- Disturbance in attention & awareness — reduced ability to direct, focus, sustain, and shift attention; reduced orientation to the environment
- Acute onset & fluctuating course — develops over a short period (hours to days); tends to fluctuate in severity during the course of a day
- Additional disturbance in cognition — memory deficit, disorientation, language disturbance, visuospatial ability, or perception
- Not explained by another neurocognitive disorder — not occurring in the context of a severely reduced level of arousal (e.g., coma)
- Evidence of a causative medical condition — direct physiological consequence of another medical condition, substance intoxication/withdrawal, or multiple aetiologies
🔴 Hyperactive Delirium
- Agitated, restless, combative
- Pulling at lines and catheters
- Refusing care
- Shouting, calling out
- RASS +1 to +4
- Most recognised subtype
- Easier to identify
🟣 Hypoactive Delirium
- Quiet, withdrawn, drowsy
- Reduced responsiveness
- Slowed movements/speech
- Staring into space
- RASS 0 to -3
- Most common — most missed
- Confused with fatigue/depression
🟡 Mixed Delirium
- Alternates between subtypes
- Unpredictable fluctuation
- Can be hyperactive at night
- Hypoactive during daytime
- Requires vigilant monitoring
- CAM assessment every shift
Hypoactive delirium carries a WORSE prognosis than hyperactive delirium — higher mortality, longer ICU stays, more functional decline. It is frequently missed because patients appear "calm." Any patient who seems unusually quiet or withdrawn must be formally assessed with CAM/CAM-ICU.
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute (hours-days) | Chronic (months-years) | Gradual (weeks-months) |
| Course | Fluctuating — worse at night | Slowly progressive | Persistent, diurnal variation |
| Reversibility | Reversible with treatment | Largely irreversible | Reversible with treatment |
| Attention | Severely impaired | May be preserved early | Mildly impaired |
| Consciousness | Altered (clouded) | Clear until late stages | Clear |
| Orientation | Impaired | Impaired | Intact |
| Memory | Impaired (short-term) | Impaired (short > long) | Patchy — effort-dependent |
| Psychomotor | Variable (hyper/hypo) | Usually normal early | Slowed (psychomotor retardation) |
| Sleep | Severely disrupted, reversed | Disrupted | Insomnia/hypersomnia |
| Mood | Labile — fear/paranoia | Variable | Persistently low/anhedonic |
| Investigations | Abnormal — identify cause | Often normal early | Normal |
Very common and dangerous. Patients with dementia are at 2-5× higher risk of developing delirium. DSD is frequently missed because cognitive changes are attributed to baseline dementia. Always establish baseline cognitive function from family/carers. Any ACUTE change from baseline = delirium until proven otherwise.
- Increased mortality (2-4× in ICU patients)
- Prolonged mechanical ventilation duration
- Longer ICU and hospital length of stay
- Higher rates of self-extubation and line removal
- Post-ICU Cognitive Impairment (PICI) — up to 1 year post-discharge
- Post-ICU Syndrome (PICS) — cognitive, psychological, physical sequelae
- Increased institutionalisation and functional decline
- Greater healthcare costs
For verbal patients on general wards. Takes 5 minutes. Sensitivity 94–100%, Specificity 90–95%.
Is there evidence of an acute change in mental status from baseline? Does the abnormal behaviour fluctuate during the day — tend to come and go, or increase and decrease in severity?
Does the patient have difficulty focusing attention — e.g., easily distracted, difficulty keeping track of conversation? Assess using: Months of year backwards / Days of week backwards / Letter attention test (SAVEAHAART)
Is the patient's thinking disorganised or incoherent — rambling or irrelevant conversation, unclear/illogical flow of ideas, unpredictable switching between subjects?
Overall, how would you rate this patient's level of consciousness? Alert (normal), Vigilant (hyperalert), Lethargic, Stuporous, Comatose.
Feature 1 (Acute onset/Fluctuating) + Feature 2 (Inattention) + either Feature 3 (Disorganised thinking) or Feature 4 (Altered consciousness)
Validated for intubated and non-verbal patients. Requires RASS ≥ -3. Uses non-verbal responses.
If RASS = -4 or -5 → STOP. Patient is unarousable. CAM-ICU cannot be assessed.
Is the patient's mental status different from baseline? Or has the mental status fluctuated in the last 24 hours (as evidenced by fluctuating RASS/GCS)?
