Delirium Assessment & Management Guide

⚠ Hypoactive delirium is the most common subtype (~50%) and is easily missed. It carries the highest mortality risk. Always assess — do not assume the quiet patient is fine.

🧠 Definition (DSM-5)

Delirium is an acute change in cognition with a fluctuating course, characterised by:

Disturbance in attention (reduced ability to focus, sustain, or shift attention)
An additional disturbance in cognition (memory, language, visuospatial, perception)
Develops over a short period (hours to days), tends to fluctuate through the day
Not explained by pre-existing neurocognitive disorder
Evidence it is caused by a medical condition, substance intoxication/withdrawal, or medication

Types of Delirium

Hyperactive

~25% of cases — easily recognised

Agitated, restless, combative
Pulling at tubes and lines
Trying to get out of bed
Hallucinations (visual > auditory)
Risk of self-extubation and falls

Hypoactive

~50% of cases — most dangerous

Withdrawn, quiet, lethargic
Reduced response to stimuli
Slow speech, flat affect
Easily confused with depression or "good sedation"
Highest mortality risk

Mixed

~25% of cases — fluctuates between hyperactive and hypoactive features throughout the day

Delirium vs Dementia vs Depression

Feature	Delirium	Dementia	Depression
Onset	Acute (hours–days)	Gradual (months–years)	Gradual (weeks–months)
Course	Fluctuating, worse at night	Stable/progressive	Diurnal variation
Consciousness	Altered (reduced/increased)	Usually normal early	Normal
Attention	Severely impaired	Impaired late	Mildly impaired
Reversible?	Yes — if treated promptly	Mostly no	Yes with treatment
Psychomotor	Variable (agitated or sluggish)	Variable	Slowed or agitated
EEG	Diffuse slowing	Normal or mild slowing	Normal

Pathophysiology

Neurotransmitter imbalance: Reduced acetylcholine, excess dopamine; inflammatory cytokines disrupt neurotransmitter synthesis
Neuroinflammation: Systemic inflammation (sepsis, surgery, trauma) activates microglia → blood-brain barrier disruption
Reduced cerebral blood flow: Hypotension, hypoxia, anaemia all reduce oxygen delivery to the brain
Sleep-wake cycle disruption: ICU environment, noise, and medications alter melatonin and circadian rhythm

Epidemiology in GCC ICUs

Up to 80%

of mechanically ventilated ICU patients develop delirium

14–56%

of general ICU patients (non-ventilated) develop delirium

Consequences of Untreated Delirium

Prolonged ICU stay Increased mortality Long-term cognitive impairment PICS Increased falls risk Self-extubation Line/catheter removal Aspiration pneumonia Pressure injuries

PICS (Post-Intensive Care Syndrome): Long-term cognitive, psychological, and physical impairments that persist after ICU discharge. Delirium duration is directly correlated with the severity of PICS. ICU follow-up clinics are essential for these patients.

📋 Assess every 8–12 hours in ICU (each nursing shift). In ward settings, assess each shift. Document findings and any change from baseline.

📄 CAM — Confusion Assessment Method Ward / Non-ICU

For non-ventilated, communicative patients on general wards. CAM is positive (= delirium) when Feature 1 + Feature 2 + (Feature 3 OR Feature 4) are all present.

Feature 1 — Acute Onset & Fluctuating Course REQUIRED

Is there evidence of an acute change in mental status from the patient's baseline? Does the abnormal behaviour fluctuate during the day (come and go or increase/decrease in severity)?

Sources: family, previous nursing notes, medical notes

Feature 2 — Inattention REQUIRED

Did the patient have difficulty focusing attention? Tests:

Spell "WORLD" backwards (D-L-R-O-W)
Count backwards from 20
Months of the year backwards

2+ errors = positive for inattention

Feature 3 — Disorganised Thinking

Was the patient's thinking disorganised or incoherent? Ask 4 yes/no questions:

"Will a stone float on water?"
"Are there fish in the sea?"
"Does one pound weigh more than two pounds?"
"Can you use a hammer to pound a nail?"

2+ errors = positive

Feature 4 — Altered Level of Consciousness

Overall level of consciousness: Alert, Vigilant (hyperalert), Lethargic (drowsy), Stuporous, or Comatose. Any level other than alert = positive.

✓ CAM Positive = Feature 1 + Feature 2 + (Feature 3 OR Feature 4). All three criteria must be met.

💪 CAM-ICU — ICU Confusion Assessment Method ICU / Ventilated

Validated for non-verbal and mechanically ventilated ICU patients. Uses non-verbal attention tasks. Start with RASS assessment.

Assess RASS Score First

If RASS = -4 or -5 → Patient is deeply sedated or unarousable. CAM-ICU cannot be assessed. Document as "unable to assess."

