1. Distress and agitation are different

Distress is the person’s experience of suffering. It may include fear, anxiety, helplessness, loneliness, anger, shame, pain, a sense of being trapped, or frightening hallucinations and delusional beliefs. Delirium can also make it difficult to understand where they are, why care is being given and whether other people can be trusted.

Agitation describes observable increased motor or verbal activity, such as pacing, repeated calling out or pulling at equipment. It may accompany distress, but motor activity alone does not establish whether distress is present or how severe it is. Refusal of care and purposeful walking are not, by themselves, agitation; assess the person’s communication, purpose and circumstances. A person may be quiet or drowsy yet frightened or in pain.

Behaviour is not a diagnosis. Describe what happened rather than using terms such as “difficult”, “combative” or “non-compliant”. “Pulled twice at the cannula and said, ‘Let me out'” is more useful than “agitated” because it helps the next clinician assess risk, possible meaning and change over time.

Qualitative studies conducted after the acute episode describe distress for patients and relatives. Recall can be incomplete or selective, and these studies do not establish one prevalence figure for all settings or presentations (Lange et al. 2022; Meyer et al. 2023).

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2. Ask about distress

Begin with the person whenever communication is possible. Explain why you are asking and use short questions, one at a time:

• “How are you feeling?”
• “Is anything bothering you?”
• “Are you in pain?”
• “Are you frightened?”
• “Do you feel safe here?”
• “Are you seeing or hearing anything unusual?”
• “Do you need the toilet, a drink or something else?”
• “Would you like me to contact someone you know?”

Adapt the language and response format. A person with severe inattention, difficulty using or understanding language, or hearing impairment may answer simple yes-or-no questions or communicate by gesture, pointing or pictures. Some people will not be able to give a verbal answer at that time; do not force a response. If there is no shared language, use a professional interpreter where available and follow local policy. Check that glasses and hearing aids are available and working. Pause an interview that is adding to distress without clinical benefit.

Look for facial tension, tears, guardedness, scanning the room, withdrawal, repeated attempts to move away, restlessness or a change during examination or personal care. These signs are not specific, so interpret them alongside the clinical assessment and what is known about the person. Ask family, carers or familiar staff what the person is usually like, how they show pain or fear, what reassures them, and whether the present response is new.

An exploratory research rating: the QDAT

A 2025 single-centre study used a study-specific distress rating alongside repeated 4AT assessments. It suggests that distress may be common, but the rating is not validated for clinical use and the findings are not prevalence estimates (McCartney et al. 2025).

Distress can fluctuate, as delirium does. Reassess after an intervention and when the person’s behaviour, alertness, surroundings or care needs change.

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3. Find what is driving it

Distress often has more than one contributor. Check for urgent illness and physiological disturbance first, then consider what may be uncomfortable, frightening or difficult to understand for this person.

Physical illness and unmet needs

• Acute illness, hypoxia, hypotension or another cause of clinical deterioration.
• Pain, including pain during movement, examination or personal care.
• Urinary retention, constipation or need for the toilet.
• Breathlessness, thirst, hunger, dehydration, dry mouth or temperature discomfort.
• Medication effects, recent medication changes or omitted usual medication. If withdrawal is possible, use the relevant specialist pathway.
• Immobility, an uncomfortable position, invasive equipment or an unfamiliar device.
• Sleep disruption.

Perception, emotion and communication

• Hallucinations, delusional interpretations or vivid dream-like experiences.
• Disorientation and inability to make sense of care.
• Fear of injury, imprisonment, abandonment or death.
• Difficulty expressing a need or understanding what staff are saying.
• Loss of control, privacy or dignity, or separation from familiar people and routines.

Sensory and environmental factors

• Missing or ineffective glasses and hearing aids.
• Noise, alarms, glare, darkness or crowding.
• Several people speaking or touching the person at once.
• Repeated ward moves, unfamiliar staff or lack of daytime cues.
• Care being started without explanation.

Treat what is found. Simple needs should not wait for the whole medical assessment to finish. Analgesia, bladder care, a hearing aid, a quieter space or a clear explanation may be needed while investigation and treatment of the delirium continue.

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4. Respond therapeutically

Therapeutic engagement means using ordinary clinical contact with the aim of reducing perceived threat, understanding the person and making care more tolerable. Qualitative studies report that people valued patience, kindness, explanation, familiar contact and some control over what happened. Evidence for a specific therapeutic engagement package is still limited, so it should not be presented as a treatment proven to shorten delirium (MacLullich et al. 2022).

Practical measures include:

• Reduce noise, crowding and unnecessary stimulation.
• Ask one calm staff member to lead communication where possible.
• Approach within the person’s field of vision and allow personal space.
• Introduce yourself and explain where the person is and what is happening.
• Explain before touching, examining or moving the person.
• Use short, concrete sentences and allow time for a response.
• Repeat information patiently, without testing the person’s memory.
• Offer small, genuine choices, such as which arm to use for observations.
• Use familiar conversation, music, photographs or activity if the person finds these helpful.
• Involve a familiar person when this reduces rather than increases distress.