Say the letters: S-A-V-E-A-H-A-A-R-T
Ask patient to squeeze your hand only when they hear the letter A. Count errors: fails to squeeze on A (miss) OR squeezes on non-A letter (false alarm). Score ≥2 errors = Inattention POSITIVE
Ask 4 Yes/No questions (2 sets available, alternate daily):
Set A: 1) Will a stone float on water? 2) Are there fish in the sea? 3) Does 1kg weigh more than 2kg? 4) Can you use a hammer to pound a nail?
Plus command: "Hold up this many fingers" (hold 2 fingers) then "Now do the same with the other hand."
Score ≥2 errors = Feature 3 POSITIVE
RASS anything other than 0 = Feature 4 POSITIVE
Takes <2 minutes. Suitable for all clinical settings. Score 0–12. No training required.
| Question | Assessment | Max Score |
|---|---|---|
| 1. Alertness | Normal = 0 / Mild sleepiness for <10s = 0 / Clearly abnormal = 4 | 4 |
| 2. AMT4 | Age, DOB, Place, current year — 0 errors = 0 / 1 error = 1 / 2+ errors = 2 | 2 |
| 3. Attention | Months backwards from December: 0-1 errors = 0 / 2+ errors / unable = 2 | 2 |
| 4. Acute Change | Evidence of significant change in mental status in last 2 weeks: No = 0 / Yes = 4 | 4 |
Used to assess level of consciousness before and during delirium assessment. Target RASS = 0 or -1 in most ICU patients.
| Score | Label | Description |
|---|---|---|
| +4 | Combative | Overtly combative, violent, immediate danger to staff |
| +3 | Very Agitated | Pulls or removes tubes/catheters; aggressive behaviour |
| +2 | Agitated | Frequent non-purposeful movement, fights ventilator |
| +1 | Restless | Anxious but movements not aggressive or vigorous |
| 0 | Alert & Calm | Spontaneously awake, calm, purposeful |
| -1 | Drowsy | Not fully alert but has sustained awakening to voice (>10s) |
| -2 | Light Sedation | Briefly awakens with eye contact to voice (<10s) |
| -3 | Moderate Sedation | Movement or eye opening to voice, no eye contact |
| -4 | Deep Sedation | No response to voice but movement/eye opening to physical stimulation |
| -5 | Unarousable | No response to voice or physical stimulation |
| Setting | Tool | Minimum Frequency | If Delirium Positive |
|---|---|---|---|
| General Ward | CAM or 4AT | Every shift (at minimum) | Every 4 hours + notify medical team |
| ICU — RASS ≥ -3 | CAM-ICU or ICDSC | Every shift (Q12H minimum) | Q2–4H, reassess medications, notify team |
| ICU — RASS -4/-5 | Document RASS level | Every shift | Cannot assess — document as "unable to assess" |
| High-risk patients | CAM + RASS | Every 4 hours | Continuous monitoring, family notification |
- Record tool used, score, and interpretation (positive/negative/unable)
- Document baseline cognitive function on admission (from family/carers)
- Record contributing factors identified (infection, pain, sleep deprivation, etc.)
- Document non-pharmacological interventions implemented
- Record any pharmacological management with dose, route, and response
The ABCDEF Bundle (Marra et al. 2017, Ely et al.) demonstrated that implementation of all bundle elements together — not individually — achieves the greatest reduction in delirium, coma, mechanical ventilation days, ICU readmissions, and 1-year mortality. The bundle is most effective when implemented as a team effort across nursing, medicine, pharmacy, physiotherapy, and families.
- Pain assessment: NRS (verbal) / CPOT (non-verbal/intubated)
- Analgesia before sedation — treat pain first
- Regular scheduled analgesia (not PRN-only)
- Non-opioid adjuncts: paracetamol, NSAIDs, ketamine, pregabalin
- Opioid-sparing approach where possible
- Pain documentation and reassessment after intervention
- SAT = Spontaneous Awakening Trial — nurse-driven sedation cessation
- SBT = Spontaneous Breathing Trial — coordinated with SAT
- SAT safety screen before starting (no paralysis, no active seizures, no ETOH withdrawal, no agitation)
- Reduces ventilator days, ICU length of stay
- Monitor during SAT: respiratory rate, SpO2, RASS, vital signs
- Fail criteria: RR >35, SpO2 <88%, RASS <-2 or +2
- Analgesia-first (analgo-sedation) approach
- Target lightest effective sedation (RASS 0 to -2)
- Propofol: short-acting, titratable, less delirium than benzos
- Dexmedetomidine: preferred for delirium-prone patients — rousable, cooperative
- Avoid benzodiazepines where possible — strongly associated with delirium
- Exception: alcohol/benzo withdrawal (use CIWA protocol)
- CAM-ICU or ICDSC: minimum twice daily in ICU
- CAM on general wards every shift
- Document RASS alongside delirium tool
- Identify and treat precipitating causes (PINCH ME mnemonic)
- Non-pharmacological first — implement full bundle
- Pharmacological only for distressing/dangerous hyperactive delirium
- Passive ROM → active-assisted exercises in bed → sitting up
- Dangling at bedside → standing → walking with support
- Safe even for ventilated patients — reduce sedation for mobility
- Start within 24–48 hours of ICU admission
- Prevents PICS, ICU-acquired weakness, delirium
- Physiotherapy team collaboration essential
- Family present and active in patient care and orientation
- Communication boards and whiteboards in room
- Familiar objects from home (photos, blanket, Quran/religious items)
- Family voices for orientation and comfort
- Educate family to recognise delirium and help reassure patient
- Support family — they experience psychological distress too
Non-pharmacological interventions are the FIRST and PRIMARY treatment for ALL types of delirium. Medications are reserved for distressing or dangerous hyperactive delirium only, and only after non-pharmacological measures are optimised. Evidence consistently shows that nursing-led environmental and cognitive interventions reduce delirium duration and severity.
- Open curtains during daytime hours
- Close curtains/dim lights at night
- Cluster nursing interventions during day
- Minimise procedures at night when possible
- Silence alarms / reduce monitor volumes at night
- Large visible clock in patient's line of sight
- Large date calendar — cross off each day
- Whiteboard: patient's name, date, location, nurse name
- Orient at every patient interaction
- "Good morning Mr Ahmed, you are in Al Rashid Hospital in Dubai. Today is Monday the 7th of April."
- Ensure glasses are available and worn
- Ensure hearing aids are in and working
- Check batteries in hearing aids daily
- Use low vision aids if available
- Speak clearly and face the patient
- Photos of family at bedside
- Familiar objects from home
- Favourite music via earphones
- Religious items (Quran, prayer beads)
- Familiar scents if appropriate
- Ear plugs and eye masks offered every night (document acceptance/refusal)
- Warm non-caffeinated drink at bedtime where possible
- Cluster nursing procedures — avoid waking patient unnecessarily at night
- Reduce lighting in room and corridor at night
- Review medications that disrupt sleep (steroids, diuretics, stimulants)
- Avoid sleep-disrupting medications at night (sedating antihistamines cause delirium)
- Melatonin 0.5–2mg at night may be considered (low evidence but low risk)
- Consult medical team if severe sleep disruption persists
Physical restraints are associated with: increased delirium severity, increased agitation, increased psychological trauma, pressure injuries, aspiration pneumonia, DVT, and death from strangulation. Restraints should be a LAST resort only, after all alternatives are exhausted, with regular reassessment and documentation of justification.
- Review necessity of every line, drain, and catheter DAILY
- Remove unnecessary catheters and lines promptly — they cause discomfort and restrict mobility
- Continuous pulse oximetry and monitoring only when clinically indicated
- If patient is pulling at lines: consider soft mitts (mittens) rather than wrist restraints
- Document reason for any restraint, review every 2 hours, remove as soon as safe
- Obtain consent/family agreement for restraint use where possible
- Consider 1:1 nursing or family presence as alternative to restraints
- Approach calmly and identify yourself every time: "Hello Mr Ahmed, I am Fatima, your nurse"
- Orient the patient at every interaction — brief, calm, consistent
- Do not argue with or correct hallucinations aggressively — acknowledge the distress
- Use simple, short sentences — avoid complex explanations during acute delirium
- Maintain eye contact and speak clearly, face-to-face
- Therapeutic touch where culturally appropriate and accepted by patient
- Acknowledge the patient's fear: "You seem frightened. You are safe. I am here to help you."
