Guidelines for the diagnosis and

Management of delirium in the

Elderly

Contents

Page

Grade of evidence

Acknowledgements

Definitions

Diagnosis

Abbreviated Mental Test score

Differential diagnosis

Patients at risk

Causes

History

Examination

Investigations
Treatment of underlying cause

5
6

Management of confusion

Sedation

Prevention of complications

Referral to Old Age Psychiatry

Discharge

Follow up

References

10, 11,12

Index

13

Appendix 1

Drugs

causing

delirium
Appendix 2

Algorithm

for

Summary

of

management
Appendix 3
Carlisle guidelines for
management of delirium

Grade of evidence:
Grade 1

Based on Randomised Controlled Trial

Grade IIa

Based on well designed non-randomised controlled trial

Grade IIb

Based on well designed cohort or case-control analytic studies

Grade IIc
interventions.

Comparisons

between

times/places,

with

or

without

Dramatic results in uncontrolled trials

Grade IIl

Expert opinion, clinical experience, descriptive studies, expert

committees.

Acknowledgements:
These guidelines were compiled by Dr Lesley Young and Dr Jim George with
funding from the NHS central audit fund. We wish to acknowledge the support and
co-operation of the following groups of people who assisted in the development of
these guidelines:
Staff of the from the medical and elderly care wards and audit departments in the
following hospitals:
Cumberland Infirmary, Carlisle
Newcastle General Hospital, Newcastle upon Tyne
North Tyneside General Hospital, North Shields
Royal Victoria Infirmary, Newcastle upon Tyne
St Luke's Hospital, Bradford
Bradford Royal Infirmary, Bradford
Selly Oak Hospital, Birmingham
Members of the joint working party on "Confusion in Crises", Royal College of Physicians, October 1995.
Dr Stephen Singleton, Director of Public Health, Northumberland.

Guidelines for the diagnosis and management of delirium

Delirium (acute confusional state) is a common condition in the elderly affecting up
to 30% of all elderly medical patients. Patients who develop delirium have high
mortality, institutionalisation and complication rates, and have longer lengths of stay
than non-delirious patients [1]. Delirium is often not recognised by clinicians [2], and
is often poorly managed. The aim of these guidelines is to aid recognition of delirium
and to provide guidance on how to manage these complex and challenging patients.
Diagnosis
Delirium is characterised by a disturbance of consciousness and a change in
cognition that develop over a short period of time. The disorder has a
tendency to fluctuate during the course of the day, and there is evidence form
the history, examination or investigations that the delirium is a direct
consequence of a general medical condition, drug withdrawal or intoxication
(DSM IV) [3].
In order to make a diagnosis of delirium, a patient must show each of the
features 1- 4 listed below:
1.

Disturbance of consciousness (i.e. reduced clarity of awareness of the

environment) with reduced ability to focus, sustain or shift attention.

2.

A change in cognition (such as memory deficit, disorientation, language

disturbance) or the development of a perceptual disturbance that is not
better accounted for by a pre- existing or evolving dementia.

3.

The disturbance develops over a short period of time (usually hours to

days) and tends to fluctuate during the course of the day.

4.

There is evidence from the history, physical examination, or laboratory

findings that the disturbance is caused by the direct physiological
consequences of a general medical condition, substance intoxication or
substance withdrawal.

Delirium may have more than one causal factor (i.e. multiple aetiologies). A
diagnosis of delirium can also be made when there is insufficient evidence to
support criterion 4, if the clinical, presentation is consistent with delirium, and
the clinical features can not be attributed to any other diagnosis, for example
delirium due to sensory deprivation.

Aids to diagnosis

Cognitive testing should be carried out on all elderly patients

admitted to hospital (grade llc) Use of cognitive screening tools
(such as the Abbreviated Mental Test score [4] and Mini Mental State
Examination [5]) may increase recognition of delirium present on
admission [4, 5].

