Acute Confusion / Delirium

1 · Recognise & assess

Collateral history essential — how is this different from baseline? CAM (Confusion Assessment Method): acute onset + fluctuating + inattention + disorganised thinking/altered consciousness = delirium. 4AT score ≥4 = probable delirium. Check baseline cognitive function (AMTS).

2 · PINCH ME causes

• P – Pain (uncontrolled)
• I – Infection (urine, chest, wound, line)
• N – Nutrition (dehydration, low Na/glucose)
• C – Constipation/urinary retention
• H – Haematological (anaemia, polycythaemia)
• M – Medication (opioids, benzodiazepines, anticholinergics, steroids, new drugs)
• E – Environment (unfamiliar, darkness, immobility, sensory aids missing)

3 · Investigations

BM (hypoglycaemia). Bloods: FBC, CRP, U&E (Na, K, Cr), LFTs, Ca2+, TFTs, blood cultures. Urine dip + MC&S. 12-lead ECG. CXR. Consider CT head if: head injury, focal neurology, anticoagulated, first episode, or no clear cause found.

4 · Non-pharmacological management

This is the mainstay. Quiet environment, single room if possible. Reorientate regularly (clock, calendar, familiar faces). Restore sleep-wake cycle — avoid sedation during day. Ensure glasses and hearing aids. Encourage mobility. Address pain. Involve family.

5 · Pharmacological management

Avoid sedation if possible — increases falls and prolongs delirium. If patient is a danger to themselves/others: haloperidol 0.5–1mg oral/IM (not in Parkinson's — use quetiapine). Lorazepam 0.5–1mg if seizures or alcohol withdrawal. Never use benzodiazepines in non-alcohol-withdrawal delirium as first line.

6 · Escalation thresholds

Delirium with: hypoxia, haemodynamic instability, fever >38.5, focal neurology, post-ictal state → senior review and likely ITU/specialist input. All delirious patients need falls risk assessment and pressure ulcer prevention. Document Mental Capacity Act assessment if consent needed for treatment.