- Reassure repeatedly — delirious patients do not retain information
No medication has been shown to prevent delirium or shorten its duration when used as primary treatment. Pharmacological agents are indicated ONLY for hyperactive delirium that is distressing to the patient, dangerous (risk of self-harm, line removal, fall), or preventing essential treatment. They MUST be used alongside optimised non-pharmacological care.
| Drug | Dose | Route | Indications | Monitoring | Contraindications |
|---|---|---|---|---|---|
| Haloperidol | 0.5–1 mg (elderly: 0.25–0.5mg) |
Oral / IM / IV | Hyperactive delirium, first-line antipsychotic | ECG (QTc), EPSE, NMS, vital signs, sedation level | Parkinson's disease, Lewy Body Dementia, antipsychotic-naive elderly (caution), long QT |
| Quetiapine | 12.5–25 mg BD-TDS |
Oral only | Hyperactive delirium, sleep disturbance, Parkinson's/DLB (preferred antipsychotic) | ECG (QTc), postural hypotension, sedation, blood glucose | Severe hepatic impairment, long QT. Use with caution in elderly — high fall risk |
| Olanzapine | 2.5–5 mg once daily |
Oral / IM | Hyperactive delirium — alternative if haloperidol not tolerated | Blood glucose, weight (longer-term), ECG, sedation | Diabetics (hyperglycaemia), metabolic syndrome. IM not for IV use. |
| Dexmedetomidine | 0.2–1.4 mcg/kg/hr infusion | IV infusion (ICU only) | ICU sedation — reduces sedation-related delirium; delirium treatment in ICU | Bradycardia, hypotension, RASS, vital signs Q30-60 min | Advanced heart block (without pacemaker), severe bradycardia |
| Lorazepam / Diazepam | Variable — CIWA protocol | Oral / IV / IM | Alcohol withdrawal delirium (DT), benzodiazepine withdrawal delirium ONLY | Respiratory rate, sedation level, CIWA score, withdrawal seizures | All other delirium types — strongly associated with WORSENING delirium |
Both haloperidol and quetiapine can prolong the QT interval, increasing the risk of Torsades de Pointes (TdP) — a potentially fatal arrhythmia. GCC nurses must monitor:
- Baseline ECG before commencing antipsychotics for delirium
- Repeat ECG within 24–48 hours of starting or dose increase
- Withhold medication and notify medical team if QTc >500ms or increase >60ms from baseline
- Check for concurrent QT-prolonging medications (azithromycin, ondansetron, methadone, amiodarone)
- Correct electrolytes: hypokalaemia and hypomagnesaemia markedly increase TdP risk
- IV haloperidol carries higher QT risk than oral — requires cardiac monitoring
Delirium tremens (DT) occurs 48–96 hours after last drink. Mortality 5–15% if untreated. Benzodiazepines are the TREATMENT OF CHOICE for alcohol withdrawal — NOT other delirium. Use CIWA-Ar protocol (Clinical Institute Withdrawal Assessment for Alcohol) to guide dosing.
- CIWA-Ar score ≥10: commence benzodiazepine therapy (lorazepam IV preferred in ICU)
- Thiamine 100-200mg IV before any glucose/dextrose infusion — prevents Wernicke's Encephalopathy
- IV fluids — dehydration is universal in DT
- Seizure precautions — padded cot sides, suction available
- Monitor vital signs Q30 min during acute withdrawal
- ICU transfer for CIWA-Ar >20 or respiratory compromise
| Drug / Class | Reason to Avoid | Alternative |
|---|---|---|
| Benzodiazepines (lorazepam, midazolam, diazepam) | Strongly associated with WORSENING delirium. Paradoxical agitation in older adults. | Dexmedetomidine / low-dose haloperidol |
| Anticholinergics (cyclizine, chlorphenamine, hyoscine) | Block acetylcholine — directly causes delirium, particularly in elderly | Non-anticholinergic alternatives |
| Opioids (high-dose) | Accumulation causes delirium — opioid-sparing approach preferred | Paracetamol, NSAIDs, regional blocks |
| Sedating antihistamines (diphenhydramine) | Anticholinergic effects worsen delirium | Melatonin or non-pharmacological sleep aids |
| Corticosteroids (high-dose) | Steroid psychosis / delirium — review necessity | Minimum effective dose |
Delirium is significantly underrecognised in GCC hospitals. Key reasons include:
- Hypoactive subtype attributed to "patient being tired" or culturally quiet
- Language barriers — staff may misinterpret confusion as linguistic non-compliance
- Lack of formal delirium screening protocols in many facilities
- Delirium education gaps at nursing and physician level
- Cultural expectation that patients should be "respectful and quiet"
- Multinational nurse workforce — variable delirium training backgrounds