Serial measurements may help detect the new development of delirium

or its resolution [6] (gradellc). However by themselves these tools cannot
distinguish between delirium and other causes of cognitive impairment [4, 5].

A history from a relative or carer of the onset and course of the

confusion is essential to help distinguish between delirium and
dementia. (grade III).

Abbreviated Mental Test Score (AMT)

abnormal)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Age
Time (to nearest hour)
Address for recall at end of test (42 West St)
Year
Name of hospital
Recognition of 2 persons (eg doctor, nurse)
Date of Birth
Year of 1st World War
Name of present monarch
Count backwards 20-1 (this also tests attention)

(A score of less than 8/10 is

Differential diagnosis

The differential diagnosis of delirium includes:

Dementia
Depression
Hysteria
Mania
Schizophrenia

The simple screening tools, discussed earlier, are not able to distinguish between
delirium and other disorders, such as dementia [4, 5]. In order to differentiate
between delirium and dementia, the most helpful factor is an account of the patients
pre-admission state from a relative or carer. Serial measurements of cognition may
help to differentiate delirium from dementia or detect its onset during a hospital
admission [6] (grade Ilc).

3
Patients at risk

Delirium is more common in those with a pre-existing organic brain syndrome [7] or
dementia [8-19], and may co-exist with disorders such as depression, which are also
common in the elderly [10, 20].
Delirium is more common in patients who are:

Older [21]
Severely ill [11]
Demented [11]
Physically frail [22]
Admitted with an infection or dehydration [11, 21]
Visually impaired [11]
Polypharmacy [15, 16, 23]
Alcohol excess [12]

Early attention to possible precipitants of delirium and adopting the

approaches detailed under "management of confusion" in those patients at
increased risk of delirium may prevent the development of delirium and
improve the outcome in those who go on to develop it [24-26, 44] (Grade, l).
Identification of the underlying cause
Common causes of delirium include :

Infection (e.g. pneumonia, UTI)

Neurological (e.g. stroke, subdural haematoma, epilepsy)
Cardiological (eg myocardial infarction, heart failure)
Respiratory (eg pulmonary embolus, hypoxia)
Electrolyte imbalance (eg dehydration, renal failure)
Endocrine & metabolic (eg cachexia, thiamine deficiency, thyroid dysfunction)
Drugs ( particularly those with anticholinergic side effects, eg
antidepressants, antiparkinsonian drugs, sedatives) (see appendix 1)
Multiple causes.

History
In addition to standard questions in the history, the following information
should be specifically sought (grade III):

Full drug history including non-prescribed drugs

Alcohol history
Previous intellectual function (eg ability to manage household affairs, pay
bills etc.)
Functional status (eg activities of daily living)
Onset and course of confusion
Previous episodes of acute or chronic confusion

4
Symptoms suggestive of underlying cause (eg infection)

Sensory deficits
Aids used (eg hearing aid, glasses etc.)
Pre-admission social circumstances and care package
Comorbid illness

Many patients with confusional states are unable to provide an accurate

history. Where ever possible corroboration should be sought from the carer
(grade III).
Communication between staff from different disciplines is essential to avoid
unnecessary repetition of information gathering.
Examination
A full physical examination should be carried out including in particular the
following areas:

Neurological examination (including assessment of speech)

Conscious level
Nutritional status
Evidence of pyrexia
Evidence of alcohol abuse or withdrawal (e.g. tremor)
Cognitive function using a standardised screening tool e.g. Abbreviated MTS
or MMSE (grade IIc)
Attention (e.g. serial 7`s, months of year backwards)

Investigations
The following investigations are almost always indicated in patients with delirium in
order to identify
the underlying cause (grade III):

Full blood count

Calcium
Urea and electrolytes
Liver function tests
Glucose
Thyroid function tests
Chest X-ray
ECG
Blood cultures
Urinalysis

Other investigations may be indicated according to the findings from the history and
examination.
These include:

EEG (see below)

