People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Be aware that people in hospital or long-term care may be at risk of delirium. This can have serious consequences (such as increased risk of dementia and/or death) and, for people in hospital, may increase their length of stay in hospital and their risk of new admission to long-term care. For recommendations on managing delirium in palliative care, see the NICE guideline on care of dying adults in the last days of life. [2010]
When people first present to hospital or long-term care, assess them for the following risk factors. If any of these risk factors are 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 the section on 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). [2010]
Observe people at every opportunity for any changes in the risk factors for delirium. [2010]
At presentation, assess people at risk for recent (within hours or days) changes or fluctuations that may indicate delirium. These may be reported by the person at risk, or a carer or relative. These 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, difficulty engaging with or following requests, withdrawal, or alterations in communication, mood and/or attitude.
If any of these changes are present, the person should have an assessment (see recommendation 1.6.1). [2010, amended 2023]
Be particularly vigilant for changes that may indicate hypoactive delirium, which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite. [2010]
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. [2010]
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 1.4.4 to 1.4.13. [2010]
The tailored multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention. [2010]
Address cognitive impairment and/or disorientation by:
providing appropriate lighting and clear signage; a clock (consider providing a 24-hour clock in critical care) and a calendar should also be easily visible to the person at risk
talking to the person to reorientate them by explaining where they are, who they are and what your role is
introducing cognitively stimulating activities (for example, reminiscence)
facilitating regular visits from family and friends. [2010]
Address dehydration and/or constipation by:
ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink; consider offering subcutaneous or intravenous fluids if necessary
taking advice if necessary, when managing fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease). [2010]
Assess for hypoxia and optimise oxygen saturation if necessary, as clinically appropriate.
Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes. [2010]
Address infection by:
looking for and treating infection
avoiding unnecessary catheterisation
implementing infection control procedures in line with the NICE guideline on healthcare-associated infections. [2010]
Address immobility or limited mobility through the following actions:
Encourage people to:
mobilise soon after surgery
walk (provide appropriate walking aids if needed; these should be accessible at all times).
Encourage all people, including those unable to walk, to carry out active range-of-motion exercises. [2010]
Address pain by:
assessing for pain
looking for non-verbal signs of pain, particularly in those with communication difficulties (for example, people with learning difficulties or dementia, or people on a ventilator or who have a tracheostomy)
starting and reviewing appropriate pain management in any person in whom pain is identified or suspected. [2010]
Carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications. For information on medicines optimisation see the NICE guideline on medicines optimisation. [2010]
Address poor nutrition by:
following the advice given on nutrition in the NICE guideline on nutrition support for adults
if people have dentures, ensuring they fit properly. [2010]
Address sensory impairment by:
resolving any reversible cause of the impairment, such as impacted ear wax
ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order. [2010]
Promote good sleep patterns and sleep hygiene by:
avoiding nursing or medical procedures during sleeping hours, if possible
scheduling medication rounds to avoid disturbing sleep
reducing noise to a minimum during sleep periods. [2010]
Observe, at least daily, all people in hospital or long-term care for recent (within hours or days) changes or fluctuations indicating delirium (for example, see recommendation 1.3.1). These may be reported by the person at risk, or a carer or relative. If any of these changes are present the person should have an assessment using an appropriate tool (see recommendation 1.6.1). [2010, amended 2023]
Ensure that any changes that may indicate delirium are documented in the person's record or notes. [2023]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on indicators of delirium: daily observations.
Full details of the evidence and the committee's discussion are in evidence review A: diagnostic accuracy of tests to identify delirium.
If indicators of delirium are identified, a health or social care practitioner who is competent to do so should carry out an assessment using the 4AT. In critical care or in the recovery room after surgery use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) instead of the 4AT. [2023]
If the assessment described in recommendation 1.6.1 indicates delirium, a healthcare professional with the relevant expertise should make the final diagnosis. This could be the same person who made the assessment. [2023]
If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, manage the delirium first. [2010]
Ensure that the diagnosis of delirium is documented both in the person's record or notes, and in their primary care health record. [2010]
For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on assessment and diagnosis.
Full details of the evidence and the committee's discussion are in evidence review A: diagnostic accuracy of tests to identify delirium.
In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes. [2010]
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 1.4.1 in the section on preventing delirium). [2010]
If a person with delirium is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. For more information on de-escalation techniques, see the NICE guideline on violence and aggression. Distress may be less evident in people with hypoactive delirium, who can still become distressed by, for example, psychotic symptoms. [2010]
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 haloperidol (usually for 1 week or less). Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms. Take into account the Medicines and Healthcare products Regulatory Agency's advice about the risks of using haloperidol for the acute treatment of delirium in older people, including the risks of cardiac and neurological side effects (especially in people living with Parkinson's disease or dementia with Lewy bodies). [2010]
For people in whom delirium does not resolve:
re-evaluate for underlying causes
follow up and assess for possible dementia (see the NICE guideline on dementia). [2010]
Offer information to people who are at risk of delirium or who have delirium, and their family and/or carers, which:
informs them that delirium is common and usually temporary
describes people's experience of delirium
encourages people at risk and their families and/or carers to tell their healthcare team about any sudden changes or fluctuations in behaviour
encourages the person who has had delirium to share their experience of delirium with the healthcare professional during recovery
advises the person of any support groups. [2010]
Ensure that information provided meets the cultural, cognitive and language needs of the person. [2010]
This section defines terms that have been used in a particular way for this guideline.
Health and social care staff across the wider care team. This could include registered nurses and care workers (also called care assistants or support workers), social workers, therapists, case managers, GPs, lead clinicians, community nurses and allied professionals, such as physiotherapists, occupational therapists and dietitians.
Health professionals regulated or licensed with a professional body to provide care and support, for example, generalist and specialist doctors registered with the General Medical Council, and nurses registered with the Nursing and Midwifery Council.
A subtype of delirium characterised by people who have heightened arousal and can be restless, agitated or aggressive.
A subtype of delirium characterised by people who become withdrawn, quiet and sleepy.
Residential care in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes.