Communication in delirium care

Someone with delirium may lose track of a sentence, misunderstand touch or struggle to answer. Approach within their field of vision. Say your name and role. Use their preferred name. Check hearing aids, glasses, preferred language and communication aids. Reduce competing conversation and allow time for a response.

“Hello, Mrs Ali. I'm Jo, your nurse this morning.”

Pause. Give the next piece of information only when the person is ready.

“I'd like to check whether you're comfortable.”

Use ordinary adult language. A short sentence can still be respectful. Ask one question at a time. Offer a small, genuine choice if appropriate. A yes-or-no answer, pointing or a gesture may be easier than a detailed explanation. Check that you have understood the response. Ask how the person usually shows yes, no, discomfort and a wish to stop. Use their usual communication aid where possible. Do not assume that a nod or silence means agreement.

“I think you are saying you want me to stop. Have I understood?”

“Are you sore anywhere? You can point.”

Some people are too drowsy or inattentive to answer. Continue to explain care, observe their response and seek clinical assessment. Lack of an answer does not establish lack of understanding, absence of pain or lack of capacity. New difficulty waking someone needs immediate escalation.

Arrange a professional interpreter when needed, including a British Sign Language interpreter. Speak to the person directly, use one short turn at a time and allow the interpreter to finish. Relatives can explain usual preferences and communication, but should not routinely replace an interpreter for clinical decisions. Seek speech and language therapy advice when communication remains difficult. Record successful approaches for the next staff member.

Explain before touching and ask permission. Touch that reassures one person may frighten another.

“May I help you move your arm?”

In a formal assessment such as the 4AT, follow the tool's wording and instructions. The conversational examples in this module do not replace assessment items or scoring rules.

Use diagnostic language that matches the assessment. A support worker can describe the change and call the nurse. The responsible clinician can explain a suspected or established diagnosis.

When delirium is suspected

“This sudden change may be delirium. We need to assess what has caused it.”

When delirium has been diagnosed

“You have delirium. Your illness has affected your attention and thinking. We are treating the problems we have found.”

For a family conversation, ask what they have noticed and understood before adding detail. Explain that delirium can include drowsiness, reduced communication, restlessness or frightening experiences. The symptoms can change during the day. Describe the person's actual presentation rather than reciting every possible symptom.

“Your mother is much sleepier and finds it harder to follow a conversation. That change is part of her delirium. We are checking how she is responding to treatment.”

Explain known contributors and remaining uncertainty separately. Name the actual next action. Avoid implying that an infection explains every symptom or that completing antibiotics guarantees recovery.

“We have found a chest infection. We are treating it and checking for other problems that could be contributing.”

Repeat the explanation when needed and offer written information. Later, when attention allows, invite the person to tell you what they have understood. Take responsibility for making the explanation clear. Repeated testing during severe inattention can cause frustration.

“I've given you a lot of information. What would you like me to go over again?”

For a relative or someone able to take part in a longer discussion:

“To check that I explained the plan clearly, could you tell me what you understand will happen next?”

The approach follows NICE delirium guidance and NICE guidance on sharing information and checking understanding.

First check immediate danger, acute deterioration and unmet needs. Pain, urinary retention, breathlessness, noise or an unexplained procedure may be contributing. One calm person speaking is usually easier to follow than several people giving instructions.

A frightening perception

“That sounds frightening. I don't see someone there. I'm here with you now.”

Then ask what would help or offer a concrete action. Acknowledge distress without arguing or confirming a frightening belief. Repeated correction may increase distress. Check the surroundings: a shadow, unfamiliar equipment or a real event may explain part of the concern.

A report of harm

“Thank you for telling me. Please tell me what happened. I'll get help to check your concern.”

Delirium does not make every allegation untrue. Record the person's words, assess immediate safety and follow the safeguarding or incident route for the concern. Do not put an allegation into the record as a delusion merely because delirium is present.

Care is being refused

“You don't want me to do that. Tell me what is worrying you.”

Pause non-urgent care if safe. Explain its purpose, check pain or fear and offer a real alternative. Seek the responsible clinician's review when refusal creates a clinical risk. Neither delirium nor refusal alone establishes incapacity. Respect a valid refusal. When a non-urgent decision can safely wait and capacity may improve, consider postponing it. Support communication and assess the specific decision under the applicable legal framework. A relative's presence does not automatically give them authority to consent.

The person wants to leave

“You want to go home. Can you tell me what you need to do there?”

Listen, check risk and ask the team to review the situation. Avoid threats, bargaining about access to family or promises about discharge that have not been agreed. If serious harm is imminent, summon immediate help through the local emergency route.

For Scottish practice, use the Adults with Incapacity medical treatment code. This module teaches communication; it does not confer authority to treat or restrict a person.