CT head (see below)
B12 and folate
Arterial blood gases
Specific cultures eg urine, sputum
Lumbar puncture (see below)

CT Scan (grade llb)

Although many patients with delirium have an underlying dementia or structural
brain lesion (eg previous stroke), CT has been shown to be unhelpful on a routine
basis in identifying a cause for delirium [7] and should be reserved for those
patients in whom an intracranial lesion is suspected. This might include patients with
the following features (grade III):

Focal neurological signs

Confusion developing after head injury
Confusion developing after a fall
Evidence of raised intracranial pressure

EEG
Although the EEG is frequently abnormal in those with delirium [27 -29], showing
diffuse slowing, its routine use as a diagnostic tool has not been fully evaluated.
EEG may be useful where there is difficulty in the following situations (grade III):

Differentiating delirium from dementia

Differentiating delirium from non-convulsive status epilepticus and temporal
lobe epilepsy
Identifying those patients in whom the delirium is due to a focal intracranial
lesion, rather than a global abnormality.

Lumbar puncture
Although various abnormalities have been seen in the CSF of patients with delirium
[30], routine LP is not helpful [31] in identifying an underlying cause for the delirium
(grade III). It should therefore be reserved for those in whom there is reason to
suspect a cause such as meningitis. This might include patients with the following
features:

Meningism
Headache and fever

6
Treatment of underlying cause
The most important approach to the management of delirium is the identification and
treatment of the underlying cause (grade III).

Incriminated drugs should be withdrawn where ever possible (grade III).

Biochemical derangements should be corrected promptly [32] (grade
IIb)
Infection is one of the most frequent precipitants of delirium. If there is a
high likelihood of infection (eg abnormal urinalysis, abnormal chest
examination etc.), appropriate cultures should be taken and antibiotics
commenced promptly, selecting a drug to which the likely infective
organism will be sensitive (grade III).

Management of confusion
In addition to treating the underlying cause, management should also be directed at
the relief of the symptoms of confusion/delirium.
The patient should be nursed in a good sensory environment and with a reality
orientation approach, and with involvement of the multi-disciplinary team [18, 23, 25,
26, 33-35] (grade I).
This includes:

Good lighting levels

Regular and repeated visible and verbal clues as to orientation (eg
clocks, calendars)
Reassurance and explanation to the patient and carer of any procedures
or treatment, using short simple sentences
Sensory aids should be available and working where necessary
Avoidance of inter- and intra-ward transfers [36] (grade III)
Continuity of care from caring staff
Avoidance of physical restraints [37-39] (grade IIc) (see also under Falls)
Maintenance or restoration of normal sleep patterns
Approach and handle gently
Eliminate unexpected and irritating noise (e.g. pump alarms)
Attend to bowel and bladder elimination (see continence problems)
Encouraging visits from familiar friends and relatives may help to calm
an agitated patient. However communication with the relative regarding
the nature of the confusion is essential.

Depending on the layout and nature of the ward, these measures may be facilitated
by nursing the patient in a single room. For example, in a busy Nightingale ward, a
patient with delirium may be better managed in a side room, whereas in a ward with
small bays the presence of other patients may have a reassuring influence (grade
III).

7
Wandering and rambling speech
Patients who wander require close observation within a safe and reasonably closed
environment. It is often preferable to try distracting the agitated wandering patient
rather than using restraints or sedation. Relatives could be encouraged to assist in
this kind of management.
Attempts should be made to identify and remedy possible cause of agitation - e.g.
pain, thirst, need for toilet. Patients with delirium often exhibit confused and
rambling speech, it is usually preferable not to agree with rambling talk, but to adopt
one of the following strategies, depending on the circumstance (grade III) [40]:

Tactfully disagree (if the topic is not sensitive)

