EXAMPLE CASE 01 · BASIC · Care home
Less conversation at breakfast
Mrs Malik, 82, lives in a care home. She usually talks with staff while eating breakfast. This morning she keeps closing her eyes and has left her tea untouched. When a care worker asks about breakfast, she answers after a long pause, then loses track of the question. Yesterday she ate and talked as usual. She is calm and asks for nothing. A colleague suggests letting her sleep until lunchtime.
Consider before reading on
- What are the risks of waiting until lunchtime?
- What would you report, to whom, and how soon?
Learning points
Recognising hypoactive delirium
New drowsiness, slow responses and difficulty following a conversation may indicate delirium. A person with delirium may be withdrawn rather than restless. When delirium is present with reduced activity, this is called hypoactive delirium.
Report the new change promptly and arrange urgent clinical assessment through the local pathway. Describe what you have seen and when it started.
Check immediate safety. If she is difficult to wake, has abnormal breathing or appears seriously unwell, use the emergency response route. Do not wait for a delirium test.
Apply this
Practise a report that includes the change, its timing and the help needed now. In my workplace I would contact: ____________________
EXAMPLE CASE 02 · BASIC · Hospital ward
Her daughter notices first
Mrs Patel, 76, is in hospital with an infection. She gives her name and knows she is in hospital. Her daughter says that yesterday her mother could discuss the family’s plans, but today she keeps losing the thread. During the visit, Mrs Patel asks several times why she is there. A member of staff says that she seemed fine earlier.
Consider before reading on
- What would you ask the daughter, and where would you record it?
- A colleague says Mrs Patel seemed fine earlier and her answers are correct. How would you respond?
Learning points
Knowing the person’s usual abilities
Ask about usual attention, thinking, alertness and everyday abilities, as well as the time of the new change. Record concrete examples.
A person may answer orientation questions correctly and still have delirium. Symptoms also fluctuate.
Take the concern seriously, assess for delirium and arrange clinical review. A reassuring earlier encounter does not remove the need to act on new information.
Apply this
Ask someone who knows the person: “How is she different from her usual self?”
EXAMPLE CASE 03 · BASIC · Care home
Dementia and a new change
Mr Lewis, 87, has dementia. He usually needs help with washing but enjoys music and eats with little prompting. Over one afternoon he becomes sleepy, needs repeated encouragement to eat and struggles to follow familiar instructions. The evening handover describes him as “confused, as usual”. His regular care worker says this is a marked change.
Consider before reading on
- What is missing from the handover?
- How should the team respond?
Learning points
Delirium in a person with dementia
Dementia increases vulnerability to delirium. Both conditions may be present at the same time.
Describe the new change relative to the person’s usual abilities. A label such as “confused” gives too little information.
Arrange prompt assessment of possible delirium and underlying illness. If it is difficult to distinguish delirium from dementia, manage possible delirium first while seeking further information.
Apply this
Rewrite the handover using his usual abilities and the changes seen this afternoon.
EXAMPLE CASE 04 · BASIC · Hospital ward
A normal conversation at lunchtime
At lunchtime, a student nurse finds Mrs Grant, 71, alert. She recognises the nurse and explains why she came to hospital. The student then reads the notes. At 08:00 Mrs Grant struggled to stay awake and said she was at home. Night staff recorded several episodes of disorientation after surgery. The student is asked to update the record and wonders whether to write that the confusion has resolved.
- Overnight: Several episodes of disorientation
- 08:00: Drowsy; says she is at home
- Lunchtime: Alert; explains admission
Consider before reading on
- What should the student write in the record?
- What should be arranged for this evening and tonight?
Learning points
Fluctuation
Record what was observed and when, including the morning and lunchtime findings. A period of better attention does not establish that delirium has resolved.
Use observations across the day and night, alongside information from the person and people who know them.
Continue clinical assessment, treatment of causes and supportive care. Record when symptoms occur and review for sustained improvement.
Apply this
Give a handover that includes both the improvement and the earlier changes.
EXAMPLE CASE 05 · BASIC · Assessment area
The hearing aid is missing
Mr Davies, 79, gives unrelated answers during a bedside assessment. His hearing aid is in a bag, switched off. The room is busy and several people speak at once. His niece says that he normally follows conversation well with the aid. She is also concerned that he has been unusually drowsy since this morning.
Consider before reading on
- What can you improve before asking further questions?
- Which concern still needs assessment?
Learning points
Communication and sensory needs
Check hearing and visual aids, reduce competing noise and speak clearly, one person at a time. Ask about preferred language and communication needs.
A missing hearing aid may explain the unrelated answers. It does not explain new drowsiness. Seek clinical assessment of the reported change.
Document which communication supports were used, the responses observed and the relative’s account. Repeat assessment as clinically indicated.
Apply this
Ask what would help this person understand and respond before continuing.