Ask the patient who they want involved where possible. Respect a wish not to involve family, and consider another trusted person or an advocate. Use their preferred relationships and names. When the patient is present, speak to them first and include them throughout. Avoid talking about them as though they are absent. Ask about individual preferences for care and information without making assumptions about culture or religion. Check identity and privacy before a telephone update. Follow consent and confidentiality requirements. Staff can listen to information from a relative even when the information they may share in return is limited.

“What is your father usually like when he is well? When did you first notice this change?”

Ask about usual thinking, communication, daily activities and support. Establish the last time the person was at their usual level. Attribute the account in the record. Ask what helps the person feel comfortable and what tends to upset them.

“Would you like to help with a short visit or a familiar activity? It is also useful to tell us what you have noticed.”

Offer choices. A family may live far away, be unwell or have other responsibilities. Some relationships are difficult or unsafe. A visit or phone call may help, do little or increase distress. Review the person's response. The care team remains responsible for care. Ask how the relative is coping and offer appropriate support if wanted.

“Please tell us what you can manage. The ward team remains responsible for care while they are in hospital.”

When relatives are worried that a change has been dismissed:

“You know that this is different. I'll pass on the change now and arrange for the team to review it.”

Only promise a review or update you can arrange. If the first request receives no response and concern remains, escalate through the local clinical route. Give a named contact or role and a realistic update time. Do not require the family to repeat the whole history at every handover.

If no relative or friend is available, seek relevant information from existing records, care staff or other appropriate contacts. Provide communication support and consider advocacy through local services. A person without family still needs explanation, reassurance and follow-up.

Words patients and families can use

“This is different from how I usually am. Please ask someone to assess the change.”

“This is a new change from yesterday. Who will review it, and when?”

“Please explain one thing at a time. I need longer to understand.”

“I can help with [task], but I am unable to provide [task or hours]. What other support can be arranged?”

“Please write down who to contact and what happens next.”

People may be unable to ask these questions during delirium. Staff remain responsible for noticing changes, explaining care and arranging help. The Delirium Support downloads include Telling the team and Raising concerns with staff.

An explanation needs both uncertainty and a plan. Delirium may continue for weeks or months. Improvement can be uneven, and some people have continuing difficulties. A treated trigger does not prove that delirium has resolved. Reassess possible contributors and the diagnosis when symptoms persist or change.

Opening the conversation

“The delirium is still affecting your attention and thinking. We will review what could be contributing and what help you need.”

Explaining the outlook

“Delirium can take time to improve. We will keep checking for problems we can treat and what help you need now.”

When discussing prognosis:

“I don't yet know how much you will improve. At [review time], we will discuss what has changed and the next plan.”

Describe improvement that has actually been observed and acknowledge worry if progress has been limited. Complete the review arrangement before using it.

Pause and ask what the person or family most wants to understand. Discuss the changes observed in this person and the next review. Avoid setting a recovery deadline or presenting every difficult day as expected fluctuation.

“Yesterday you followed more of the conversation. Today you are sleepier. We need to check that change.”

A question about dementia

“Delirium and dementia can occur together. The sudden change needs assessment. We will review ongoing memory and thinking difficulties as your condition develops.”

Do not diagnose dementia from a delirium assessment score alone. There is no single waiting period that is suitable for every person. Arrange assessment and follow-up according to the clinical situation, rather than promising that all difficulty will resolve or postponing review indefinitely.

Frightening memories during recovery

“Some people remember frightening things from when they were unwell. Would you like to talk about anything you remember?”

Respect a wish to stop or leave the discussion for another day. Offer an explanation of known events. Do not tell someone that everything they remember was imaginary. Ask about continuing distress, sleep difficulties and effects on daily life, and arrange appropriate review.

When the person is very seriously ill or dying

“They are very unwell. We are checking what could be causing discomfort and treating what we can. We also want to understand what is most important to them and to you.”

A senior clinician should explain prognosis and agreed goals of care. Avoid saying delirium always reverses or always means a person is dying. Follow the relevant palliative care pathway. This brief conversation does not replace specialist end of life assessment.

See SIGN delirium guidance, NICE delirium guidance and NICE care in the last days of life.

Speaking with colleagues

When handing over, identify the person and yourself, describe the change, and state what needs to happen next. Use the relevant identifiers and current observations required by your local handover process. Speak discreetly. Include the patient where appropriate and avoid discussing them as though they are absent.

These are short teaching examples. Replace the names and details with the actual findings. They are openings for a conversation; give the additional clinical information the receiving colleague needs.

1. At a shift change

“Mrs Grant still has delirium. She is more alert than yesterday but loses track of conversation. Her daughter says she usually manages her own medicines. She needs help with drinks and one instruction at a time. The medical team will review her this morning. Please hand over any new change straight away.”

Add the current observations, treatment, outstanding tasks and named staff responsible. Do not describe someone simply as “confused”.

2. Reporting a new change to the nurse or doctor

“I'm concerned about Mr Reid. At breakfast he was talking as usual. Since ten o'clock he has said very little and keeps losing track of what I'm asking. This is a new change. Can you assess him now?”

