — chronic; no acute change; no fluctuation; attention often preserved early) vs depressive pseudo-dementia (slow tempo; PHQ-9 high; routes to psych.depression.core.v1) vs psychotic disorder (younger; chronic; preserved attention) vs non-convulsive status epilepticus (EEG diagnostic) vs Wernicke encephalopathy (triad ophthalmoplegia + ataxia + confusion; thiamine 100 mg IV BEFORE glucose) vs CNS infection vs intracranial pathology vs hypoglycaemia vs metabolic derangement vs intoxication/withdrawal (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)
Scope: Confirm DSM-5-TR 2022 delirium criteria (A: disturbance of attention + awareness; B: develops over short time + fluctuates; C: additional cognitive disturbance; D: not better explained by pre-existing/established neurocognitive disorder + not in context of severely reduced arousal/coma; E: evidence of medical cause / intoxication / withdrawal / multiple etiologies). CAM 4-feature bedside screen anchor (Inouye NEJM 2006 PMID 16540616)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Identify + treat underlying cause (always first; DELIRIUMS mnemonic) (Marcantonio NEJM 2017 PMID 29020579; NICE CG103 2010)".
1. 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_intervention, first line) — 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)
2. 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 (vitamin_B1, first line) — 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)

Setting playbook (outpatient) — Detect new delirium / persistent post-discharge cognitive features in older adult; screen for reversible causes; manage at home with caregiver if mild + cause identified + safe environment; refer for inpatient workup if new + uncharacterised + safety concern (NICE CG103 2010; Marcantonio NEJM 2017 PMID 29020579)
3. identify and treat underlying cause first Per cause: infection → outpatient or admit; medication → deprescribe anticholinergic / sedative / opioid; metabolic → repletion; goals of care per_cause per_cause — Every confirmed delirium (NICE CG103 2010 / Marcantonio NEJM 2017 PMID 29020579 — cause-directed treatment foundation)
4. AVOID antipsychotic prescription at outpatient discharge unless independent indication NA NA NA — Patient discharged on antipsychotic for inpatient delirium agitation (NICE CG103 2010 + AGS Beers 2023 PMID 36968894 — antipsychotic should taper within 24-48 h of agitation resolution; should NOT continue at outpatient discharge unless indication independent of delirium)
5. caregiver education on non-pharm bundle if managing at home NA environmental_behavioural daily — Home management of mild delirium (Inouye NEJM 1999 PMID 10089183 — HELP bundle principles transferable to home setting: reorientation, sleep, sensory aids, hydration, family presence, minimise PIMs)

Non-pharmacologic actions:
- CAM or 4AT bedside screen at every visit for older adult with cognitive concern (NICE CG103 2010)
- Medication reconciliation with anticholinergic burden score + deprescribe PIMs per AGS Beers 2023 PMID 36968894
- Goals-of-care discussion in advanced illness / dementia / palliative (NICE CG103 2010)
- Caregiver support + education on delirium-precaution non-pharm bundle (HELP principles; Inouye NEJM 1999 PMID 10089183)
- Refer to geriatric medicine / behavioural neurology if persistent cognitive features post-discharge — 30-50 % have persistent features; 40-60 % progress to dementia within 1 yr (Marcantonio NEJM 2017 PMID 29020579)
- Functional rehabilitation referral if functional decline persists
- Driving safety review for any persistent cognitive features
- Advance care planning revisit after delirium episode (NICE CG103 2010)

AVOID / contraindication checks:
- No_antipsychotic_prophylaxis_in_delirium (MIND USA Girard NEJM 2018 PMID 30346242; Hope ICU Page 2013 NEEDS_SOURCE_REVIEW)
- Avoid_benzodiazepines_in_delirium_except_alcohol_or_benzodiazepine_withdrawal (NICE CG103 2010; AGS Beers 2023 PMID 36968894; PADIS 2018 PMID 30113379)
- Avoid_anticholinergics_in_delirium_or_risk (AGS Beers 2023 PMID 36968894)
- Haloperidol_avoid_parkinson_or_lewy_body_use_quetiapine (Marcantonio NEJM 2017 PMID 29020579; AGS Beers 2023)
- Antipsychotic_qtc_monitoring (DailyMed haloperidol boxed warning)
- Antipsychotic_dementia_mortality_boxed_warning_all_antipsychotics (FDA 2005 atypicals; 2008 expanded to haloperidol; AGS Beers 2023)
- Thiamine_BEFORE_glucose_in_suspected_wernicke_or_alcohol_withdrawal (NICE CG100 alcohol use disorders; Royal College of Physicians)
- Opioid_minimisation_to_reduce_delirium (PADIS 2018 PMID 30113379; AGS Beers 2023)
- Dexmedetomidine_preferred_over_benzodiazepine_for_ICU_sedation (PADIS 2018 PMID 30113379; Reade SPICE III NEJM 2019 NEEDS_SOURCE_REVIEW)
- Cam_or_4at_at_admission_and_every_shift_for_older_adult (NICE CG103 2010; Inouye CAM NEJM 2006 PMID 16540616; Bellelli 4AT 2014 PMID 25028342)
- 1_to_1_sitter_for_severe_agitation_with_safety_risk (NICE CG103 2010; PADIS 2018)
- Avoid_olanzapine_IM_with_IM_benzodiazepine_cardiopulmonary_depression (FDA olanzapine IM label)
- Minimum_effective_dose_shortest_duration_for_any_antipsychotic_in_delirium (NICE CG103 2010; AGS Beers 2023 PMID 36968894)

Monitoring

Regimen monitoring:
- CAM or 4AT q shift for older adult admission through discharge (NICE CG103 2010; Inouye NEJM 2006 PMID 16540616; Bellelli 2014 PMID 25028342)
- CAM ICU plus RASS q shift in ICU (PADIS 2018 PMID 30113379; Ely JAMA 2001 PMID 11730446; Sessler AJRCCM 2002 PMID 12421743)
- CAPD or p CAM ICU q shift in PICU (Traube Crit Care Med 2014 PMID 24717459)
- ECG QTc baseline and with dose increase for haloperidol or any antipsychotic (DailyMed haloperidol)
- HR BP continuous or q1h during active titration then q4h (PADIS 2018)
- Glucose q4 6h or more frequently if DKA or hypoglycaemia suspected (NICE CG103 2010)
- Electrolyte repletion with recheck q12 24h until stable (Marcantonio NEJM 2017 PMID 29020579)
- Daily medication reconciliation with anticholinergic burden review (AGS Beers 2023 PMID 36968894; STOPP/START v3 2023 NEEDS SOURCE REVIEW)
- Daily HELP NICE non pharm bundle adherence audit (Inouye NEJM 1999 PMID 10089183; NICE CG103 2010)
- Daily SAT plus SBT in ICU (PADIS 2018 PMID 30113379)
- Antipsychotic taper within 24 48h of agitation resolution NOT continued at discharge (NICE CG103 2010; AGS Beers 2023)
- Duration of delirium tracked each day more than 1 week predicts worse outcomes (Marcantonio NEJM 2017 PMID 29020579)
- Post discharge cognitive assessment at 4 6 weeks 3 months 6 months (Marcantonio NEJM 2017 PMID 29020579)

Setting (outpatient) monitoring:
- Brief neurocognitive screen (MoCA / MMSE) at 4-6 wk + 3 mo + 6 mo post-delirium (Marcantonio NEJM 2017 PMID 29020579)
- Caregiver well-being check + delirium-recurrence surveillance
- Medication list reviewed at every visit with anticholinergic burden score (AGS Beers 2023 PMID 36968894)

Follow-up plan: 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
- Close-out criterion: Post-discharge cognitive follow-up scheduled + caregiver education complete + relevant referrals placed

Monitoring phase: CAM / 4AT q-shift (ward) or q-2-hr (ICU CAM-ICU + RASS continuous + CPOT pain assessment); RASS target -2 to 0 for ICU; SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial) daily per PADIS 2018; medication reconciliation daily; non-pharm bundle adherence; antipsychotic taper as soon as agitation resolves (typically 24-48 h post-resolution); duration tracking (mortality + LOS predictor); pediatric CAPD + p-CAM-ICU q-shift (Traube 2014 PMID 24717459)

Disposition

Current setting: outpatient — Detect new delirium / persistent post-discharge cognitive features in older adult; screen for reversible causes; manage at home with caregiver if mild + cause identified + safe environment; refer for inpatient workup if new + uncharacterised + safety concern (NICE CG103 2010; Marcantonio NEJM 2017 PMID 29020579)

Disposition criteria:
- Continue outpatient management if mild + cause identified + safe environment + caregiver capable
- Refer to inpatient if new + uncharacterised cause OR safety concern OR caregiver inability to manage OR severe agitation
- Refer to geriatric medicine / behavioural neurology for post-discharge cognitive follow-up (Marcantonio NEJM 2017 PMID 29020579)
- Refer to palliative care for terminal delirium in advanced illness (NICE CG103 2010; EAPC palliative)

Escalation triggers (move to higher acuity):
- New unexplained delirium → ED for workup if no clear cause identifiable in outpatient (NICE CG103 2010)
- Severe agitation at home unmanageable by caregiver → ED + admission (NICE CG103 2010)
- Active suicidal ideation emerging during persistent post-delirium cognitive features → psych.suicidality.ed.core.v1 + ED
- Persistent post-discharge cognitive features at 6 mo → behavioural neurology + dementia workup (Marcantonio NEJM 2017 PMID 29020579)

Patient Action Plan

**Delirium caregiver + family action plan (NICE CG103 2010; HELP bundle Inouye NEJM 1999 PMID 10089183)**
Personalised values: baseline_cognition, current_medication_list, identified_caregivers, home_environment, sensory_aids_inventory, goals_of_care.

**Mental status at baseline — no signs of delirium (NICE CG103 2010)** (green):
Triggers:
- 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
Actions:
- 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

**Caution — early signs of delirium developing (NICE CG103 2010)** (yellow):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- 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

**Medical alert — severe delirium / safety risk (NICE CG103 2010; Marcantonio NEJM 2017 PMID 29020579)** (red):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (NICE CG103 2010)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)
- [SEVERE] Severe hyperactive delirium with safety risk — falls / self-extubation / aggression / inability to deliver essential care; ~ 25 % of all delirium subtypes
- [SEVERE] Hypoactive delirium (~ 50 % of all delirium) — withdrawn, drowsy, low-arousal; MOST COMMONLY missed; under-detection 60-80 % in routine care; high mortality

Citations

- 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 [PMID:30113379](https://pubmed.ncbi.nlm.nih.gov/30113379/)
- Cited evidence (PMID 16540616) [PMID:16540616](https://pubmed.ncbi.nlm.nih.gov/16540616/)
- Cited evidence (PMID 25028342) [PMID:25028342](https://pubmed.ncbi.nlm.nih.gov/25028342/)
- Cited evidence (PMID 11730446) [PMID:11730446](https://pubmed.ncbi.nlm.nih.gov/11730446/)
- Cited evidence (PMID 12421743) [PMID:12421743](https://pubmed.ncbi.nlm.nih.gov/12421743/)

Last reconciled with current guidelines: 2026-05-15.

References

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 — PMID:30113379
Cited evidence (PMID 16540616) — PMID:16540616
Cited evidence (PMID 25028342) — PMID:25028342
Cited evidence (PMID 11730446) — PMID:11730446
Cited evidence (PMID 12421743) — PMID:12421743

Clinical Commander