When a person expresses a frightening belief, acknowledge the emotion without confirming the belief or entering an argument. For example:

Offer orientation as information, not as repeated correction. “It is Tuesday morning and you are in the medical ward” is usually kinder and clearer than repeatedly asking the person to state the date and place. If an explanation increases fear or suspicion, pause and try another approach.

Ask the person who they want involved where possible, and respect their preferences and confidentiality. Family or carers may provide baseline information, preferred forms of address, language needs, signs of pain, routines and known sources of comfort. They may also bring glasses, hearing aids or familiar objects and take part in ordinary conversation. Explain the purpose and do not transfer clinical responsibility to them.

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5. Manage risk with the least restrictive care

Assess risk dynamically. A person who is walking towards a door, pulling at a cannula or refusing care may be responding to fear, discomfort or a perceived need. Establish what the person is trying to do, check for immediate danger, and address the likely reason while protecting them and others.

If serious harm is imminent, summon appropriate help and use the least restrictive response that can keep people safe. Continue verbal and non-verbal de-escalation. Restrictive measures should be proportionate, last for the shortest possible time, and be accompanied by frequent monitoring and repeated reassessment. The 2025 American Psychiatric Association guideline recommends that physical restraint should not be used except when injury to the person or others is imminent, after reviewing factors that may contribute to racial, ethnic or other biases in restraint decisions, and with frequent monitoring and repeated risk-benefit assessment against less restrictive alternatives. This is a strong recommendation with a low-confidence evidence rating (1C), reflecting limited direct evidence and expert consensus (Crone et al. 2025).

Antipsychotics and sedatives used for neuropsychiatric disturbance do not treat delirium as a syndrome and should not be used simply because delirium, confusion or agitation is present. The 2025 American Psychiatric Association guideline recommends medication, including an antipsychotic, only when all of the following apply:

1. Verbal and non-verbal de-escalation has been ineffective.
2. Contributing factors have been assessed and, as far as possible, addressed.
3. The disturbance is causing significant distress or a risk of physical harm.

NICE similarly advises verbal and non-verbal de-escalation first. If this is ineffective or inappropriate and the person remains distressed or is considered a risk to themselves or others, NICE advises considering short-term haloperidol, usually for one week or less, starting at the lowest clinically appropriate dose and adjusting the dose cautiously according to symptoms.

Follow local prescribing guidance and check contraindications and interactions. In UK practice, MHRA advice for older people states that haloperidol is contraindicated in Parkinson’s disease and dementia with Lewy bodies. Before treatment, a baseline electrocardiogram and correction of electrolyte disturbance are recommended; repeat cardiac and electrolyte monitoring during treatment. Use the lowest possible dose for the shortest possible time and monitor for cardiac effects, movement-related (extrapyramidal) adverse effects, swallowing difficulty, dizziness on standing (orthostatic hypotension) and falls.

Benzodiazepines should not be used routinely for delirium; they require a specific indication. If relevant withdrawal is suspected, activate the appropriate specialist pathway. Its management is outside this module’s scope.

Role boundary: prescribing and restrictive interventions are for appropriately trained and authorised staff. Follow local escalation routes and work within your role.

Record the indication, measures already tried, expected benefit, monitoring plan, review time and stopping plan whenever medication or a restrictive intervention is used.

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7. Review, record and support recovery

Review the person’s response rather than recording only that they are “settled”. Ask again about pain, fear and safety. Repeat relevant clinical observations. Check whether distress has changed, which intervention preceded the change, and whether a new problem has appeared.

Document:

• The person’s own words where possible.
• The exact behaviour and context rather than a label alone.
• Non-verbal signs and communication limitations.
• Urgent risks and possible contributors assessed.
• What was found and treated.
• Therapeutic and de-escalation measures tried.
• The person’s response and the time of review.
• Information from and communication with family or carers.
• Any medication or restrictive intervention, with its indication, monitoring, review and stopping plan.

During recovery, explain to the person and family that delirium can cause frightening experiences and that recall varies. Offer the person an opportunity to discuss what they remember, without pressing for an account. Check for continuing anxiety, sleep disturbance, frightening memories or fear of recurrence.

When the person transfers to another care setting, the follow-up plan should cover persistent delirium, medication review, assessment for possible effects such as cognitive difficulty or post-traumatic symptoms, and clear information about delirium for the person and their family members or carers.

Recovery time varies. Avoid promising that distress or delirium will resolve within a fixed number of days. If delirium or distress persists, review possible causes, medication, communication needs and the care environment again. Arrange follow-up with a named member of the local clinical team or the person’s primary care clinician, including when the review should occur.

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