Give the current observations and any other symptoms, if available. Assessment should not wait until a full set of observations or a delirium score has been obtained.

3. Calling for immediate help

“I need emergency help at [precise location]. Mrs Ali is newly difficult to wake. She was speaking to me earlier.”

Use the local emergency response immediately. Follow the responder's instructions and provide observations as available. Do not delay the call to complete a longer handover.

4. When the first request has not led to a review

“I reported this change at ten o'clock. Mr Reid has not yet been assessed and I remain concerned. Who can review him now? If you are unable to come, I will contact the next clinician through our escalation route.”

Escalate according to urgency. A message left or a referral sent does not establish that someone has accepted responsibility.

5. Passing on an approach that helps

“Mrs Ali became frightened when several of us spoke at once. She followed better when one person spoke from in front of her, with her hearing aids in. Please explain before touching her and pause after each sentence. If she pulls away, stop when safe and check what is troubling her.”

Describe what happened and what helped. Avoid labels such as “difficult” or “uncooperative”. Record successful approaches for colleagues on later shifts.

6. Raising a concern at the team meeting

“Mr Brown walked to the bathroom with me, but he needed repeated prompts to use his frame. His attention still fluctuates. Before we agree discharge, can we review what help he needs between visits and overnight? His daughter has said she is unable to stay.”

A successful task during one assessment may not represent what the person can manage throughout the day. Ask the relevant team members to agree a feasible plan with the person and carers.

7. Handover to a ward or care home receiving the person

“I'm calling about Mrs Grant's planned transfer. Her delirium has improved but is still present. She needs [specific support], including [needs overnight]. The written handover includes her current assessment, medicine changes and review plan. Can your team provide this support from arrival? Is there anything we need to resolve before she moves?”

Confirm the receiving team's actual arrangements. A document sent does not establish that the destination can provide the required care.

8. Agreeing who will follow up an outstanding action

“The referral to [service] was sent today, but the review is not confirmed. We need an agreed time for [specific assessment]. Who will check the referral has been received and arrange the next step? Let's record the responsible person and deadline in the handover.”

Use the same approach for outstanding results and medicine reviews. Set the urgency from the clinical situation. Resolve any outstanding action that is essential for safe discharge before transfer.

9. The receiving colleague confirms the plan

“I'll assess Mr Reid now and update you afterwards. Please use the emergency response immediately if he becomes difficult to wake or develops another emergency sign. Who should I contact when I've seen him?”

The person receiving the handover should confirm the action and timing, ask about missing information, and explain any delay. Record the agreed plan and escalate again if the response is inadequate or the person deteriorates.

Planning discharge

Before discharge or transfer, explain whether delirium is resolved, still present or suspected. Describe its duration and recent course separately: persistent delirium may also be improving. Give the date and basis of the latest assessment. Describe current thinking, communication, mobility and everyday support needs. A brief fluent conversation alone does not establish recovery.

“Your delirium has improved, but you still need help with medicines and meals. Let's go through the support arranged and what to do if things change.”

Use that wording only if it fits the assessment. Discharge with persistent delirium needs an individual plan that is feasible in the destination setting. Establish what the person and carers can manage, including between care visits. Do not assume that living with someone means sufficient support is available.

The written handover should include:

• The diagnosis or diagnostic uncertainty, usual baseline and current state, with dates and sources of information.
• Contributors identified, treatment given and remaining questions.
• Communication needs, what helps, distress or safety concerns and relevant decision-specific capacity findings.
• Medicine changes with reasons, monitoring, review and stopping arrangements where relevant.
• Support actually arranged, outstanding results or referrals, the responsible service and review dates.
• What the patient and family have been told, information supplied and the plan for seeking help.

Avoid an instruction such as “GP to follow up” without stating the problem, urgency and action requested. Distinguish a referral sent from an appointment confirmed. Send the information to the services providing care. Check that urgent requests have been received. Check that the receiving service has the information and resources needed for the agreed care, including medicines and communication support. Resolve gaps that would make transfer unsafe before the person moves. Check that the person can use the contact plan. If they need an accessible contact method or another person or service to help, confirm that arrangement.

“The review with [service] is [confirmed for date / requested but not yet confirmed]. If you have not heard by [date], contact [number].”

Complete every bracket and check the details before giving this wording to someone. Do not ask the family to act as the only route for a clinical handover.

Explain what warrants urgent help using the local pathway. In hospital, call staff immediately and use the hospital emergency response for acute deterioration. New sudden confusion at home or in a care home needs urgent medical assessment. Call the local emergency number immediately for severe breathing difficulty, new stroke symptoms, collapse or new difficulty waking the person. Tell care staff as well. Do not delay emergency help while trying to find a particular staff member. Give the person a written contact plan appropriate to their location and needs.

Use the downloadable discharge templates below. The Delirium Support family pack provides information to discuss and leave with the person and family.