Key priorities for implementation

Risk factor assessment

  • When people first present to hospital or long-term care, assess them for the following risk factors. If any of these risk factors is present, the person is at risk of delirium.

    • Age 65 years or older.

    • Cognitive impairment (past or present) and/or dementia (for guidance on diagnosing dementia, see diagnosis in the NICE guideline on dementia). If cognitive impairment is suspected, confirm it using a standardised and validated cognitive impairment measure.

    • Current hip fracture.

    • Severe illness (a clinical condition that is deteriorating or is at risk of deterioration; for further information on recognising and responding to acute illness in adults in hospital, see the NICE guideline on acutely ill adults in hospital).

Indicators of delirium: at presentation

  • At presentation, assess people at risk for recent (within hours or days) changes or fluctuations in behaviour. These may be reported by the person at risk, or a carer or relative. Be particularly vigilant for behaviour indicating hypoactive delirium (marked*). These behaviour changes may affect:

    • Cognitive function: for example, worsened concentration*, slow responses*, confusion.

    • Perception: for example, visual or auditory hallucinations.

    • Physical function: for example, reduced mobility*, reduced movement*, restlessness, agitation, changes in appetite*, sleep disturbance.

    • Social behaviour: for example, lack of cooperation with reasonable requests, withdrawal*, or alterations in communication, mood and/or attitude.

      If any of these behaviour changes are present, a healthcare professional who is trained and competent in diagnosing delirium should carry out a clinical assessment to confirm the diagnosis.

Interventions to prevent delirium

  • Ensure that people at risk of delirium are cared for by a team of healthcare professionals who are familiar to the person at risk. Avoid moving people within and between wards or rooms unless absolutely necessary.

  • Give a tailored multicomponent intervention package:

    • Within 24 hours of admission, assess people at risk for clinical factors contributing to delirium.

    • Based on the results of this assessment, provide a multicomponent intervention tailored to the person's individual needs and care setting as described in recommendations–

  • The tailored multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention.

Diagnosis (specialist clinical assessment)

  • If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis. In critical care or in the recovery room after surgery, CAM-ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment. If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.

  • Ensure that the diagnosis of delirium is documented both in the person's hospital record and in their primary care health record.

Initial management

  • In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes.

  • Ensure effective communication and reorientation (for example, explaining where the person is, who they are, and what your role is) and provide reassurance for people diagnosed with delirium. Consider involving family, friends and carers to help with this. Provide a suitable care environment (see recommendation 1.3.1).

Distressed people

  • If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.

  • National Institute for Health and Care Excellence (NICE)