GCC ICUs and wards serve Arabic-speaking patients assessed by non-Arabic-speaking nurses. Challenges:
- CAM verbal questioning requires language proficiency — use interpreter or family
- CAM-ICU is the preferred tool — non-verbal, validated, language-independent
- Arabic-validated CAM exists and should be used with Arabic-speaking patients
- 4AT has been translated into Arabic — rapid and usable in wards
- Document language used and whether interpreter was involved
- Avoid using children as interpreters for cognitive assessment
Disorientation in delirium is amplified by cultural unfamiliarity. In GCC hospitals:
- Arabic Quran recitation as orienting auditory stimulus — familiar and calming
- Prayer times as temporal orientation anchors (Fajr, Dhuhr, Asr, Maghrib, Isha)
- Prayer bead (Masbaha) at bedside as familiar tactile object
- Orientation in Arabic by Arabic-speaking staff or family
- Halal food and familiar meals to support orientation and nutrition
- Cultural sensitivity around touch and personal space
GCC families are typically highly present during hospitalisation — this is a powerful, underutilised non-pharmacological intervention:
- Families often stay 24 hours — leverage this for continuous reorientation
- Educate family about delirium, delirium-friendly language, and orientation
- Family to hold patient's hand, use patient's name, remind of familiar stories
- Identify key family member as "delirium buddy" — trained by nursing team
- Family presence reduces agitation, restraint use, and delirium duration
- Respect privacy — ensure appropriate family rota during examinations
Ramadan presents unique delirium risk factors for hospitalised patients in GCC:
- Daytime fasting → dehydration and electrolyte disturbances
- Sleep pattern reversal (eating/praying at night) disrupts circadian rhythm
- Medication timing changes — some patients refuse medications during fast
- Night eating → nocturnal hyperglycaemia in diabetics
- Increased social visits at night → nighttime noise and sleep disruption
- Clinical team should plan Ramadan-specific delirium prevention strategies
- Involve Islamic authority (hospital imam) to advise on fasting exemptions for sick patients
PICS awareness is growing as ICU survival rates improve across GCC hospitals:
- PICS encompasses: cognitive, psychological, and physical dysfunction after ICU
- Delirium is the strongest risk factor for post-ICU cognitive impairment
- PICS-F: family members of ICU patients develop PTSD, anxiety, depression
- ICU follow-up clinics emerging in Gulf hospitals — advocate for your patients
- Document delirium days accurately — informing rehabilitation planning
- Discharge communication should include delirium history for GP/specialist care
Malnutrition is prevalent in hospitalised elderly patients across the Gulf region:
- Malnutrition rates in GCC hospitalised elderly: 30–50% on admission
- Thiamine (Vitamin B1) deficiency causes Wernicke's Encephalopathy — presents as delirium
- At-risk groups: alcohol use disorder (underreported in GCC), malabsorption, prolonged IV fluids without vitamins, post-bariatric surgery
- Empirical thiamine 100mg IV for any unexplained delirium with nutritional risk
- Always give thiamine BEFORE glucose in suspected deficiency
- Screen all admitted patients with MUST / MNA nutritional tools
Key actions for GCC nurses and nurse leaders:
- Advocate for formal delirium screening protocol (CAM-ICU / 4AT) in your unit
- Include delirium assessment in nursing handover and documentation systems
- Educate junior nursing staff — delirium is nursing-diagnosed and nursing-managed
- Create Arabic-language patient and family education materials
- Collaborate with medical and pharmacy teams on delirium-safe prescribing
- Audit delirium rates — quality improvement metric in JCI/CBAHI accreditation
- Develop cultural adaptation of Hospital Elder Life Program (HELP) for GCC
- PADIS Guidelines 2018 (Devlin et al.) — Pain, Agitation/Sedation, Delirium, Immobility, Sleep in ICU Adults
- NICE Guideline CG103 (2010, updated 2019) — Delirium: Prevention, Diagnosis and Management
- Ely EW et al. — CAM-ICU development and validation (JAMA 2001)
- Inouye SK et al. — Hospital Elder Life Program (HELP), CAM development
- Marra A et al. — ABCDEF Bundle implementation and outcomes (Crit Care Med 2017)
- 4AT Tool — Bellelli G et al. (Age Ageing 2014)
- Arabic CAM-ICU validation — Al-Qadhi SA et al. (Middle East J Anaesthesiol)
- DSM-5 — American Psychiatric Association (2013)