EXAMPLE CASE 06 · BASIC · Home visit
Sudden confusion at home
A community care worker arrives at the home of Mr Jones, 78. He is usually able to manage a conversation, but today he is disorientated and repeatedly asks where he is. His partner says the change began an hour ago. The care worker’s next visit is due shortly.
Consider before reading on
- How urgent is this change?
- What should the worker report?
Learning points
Urgent assessment
Sudden confusion needs urgent medical help. In the UK, NHS public advice is to call 999 or go to A&E for sudden confusion. Follow the local emergency route in other countries.
Stay with the person if safe, provide reassurance and seek help. Avoid leaving the concern for a later routine visit.
Report the onset, usual abilities, current symptoms and any signs of serious illness. A delirium assessment tool should never delay emergency care.
Apply this
Identify the emergency contact route used by your service.
EXAMPLE CASE 07 · BASIC · Surgical ward
A restless patient after surgery
Mr Campbell, 68, had abdominal surgery this morning. That evening he becomes restless, pulls at his bedding and tries to get out of bed. He struggles to follow the nurse’s explanation. He grimaces when he moves and says he needs to pass urine. He has received several medicines today. A colleague suggests asking for something to settle him.
Consider before reading on
- What needs attention now, alongside keeping him safe?
- Which clues suggest possible causes, and what else needs assessment?
Learning points
Looking for causes and unmet needs
Assess immediate safety and acute illness. New restlessness with impaired attention may indicate delirium. Treatment of pain and other urgent problems proceeds alongside assessment.
Look for causes and contributors, including pain, urinary retention, constipation, infection, low oxygen, dehydration and medicine effects. More than one may be present.
De-escalation and treatment of causes are the first approach. An appropriately skilled health professional reviews medicines; prescribing changes require an authorised prescriber. Review the response to treatment.
Apply this
Describe the symptoms without using “difficult” or “non-compliant”.
EXAMPLE CASE 08 · BASIC · Orthopaedic ward
Food and drink within reach
Mrs Brown, 84, is recovering from a fracture. Her water is beyond reach and she struggles to open food packaging. She has a documented swallowing plan. At night she is woken repeatedly by ward activity. She uses glasses but they are still at home. She has no new change today. A colleague says delirium is only a concern once someone becomes confused.
Consider before reading on
- How would you respond to the colleague?
- Which changes can the team make today, and what needs an individual care plan?
Learning points
Prevention and everyday care
Prevention combines several measures: hydration and nutrition, mobility, sleep, pain care, sensory aids, orientation and medicine review.
Offer help that follows the swallowing plan and any fluid restriction. Position food and drink safely and check whether assistance is needed.
Support safe movement within the mobility plan. Reduce avoidable night disturbance and help obtain the person’s glasses. Continue to observe for new changes.
Apply this
Choose two actions within your role and record who will address the other needs.
EXAMPLE CASE 09 · BASIC · Hospital ward
Frightened by people in the room
Mr Wilson, 74, has delirium. When several staff approach his bed, he says that strangers are trying to hurt him. He becomes more frightened as they come closer. His wife says he finds a familiar voice reassuring. He appears uncomfortable when moving in bed. The nurse needs to check his observations.
“You’re going to hurt me. Stay away.”
Words from this example case
Consider before reading on
- What could the nurse say and do before approaching again?
- What needs assessment alongside the fear?
Learning points
Responding to distress
Acknowledge the fear and offer reassurance. Introduce yourself, explain what you are doing and use short, calm sentences. Avoid arguing about the experience.
Reduce noise and the number of people speaking. Offer a familiar person’s support when appropriate and wanted.
Assess pain and other causes of distress, alongside illness and immediate safety. De-escalation and treatment of causes are the first approach.
Apply this
Practise a reassuring opening sentence and one explanation before providing care.
EXAMPLE CASE 10 · BASIC · Hospital ward
Explaining the diagnosis
A clinician has diagnosed delirium in Mrs Chen, 80. Her son has been told that she is “confused” but does not know why. He is frightened that the change is permanent. Mrs Chen is able to follow a short conversation this afternoon and asks what happened to her.
Consider before reading on
- What would you explain first?
- What would you avoid promising?
Learning points
Patient and family information
Use the word delirium and explain it in ordinary language: a change in thinking, attention or alertness that usually develops over hours or days, often with illness or medicine effects.
Explain the causes and treatment established by the clinical team and what the family can do to help. Ask the responsible clinician to clarify anything you do not know. Check understanding and offer written information, such as deliriumsupport.com.
Recovery varies. Some people improve quickly and others need longer. Avoid promising a fixed recovery time. Give a contact route for questions and concerns.
Apply this
Give a two-sentence explanation, then ask what the person or family would like to know.