Change the subject
Acknowledge the feelings expressed - ignore the content

Sedation
All sedatives may cause delirium, especially those with anticholinergic side effects
[41] (such as thioridazine, chlorpromazine etc.). The use of sedatives and major
tranquillisers should therefore be kept to a minimum (grade III). Many elderly
patients with delirium have hypoactive delirium (quiet delirium) and do not require
sedation [42].
Early identification of delirium and prompt treatment of the
underlying cause may reduce the severity and duration of delirium [24-26].
Drug sedation may be necessary in the following circumstances (grade III)

in order to carry out essential investigations or treatment

to prevent patients endangering themselves or others
to relieve distress in a highly agitated or hallucinating patient

It is preferable to use one drug only, starting at the lowest possible dose and
increasing in increments if necessary after an interval of 30 minutes (grade III).
The preferred drugs are:

Haloperidol - 0.5mg-3mg orally as tablets or liquid up to 4 times daily or 2.5

- 5 mg by
intramuscular injection (grade III) (NB the oral and IM doses of haloperidol
are not equivalent)

Droperidol daily.

5-10mg orally or 5mg by intramuscular injection up to 4 times

If sedatives are prescribed, the prescription should be reviewed regularly and

discontinued as soon as possible.
For delirium due to alcohol withdrawal (delirium tremens) a benzodiazepine (eg
diazepam or chlordiazepoxide) or chlormethiazole are preferred in a reducing
course. Detailed guidelines for this condition are beyond the scope of these
guidelines.
8

Prevention of complications
The main complications of delirium are :

Falls
Pressure sores
Nosocomial infections
Functional impairment
Continence problems
Over sedation

Restraints (including cotsides, "geriatric chairs" etc.) have not been shown to
prevent falls and may increase the risk of injury [37-39]. It may be preferable to
nurse the patient on a low bed or place the mattress directly on the floor. Adoption of
the good practices described should make the use of physical restraints
unnecessary for the management of confusion (grade III).
Pressure sores
Patients should have a formal pressure sore risk assessment ( eg Norton score, or
Waterlow score), and receive regular pressure area care, including special
mattresses where necessary (grade III). Patients should be mobilised as soon as
their illness allows.
Functional impairment
Assessment by a physiotherapist and occupational therapist to maintain and
improve functional ability should be considered in all delirious patients (grade III).
There is evidence that patients who are managed by a multidisciplinary team do
better than those cared for in a traditional way [18, 23, 25-26, 33-35] (grade I, IIb).
Continence
A full continence assessment should be carried out. Regular toiletting and prompt
treatment of UTI`s may prevent urinary incontinence. Catheters should be avoided
where possible because of the increased risks of trauma in confused patients, and
the risk of catheter associated infection (grade III).
Referral to Old Age Psychiatry services
Many patients with delirium have an underlying dementia which may be best
followed up and managed by an Old Age Psychiatrist. Patients who fail to improve
despite adequate treatment and resolution of the suspected cause of the delirium
may benefit from referral to an Old Age Psychiatrist for further assessment (grade
III) [35].

Discharge
As with all elderly patients discharge should be planned in conjunction with all
disciplines involved in caring for the patient, both in hospital and in the community
(including informal carers). Practical arrangements should be in place prior to
discharge for activities such as washing, dressing, medication etc. in accordance
with the joint statement of the British Geriatrics Society and the Association
Directors of Social Services [43] (grade III).

Communication with all parties involved in the patients care is vital.

Prior to discharge it is useful to assess the patients cognitive and
functional status ( eg using standardised tools such as AMT and Barthel
Index).
Discharge summaries should be completed promptly.

Follow up
Delirium is a common first presentation of an underlying dementing process. It may
also be a marker of severe illness and comorbidity. It is therefore often appropriate
to refer the patient to a Geriatrician, Psychiatrist of Old Age, CPN or Social Worker
for the Elderly or Consultant in Geriatric Medicine for further assessment and follow
up.