If RASS = -3 to +4 → Proceed to Step 2.

Feature 1 — Acute Change or Fluctuation in Mental Status REQUIRED

Is there an acute change from mental status baseline? Or has the patient's mental status fluctuated in the last 24 hours (RASS or GCS scores)?

Yes to either = Feature 1 positive

Feature 2 — Inattention (ASE) REQUIRED

Attention Screening Examination (ASE) — choose one method:

Letter Vigilance Test (Auditory):

Read letters aloud: S A V E A H A A R T — patient squeezes hand only when they hear "A"

Picture Recognition (Visual):

Show 5 pictures. Later show 10 pictures (5 new + 5 original) — patient nods/shakes head to indicate recognition.

More than 2 errors = Feature 2 positive (inattention present)

Feature 3 — Disorganised Thinking

Yes/no questions (patient nods or shakes head, or holds up fingers):

"Will a stone float on water?"
"Are there fish in the sea?"
"Does one pound weigh more than two pounds?"
"Can you use a hammer to pound a nail?"

Then ask patient to follow 2 commands:

"Hold up this many fingers" (hold up 2 fingers)
"Now do the same with the other hand" (or "Add one more finger")

More than 1 combined error = Feature 3 positive

Feature 4 — Altered Level of Consciousness

Any RASS score other than 0 (alert and calm) = Feature 4 positive.

✓ CAM-ICU Positive = Feature 1 (REQUIRED) + Feature 2 (REQUIRED) + Feature 3 OR Feature 4

📈 RASS — Richmond Agitation–Sedation Scale

Click any row for clinical notes. Target for most ICU patients: RASS 0 to -2

☑ The ABCDEF Bundle (Society of Critical Care Medicine) is the evidence-based ICU care bundle that reduces delirium incidence, duration, and long-term cognitive impairment when implemented together.

THINK Mnemonic — Reversible Causes

Non-Pharmacological Interventions

🕐 Orientation Strategies

Place a visible clock and calendar in patient's line of sight
Address patient by their preferred name (ask family)
Inform patient of date, time, location, and reason for hospitalisation at every interaction
Place familiar objects (photos, prayer items) in the environment
Minimise room changes when possible

😴 Sleep Hygiene Protocol

Daytime

Open curtains / natural light
Encourage activity and mobility
Limit daytime sedation if possible
Group nursing tasks to minimise interruptions

Night-time

Dim lights from 22:00–06:00
Offer ear plugs and eye masks
Reduce monitor alarm volumes
Avoid non-urgent procedures 22:00–06:00
Consider melatonin 0.5–3mg if prescribed

👣 Early Mobilisation Protocol

Progression — begin as early as haemodynamically stable, RASS -1 to +1:

Level 1

Passive ROM

→

Level 2

Active in bed

→

Level 3

Sitting up/dangle

→

Level 4

Standing

→

Level 5

Walking

Discontinue if: HR >130 or <40, SpO2 <88%, MAP <65 or >120, new arrhythmia, or patient distress

👪 Family Engagement (GCC Priority)

Family presence is culturally essential in GCC — utilise this as a therapeutic tool
Educate family on delirium — it is reversible, not a sign of permanent brain damage
Encourage family to speak to patient in home language (Arabic, Urdu, Malayalam, etc.)
Family to bring familiar items: prayer beads (tasbih), Quran/religious texts, family photos
Guided family orientation script: "This is your son/daughter. You are in hospital. It is [day]. You are safe."
Caution: limit visitors to 1–2 at a time to avoid overstimulation in acute delirium
Involve family in bedside exercises and mobility

👁 Sensory Aids & Environment

Ensure hearing aids are in place and functioning (bring from home if needed)
Ensure glasses are available and clean
Avoid unnecessary physical restraints — they worsen agitation and delirium
Ensure urinary catheter is not causing discomfort (consider removal when clinically safe)
Treat pain proactively (pain is a major precipitant of delirium)
Maintain adequate hydration and nutrition
Correct sensory deprivation: TV/radio in familiar language, natural light

⚠ Non-pharmacological interventions are first-line. Medications are reserved for patient safety (risk of harm to self or others) or when non-pharmacological measures are insufficient. No medication has been shown to shorten delirium duration in RCTs.

Antipsychotics — ICU Delirium

Drugs to Avoid in Delirium

🚫 Benzodiazepines (e.g., midazolam, lorazepam, diazepam) independently worsen ICU delirium and increase duration. Avoid except in alcohol withdrawal or benzodiazepine withdrawal seizures.