EXAMPLE CASE 11 · INTERMEDIATE · Acute medical unit
The first score was zero
Mr Ali, 75, is fully alert throughout an initial 4AT assessment. He answers all AMT4 questions correctly and recites the months backwards from December to June correctly. No evidence of acute change has yet been found from the available information. The initial score is recorded as 0, with the history documented as incomplete. His daughter then arrives. She describes new episodes of disorientation and markedly impaired attention during the past day.
Consider before reading on
- Which 4AT item should you reconsider?
- The score of 0 is already in the record. What should happen to it?
Learning points
New information changes assessment
Use the new history to reassess Item 4: acute change or fluctuating course. Significant change within the last 2 weeks that is still evident within the last 24 hours scores 4.
With the other three items still scoring 0, the updated total is 4. This suggests possible delirium, with or without cognitive impairment, and requires clinical assessment.
Record the revised result and its source. A screening result supports assessment; the clinician makes the diagnosis.
Apply this
Explain to a colleague why the initial result should be updated.
EXAMPLE CASE 12 · INTERMEDIATE · Emergency department
Too drowsy for the questions
Mrs Evans, 81, is in the emergency department. Emergency assessment and treatment have started. She is clearly abnormally drowsy and is unable to attempt the AMT4 or months backwards. A colleague suggests leaving the 4AT blank until she is more awake. There is no reliable history yet about her usual abilities or when the change began.
Consider before reading on
- Using the official form, how should a nurse trained in the 4AT score Items 1, 2 and 3?
- What should you do about the missing history?
Learning points
Untestable cognitive items
Clearly abnormal alertness scores 4 on Item 1. When the person is untestable because of drowsiness, AMT4 scores 2 and months backwards scores 2.
These three items total 8. Continue to seek evidence for Item 4 and document that the history is incomplete. Absence of available history is not proof that no change occurred.
Continue urgent clinical care and diagnostic assessment. Do not postpone treatment to complete the score. Follow the official user guide for the full assessment.
Apply this
State the evidence for each score rather than assigning a number from a general impression.
EXAMPLE CASE 13 · INTERMEDIATE · Assessment area
No shared language
Mrs Hassan, 70, speaks little English. Staff have no interpreter present. Her son reports a sudden change in her conversation and behaviour since yesterday. She is awake and looking around, but does not respond meaningfully to questions in English. Someone suggests recording the cognitive items as normal because of the language barrier.
Consider before reading on
- How should the assessment be made more reliable?
- What needs action while this is arranged?
Learning points
Language and test interpretation
Arrange an appropriate interpreter and use an official translated assessment where available. Establish hearing, vision, usual cognition and communication needs.
Do not record an unperformed cognitive test as normal. Follow the official user guide, document the limitation and interpret the findings in context.
The reported sudden change still needs urgent clinical assessment. Communication support should be arranged alongside care, without delaying treatment of serious illness.
Apply this
Record both the concern and the communication support needed.
EXAMPLE CASE 14 · INTERMEDIATE · Medical ward
Several possible causes
Mr Anderson, 83, develops delirium during treatment for pneumonia. He is improving on antibiotics, but remains inattentive. A nurse notices pain on movement, poor fluid intake and no recorded bowel movement for several days. A new medicine may also be causing sedation. A colleague says the continuing confusion is probably a urine infection.
Consider before reading on
- How would you respond to that suggestion?
- How will you judge the response to changes in care?
Learning points
More than one cause
One identified cause does not exclude others. The clinical team reassesses illness, oxygenation, pain, hydration, bowel and bladder problems, medicines and other findings. Confusion alone does not establish a urinary tract infection.
Allocate each action to an appropriate team member and record who will review the person and when. Avoid adding medicines without reviewing the current medicines.
Follow the clinical course, function and distress. Delirium can continue after an initial cause improves and should prompt further review.
Apply this
Write a short plan with actions, named roles and a review time. Compare the reasoning with case 7.
EXAMPLE CASE 15 · INTERMEDIATE · Hospital ward
Hallucinations and Parkinson’s disease
Mrs Fraser, 78, has Parkinson’s disease and develops delirium during an acute illness. She sees insects on her blanket and is frightened. Staff have begun reassurance, reduced stimulation and assessment of pain and other needs. A colleague asks whether haloperidol should be prescribed if distress continues.
“Get those insects off my blanket.”
Words from this example case
Consider before reading on
- Which history changes the medication decision?
- What should the team do next?
Learning points
Medication risk and distress
Haloperidol must not be used in Parkinson’s disease or dementia with Lewy bodies. Escalate to a clinician with suitable expertise and follow local guidance.
Continue to assess and treat causes of delirium and distress. Medication decisions require an individual assessment of benefit, risk and alternatives.
For patients in whom haloperidol is appropriate, UK guidance limits its use to specific circumstances after de-escalation is ineffective or inappropriate, with the lowest dose for the shortest time and appropriate monitoring.