10
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11
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13
Index
A
Acknowledgements
Algorithm

Abbreviated
Test score
3
1

Mental

Appendix 2
Assessment
B, C

4
Causes
3
3
8

Cognitive tests
Complications
Continence
CT scans
D

8
5
Definitions
2

Dementia
Depression
Diagnosis
Differential diagnosis
Aids to diagnosis
Diagnostic criteria
Discharge
Drugs...
causing delirium
treatment of delirium
E

3
3
2
3
2
2
9
Appendix 1
7
EEG
5

Examination
F

4
Falls
8

Follow-up
Functional impairment
G
H
I
Investigations
J, K
L
M
Multidisciplinary team
N, O
P, Q
Prevention
R
References
Rehabilitation
Restraints
Risk factors

9
8
Grade of evidence
1
History
4
Incontinence
8
5
Lumbar puncture
6
Management
of
confusion
6,
7
6,8,9
Old age psychiatry
8
Pressure sores
8
3,6
Reality Orientation
6
10
8
6,8
3

Sedation
7
7

indications
types
Summary of guidelines

7
Appendix 3
Treatment
6
6
6,7
Underlying cause
4
Wandering
8

T
underlying cause
confusion
U, V
W
XYZ
14
Appendix 1
DRUG TYPE

EXAMPLES

RISK

COMMENTS

Benzodiazepines

Diazepam, Temazepam
Chlordiazepoxide

HIGH

Benzodiazepine withdrawal is also a common

cause of delirium

Antidepressants

Amitriptyline
Doxepin, Trazadone

HIGH

Risk greatest in drugs with anticholinergic and

sedative effects

Antiparkinsonian drugs

Levodopa
Bromocriptine
Selegeline
Benzhexol
Orphenadrine
Pergolide

HIGH

All have anticholinergic or dopaminergie effects,

which can cause confusion

Analgesics

NSAIDs
Opiates
Aspirin

HIGH

All analgesics (except paracetamol) can cause

confusion. Of the NSAIDs indomethacin is most
likely to cause delirium. Confusion due to aspairin
is dose related. Opiates have a very high risk of
causing confusion

Lithium

HIGH

Steroids

HIGH

Antihypertensive
medications

Risk may be dose related

Methyl Dopa
-Blockers
-Blockers
ACE Inhibitors
CA-Channel Blockers
Diuretics

HIGH
MEDIUM

Antiarrhythmics

Digoxin
Amiodarone
Disopyramide
Lignocaine

MEDIUM

Lignocaine has highest risk

Risk with digoxin is dose related

Major tranquillizers

Chlorpromazine
Thioridazine
Trifluoperazine
Haloperidol
Droperidol

MEDIUM

Sedating drugs, with anticholinergic effects (e.g.

Chlorpromazine) have higher risk than nonsedating drugs such as haloperidol

Anticonvulsants

Primidone
Phenytoin
Carbamazepine
Valproate

LOW

Risk highest with primidone

Lowest risk with valproate and carbamazepine
Risk with phenytoin may be dose related

Anticholinergic drugs
Antihistamines
Antispasmodics

Chlorpheniramine
Atropine

MEDIUM

Drugs in this group are often bought over the

counter

Histamine blockers

Cimetidine
Ranitidine, Famotidine

LOW

Cimetidine may be more likely to cause confusion

than the other drugs in this group

Antibiotics

Benzyl Penicillin
Co-Trimoxazole
Amphotericin
Antituberculous Drugs
Rifampicin

LOW

Although delirium has been attributed to most

antibiotics
Most cases of confusion occurring during
antibiotic treatment are likely to be due to the

LOW

LOW

MEDIUM

Diuretics may lead to delirium by causing

electrolyte disturbances

Isoniazid
Antiparasitic Drugs
Meppacrine
Chloroquine, Quinine
Antiviral Drugs
Amantadine
Acyclovir, Zidovudine

infection rather than the treatment

Respiratory drugs

Aminophylline

LOW

May cause dose related confusion

Oral hypoglycaemic
agents

Tolbutamide
Glibenclamide

UNCERTAIN

These drugs may cause hypoglycaemia and

hyponatraemia, both of which can cause delirium

Antineoplasstic drugs

Methotrexate, Vinca
Alkaloids, Fluorouracil,
Altretamine, Asparginase,
Procarbazine, Carmustine,
Dacabazine, Interferon-

