Clinical Learning
Clinical 3: Delirium in adults
Recognition, assessment, prevention and management of delirium in hospital and long-term care, with particular attention to hypoactive delirium.
Clinical safety: Use current guidance, local policy and patient-specific judgement.
Learning objectives
• Identify people at increased risk of delirium • Recognise hyperactive and hypoactive presentations • Use 4AT appropriately and understand its limits • Search systematically for underlying causes • Apply prevention, communication and documentation principles
Clinical safety note
Delirium can signal serious acute illness. This module does not replace urgent assessment for infection, hypoxia, neurological disease, medication toxicity or other causes. Capacity is decision- and time-specific and must be assessed under the applicable legal framework.
Think delirium
Delirium develops over hours or days and often fluctuates. Changes may involve attention, cognition, perception, mobility, sleep, behaviour or communication. Hypoactive delirium is commonly missed because the patient may simply appear quiet, withdrawn or slow. Important risk factors include age 65 or over, cognitive impairment or dementia, hip fracture and severe illness.
Assessment and diagnosis
If indicators of delirium are present, NICE recommends assessment with the 4AT by a competent practitioner. In critical care or the recovery room after surgery, use CAM-ICU or ICDSC instead. A positive screening assessment supports concern, but the final diagnosis should be made by a healthcare professional with relevant expertise. If it is difficult to distinguish delirium from dementia or delirium superimposed on dementia, manage the delirium first.
Find and treat contributors
Identify and manage the possible underlying cause or combination of causes. Common contributors include infection, hypoxia, dehydration, pain, constipation, urinary retention, metabolic disturbance, medication effects or withdrawal, sensory impairment and neurological disease. Avoid assuming that a single cause explains the whole picture.
Prevention, communication and documentation
For people at risk, use a tailored multicomponent approach addressing factors such as orientation, hydration, mobility, pain, sensory impairment and sleep. Avoid unnecessary moves between rooms or wards where possible. Provide reassurance and reorientation, involve family or carers where appropriate, and document both the acute change and the diagnosis. NICE recommends documenting delirium in the person's clinical record and primary-care health record.