Apply this
Include Parkinson’s disease prominently in the clinical handover and medicine review.
EXAMPLE CASE 16 · INTERMEDIATE · Surgical ward
A younger man, confused after surgery
Mr Miller, 42, becomes inattentive and disorientated two days after major surgery. He has severe pain and appears physically unwell. A colleague says that delirium is an older person’s condition.
Consider before reading on
- How does his age affect the response?
- What needs assessment?
Learning points
Age and clinical context
Delirium can occur in younger adults. New changes in attention and awareness during illness need urgent assessment at any adult age.
The clinical team assesses signs of serious illness, including abnormal observations, and looks for causes using the history, examination and appropriate investigations. Report new observations and concerns promptly.
Ask about prescribed medicines, alcohol and other substances without assumptions. Withdrawal may need urgent specialist treatment and a specific local pathway.
Apply this
Describe the new changes and request assessment without making an age-based assumption.
EXAMPLE CASE 17 · INTERMEDIATE · Critical care
Choosing an assessment in intensive care
Mrs Taylor, 64, is in intensive care. Her sedation was reduced today and her alertness has varied since. Her Richmond Agitation-Sedation Scale (RASS) score is recorded each shift. A nurse who recently moved from a medical ward reaches for the 4AT form she used there.
Consider before reading on
- Which delirium assessment should be used here, and who is trained to do it?
- What from ward practice still applies?
Learning points
Delirium assessment in critical care
Awareness of change, attention to causes, supportive care and communication remain relevant. Critical care assessment requires the appropriate local training and pathway.
NICE recommends the Confusion Assessment Method for the ICU (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) in critical care and the recovery room immediately after surgery, instead of the 4AT. Follow the instrument’s requirements.
RASS assesses agitation and sedation. Its score is not a delirium diagnosis and must not be numerically converted into a 4AT score.
Apply this
Identify the delirium assessment method and training used in your critical care service.
EXAMPLE CASE 18 · INTERMEDIATE · Hospital ward
Fluctuating attention and a treatment decision
Mr Stewart, 77, has delirium and needs a discussion about a proposed treatment. At one point he follows an explanation, but later he is distracted and struggles to retain it. His daughter asks whether a delirium diagnosis means that staff should make every decision for him.
Consider before reading on
- How can the team support his involvement?
- Who should assess the specific decision?
Learning points
Supporting involvement in decisions
A diagnosis alone does not settle a person’s ability to make every decision. Capacity is the ability to make the particular decision at the time it is needed. Legal processes differ by country or legal system.
Provide communication support and simple explanations. For a decision that can safely wait, consider a time when attention is better. Urgent treatment should follow the appropriate local legal and clinical process.
An appropriately skilled clinician should assess and document the decision in question, involve the person as far as possible and follow local policy for family involvement.
Apply this
Identify your local source of advice on capacity and urgent treatment.
EXAMPLE CASE 19 · INTERMEDIATE · Rehabilitation ward
Still affected after the infection improves
Mrs Robertson, 85, has completed treatment for an infection. A week later, her attention still varies and she needs much more help dressing than before. Her family has been told that the blood tests are better. They ask why she has not returned to her usual self.
- Treatment completed: Infection treated
- One week later: Attention varies; needs more help dressing
- Next review: What should be assessed?
Consider before reading on
- What should the team reassess?
- How would you explain the uncertainty?
Learning points
Persistent delirium
Delirium may persist after treatment of the initial illness. Review for continuing or new causes, medication effects and unmet care needs.
Assess thinking, alertness and function over time. Avoid diagnosing a new permanent dementia solely from performance during active delirium.
Explain what has improved, what remains affected and the plan for review and rehabilitation. Some people have prolonged symptoms or lasting difficulties.
Apply this
List the information you need from the team before explaining the review plan and contact route to the family.
EXAMPLE CASE 20 · INTERMEDIATE · Hospital to home
Going home after delirium
Mr Green, 73, is going home after an admission complicated by delirium. His attention has improved, but he still needs support with medicines and meals. A short course of an antipsychotic was started in hospital. The team is preparing his discharge letter.
Draft discharge letter
Diagnosis: infection, treated.
Medicines: usual medicines plus an antipsychotic started in hospital.
Follow-up: none stated.
Consider before reading on
- What is missing from this draft?
- What should the person and family know?
Learning points
Continuity of care
Record the delirium diagnosis, its course, likely causes, treatment and current cognitive and functional needs. Share the plan with the receiving team.
Review medicines before discharge. Specify the indication, review arrangements and planned stopping of any medicine used for acute distress. Avoid unintended long-term prescribing.
Explain recovery, support arrangements, warning signs and who to contact. Arrange follow-up appropriate to the person’s remaining needs.
Apply this
List the information for the delirium paragraph, marking details the team must confirm. Alternatively, practise reporting the omissions to the discharge team.