Diphenhydramine (Benadryl): Highly anticholinergic — significantly worsens delirium. Never use as a sleep aid in ICU patients.
Opioids (in excess): Necessary for pain but titrate carefully. Over-sedation with opioids → delirium. Use CPOT/NRS to guide dosing.
Anticholinergic drugs: Atropine, hyoscine, promethazine — all worsen delirium.
Corticosteroids (high dose): Can precipitate steroid psychosis/delirium in susceptible patients.

Special Situation — Alcohol Withdrawal Delirium (Delirium Tremens)

⚠ Alcohol Withdrawal — Different Pathophysiology

Delirium tremens is caused by CNS hyperexcitability due to sudden cessation of alcohol in dependent patients. GABA deficiency state — benzodiazepines ARE the treatment (opposite of other ICU delirium).

Use CIWA-Ar score to guide treatment (Clinical Institute Withdrawal Assessment)
Lorazepam or diazepam are first-line for withdrawal seizure prophylaxis and management
Thiamine 200–500mg IV before any glucose administration (to prevent Wernicke's encephalopathy)
Monitor: vitals every 1–2 hours, electrolytes (K+, Mg2+, phosphate), fluid status

Physical Restraints — Guidance

⚠ Restraints are a last resort when all other interventions have failed and there is imminent risk of patient self-harm (self-extubation, removing arterial lines, etc.).

Document: Reason for restraint, time applied, type used
Reassess: Every 2 hours — can restraints be removed?
Preferred type: Soft wrist restraints (least restrictive)
Circulation checks: Every 2 hours — capillary refill, sensation, movement
Skin checks: Under restraint site every assessment
Family communication: Explain reason and expected duration
Patient dignity: Maintain privacy; speak calmly to patient even if unresponsive

QTc Monitoring for Antipsychotics

Baseline ECG before starting antipsychotics
Repeat ECG at 24 hours and after dose increases
Withhold if QTc >500ms — notify medical team
Correct electrolytes: Target K+ >4.0 mmol/L, Mg2+ >1.0 mmol/L
Caution with concomitant QT-prolonging drugs: ondansetron, fluconazole, ciprofloxacin, amiodarone
Monitor QTc 4–6 hourly while on IV haloperidol

🇨🇦 GCC Family Culture & Delirium Care

In GCC countries, large extended families are central to patient care. This is a clinical asset in managing delirium — but requires guidance.

Therapeutic Use of Family

Familiar voices reduce agitation and improve orientation
Family can do bedside exercises
Family provides cultural and spiritual comfort
Prayer and religious recitation (Quran) is calming

Cautions with Overstimulation

Limit to 1–2 visitors during acute agitation
Avoid multiple family members speaking simultaneously
Discourage emotional outbursts at bedside
Educate family: crying/wailing can worsen patient distress

Arabic Orientation Phrases

أنت في المستشفى وأنت بأمان

Anta fi al-mustashfa wa anta bi-aman

You are in the hospital and you are safe.

اليوم هو [اليوم] و الساعة [الوقت]

Al-yawm huwa [day] wa al-sa'a [time]

Today is [day] and the time is [time].

نحن هنا لنساعدك، أنت بخير

Nahnu huna linusa'idak, anta bi-khayr

We are here to help you, you are okay.

هل تشعر بأي ألم؟

Hal tash'ur bi-ay alam?

Are you feeling any pain?

Post-ICU Discharge — PICS

📋 Post-Intensive Care Syndrome (PICS)

Delirium duration is independently associated with long-term cognitive, psychological, and physical impairment after ICU discharge.

Domain	Common Manifestations	Timeframe
Cognitive	Memory loss, executive dysfunction, poor concentration	Months to years
Psychological	PTSD, depression, anxiety, nightmares about ICU	Weeks to years
Physical	ICU-acquired weakness, fatigue, breathlessness	Months to years

ICU Follow-Up Clinics should be offered to all patients with ICU stays >3 days, delirium, or prolonged mechanical ventilation. Refer to psychology, physiotherapy, and cognitive rehabilitation as needed.

Documentation Requirements

CAM or CAM-ICU result (positive/negative/unable to assess) every nursing shift — time-stamped
RASS score at time of CAM-ICU assessment
Non-pharmacological interventions trialled and patient response
Medication administered for delirium: drug, dose, route, time, indication
Restraint documentation: reason, type, time applied, 2-hourly reassessment, circulation check
Family education provided (documented in nursing notes)
Escalation to medical team if new-onset delirium or worsening

Quick Reference Card

RASS Quick Reference

CAM-ICU Result Logic

RASS -4/-5	Unable to assess
F1+F2+F3	Delirium POSITIVE
F1+F2+F4	Delirium POSITIVE
F1+F2+F3+F4	Delirium POSITIVE
F1 or F2 absent	Delirium NEGATIVE
RASS 0, all neg	No delirium

Knowledge Check — 10 Questions