UNCERTAIN

Delirium frequently occurs in malignant disease,

therefore it is difficult to attribute the confusion to
the drugs. However the drugs listed have been
associated with confusion more often than others

Appendix 2
Guidelines for the diagnosis and management of delirium
AMT

<8/10

>8/10

Delirium unlikely
Consider other diagnosis
e.g. dementia or depression

Possible delirium

Is there a change from the usual mental

state?
YES

NO

Delirium
Identify underlying cause (or causes)
History
Examination
Investigations

Infection

Drugs

Other
Cardiac
Endocrine, Metabolic

Cultures
Urinalysis
FBC,ESR
CXR

Review all drug

treatment

U&E
LFT,TFT,Glucose
ECG
Other tests (see guidelines)

Empirical Treatment

Discontinue likely drugs

Treat any causes found

Improving

Worsening

Continue

Review Diagnosis

Avoid sedatives
Monitor
Avoid restraints
with AMT
Use reality orientation
Avoid complications
Multidisciplinary
Follow updischarge

Ensure good communication

withexpert
patient,help
carers and
Seek
otherwill
professionals
Expert
depend
on local availability, but may
(See below)
at all timesin Old Age Psychiatry or Geriatric
include Consultant

Appendix 3
Summary of Carlisle guidelines for management of delirium

The
featur
es of
deliriu
m
accor
ding
to
DSM
IV
are:

In all stages during the hospital admission, ensure good communication with

1.

Disturbance of consciousness (i.e. reduced clarity of

awareness of the
the patient and carer: and between professionals caring for the patient.

environment) with reduced ability to focus,

sustain or shift attention.

1.

2.

Identification of delirium using established diagnostic criteria (see over).

2.
A change in cognition (such as memory deficit,
disorientation, language
disturbance) or the development of a perceptual disturbance that is not better
accounted for by a pre-existing or evolving dementia.
Recognition of delirium can be increased by the routine assessment of cognitive
state, e.g. using the AMT (see over). Repeated use of the AMT may help to
determine recovery or onset of delirium in those not delirious on admission.

3.
This information may need to be clarified with the carer.

4.

3.
The disturbance develops over a short period of time (usually
hours to days) and
Tends to fluctuate during the course of the day.
Assessment of patients pre-admission cognitive, functional and social
status.
4.
There is evidence from the history,
physical examination, or laboratory
findings
that
the
disturbance is caused by the direct physiological
Consequences of a general medical condition, substance intoxication
or substance withdrawal

Identification of risk factors such as dementia, severe illness, sensory

impairments, alcohol use.
Abbreviated Mental Test Score (AMT)

5.

Identification of underlying cause (commonly infection or drugs).

1.
Age
Treatment of underlying cause or removal of offending drugs
2.
Time (to nearest hour)

6.
7.

Avoidance of physician restraints.

3.

8.

Avoidance of major tranquillizers, where possible, but if necessary use only one
drug and in the lowest dose possible (e.g. haloperidol 0.5mg orally up to QS).
Review drug treatment regularly.

9.

Multi-disciplinary team involvement in treatment and discharge planning.

10.

Create optimum environment for care (e.g. single room, good lighting).

11.

Use reality orientation techniques and rehabilative care models.

12.

Ensure adequate discharge and follow-up to avoid unnecessary readmission

and to provide support to patient and carers.

Address for recall at end of test (42

West St)
4.

Year

5.

Name of hospital

6.

Recognition of 2 persons (e.g. doctor, nurse)

7.

Date of birth

8.

Year of 1st World War

9.

10.

Count 20-1

Name of present monarch