Part 1 of 8 · About 3 minutes
Notice the change
Example case
Mrs Ahmed, 84, has dementia and was admitted after a fall. She usually chats, eats independently and walks with a frame.
On her second day in hospital, she is much less talkative. She is sleepy at times, responds slowly, eats little and needs more help to stand. Her daughter says the change began yesterday. At some points she seems more like herself.
These changes need prompt assessment. A person who becomes drowsy and withdrawn may have delirium, even if they are neither agitated nor complaining of confusion.
What delirium means
Delirium is a sudden change in mental functioning. The person has difficulty paying attention and thinking clearly. Their alertness or behaviour may change. Some see or hear things that others do not. Delirium develops over hours or days, usually during illness, after an operation or because of medicines or other physical problems. Symptoms may vary during the day.
The person may struggle to understand where they are or what staff are doing. Ordinary care can feel frightening. Delirium needs prompt assessment and treatment, together with care that helps the person feel safe.
Anyone who spends time with the person may notice the change first. You do not need to be able to diagnose delirium before asking for help.
Tell the nurse responsible for the person or the senior member of staff. For example: “Mrs Ahmed is much sleepier than usual and is eating very little. Her daughter says this began yesterday. Please arrange assessment now.”
If the person is very difficult to wake, has severe breathing problems or is rapidly getting worse, use your setting’s emergency response.
Which feature makes Mrs Ahmed’s change concerning?
Explanation
The new change is the concern. Her daughter and familiar staff help establish how she usually thinks, communicates and manages daily activities. Dementia increases the risk of delirium; it does not explain every new change.
Sources: NICE CG103
Part 2 of 8 · About 4 minutes
Recognise different presentations
Delirium has several possible appearances. Compare what you see with the person’s usual state and ask how quickly it changed.
Drowsy or withdrawn
The person may speak less, respond slowly, lose track of a conversation, move less or stop eating and drinking as usual. This is often called hypoactive delirium.
Restless or agitated
The person may be unable to settle, pull at bedding or try to leave. This is often called hyperactive delirium. Some people have both patterns at different times.
Watch for reduced engagement
Describe the man’s actions and response. Consider what information is still needed about his usual state and when the change began.
Text alternative
An older man holds a spoon above a bowl but does not eat. A nurse asks whether he will try some soup. He responds slowly. The scene illustrates reduced engagement. It does not establish a diagnosis or swallowing safety. Check alertness and the individual swallowing plan before oral intake.
In this simulated scene, the man engages little with the meal and the staff member’s question. In practice, seek information about whether this is new and assess for illness or other causes. Reduced responsiveness may also require emergency assessment.
Some people with delirium see or hear things that others do not. These experiences are called hallucinations. Some develop frightening beliefs, such as believing staff intend to harm them. Neither agitation nor hallucinations are required for delirium. Their absence should not reassure you when someone has a new change.
| Feature | Delirium | Dementia |
|---|---|---|
| Usual onset | Hours or days | Usually months or years |
| Attention and alertness | Often change; may vary during the day | Depend on type and stage; compare with the person’s usual state |
| A sudden deterioration | Needs prompt assessment | Assess for delirium or another acute problem |
Delirium and dementia often occur together. If it is difficult to distinguish them, assess and manage possible delirium promptly. A more settled hour does not exclude it.
Sources: NICE CG103
Part 3 of 8 · About 5 minutes
Find out what is usual and assess
Baseline means the person’s usual abilities and behaviour before this change. Ask the person where possible. Family, carers, familiar staff and records can help you establish what is usual, when the change began and whether it has varied.
Ask someone who knows the person
Example case
After his wife’s operation, Mr Singh says she has become suspicious and struggles to follow conversation. Staff ask how she was before admission. He describes her usual memory, conversation and daily activities, then explains when the new change began.
Consider: What information about her usual state and the time of change would you record? A new problem after an operation should prompt clinical assessment.
What is the person usually like? What has changed, and when did it begin? Has the change varied during the day?
Use a structured assessment appropriately
The 4AT is a brief assessment used to help detect possible delirium and cognitive impairment. Cognitive impairment means difficulty with mental abilities such as attention or memory. The final diagnosis requires clinical assessment.
Use the assessment recommended for your setting and follow its current instructions. Staff who administer it need to be competent to use and interpret it. If this is outside your role, report the change and ask for assessment. Urgent care should proceed while the team assesses delirium.
The 4AT has four parts:
- Alertness.
- Four questions: age, date of birth, place and year.
- Attention, tested with Months Backwards.
- A recent change in mental functioning, or variation in that change.
The months backwards task
Use the official 4AT instructions to ask the person to name the months backwards, starting at December. Score the response using those instructions. This is one part of the assessment; the other items and the history remain necessary.
| Score | Interpretation |
|---|---|
| 0 | Suggests no delirium and no moderate-to-severe cognitive impairment. Neither is definitively excluded. |
| 1–3 | Suggests cognitive impairment. Interpret with the history and clinical findings. |
| 4–12 | Suggests possible delirium. Arrange clinical diagnostic assessment. |
Help the person hear and understand. Check hearing aids and glasses, use an interpreter when needed, and account for difficulties speaking or understanding language. A communication barrier needs attention before you interpret performance.
Scoring when the person is unable to attempt a task
The 4AT provides scores for someone unable to attempt the cognitive items because of illness, drowsiness or severe inattention. Follow the official guide; do not abandon the assessment. The guide also explains interpretation in severe dementia.
Which tool in critical care?
NICE recommends CAM-ICU or ICDSC in critical care and the recovery room immediately after surgery. Use the relevant specialist pathway in these settings.
A 4AT score of 0 was recorded. A relative then reports a marked mental change that began yesterday and is still present. What should happen?
Explanation
This new history fulfils Item 4: significant mental change within two weeks, with evidence within the past 24 hours. Item 4 scores 4, so the total needs updating to at least 4. Arrange clinical assessment. If assessment is outside your role, pass this information to the clinician.
Sources: Official 4AT user guide; NICE CG103;
Part 4 of 8 · About 3 minutes
Act promptly and look for causes
A new mental change needs urgent clinical assessment. Tell the responsible nurse or clinician and confirm when assessment will happen. In a care home, use the urgent medical assessment route. Do not wait for a routine visit.
Start emergency assessment and treatment immediately when needed. The team can assess delirium alongside this care.
Check the person’s immediate condition within your role. Trained staff follow their emergency assessment procedure, including checks for low blood glucose. Report the mental change and abnormal observations, such as breathing rate, pulse, blood pressure, temperature or oxygen level.
Several problems may contribute
The clinician looks for causes and treats them. Examples include infection, low oxygen or blood glucose, medicine effects, pain, dehydration, constipation and difficulty emptying the bladder. Several may occur together.
Share changes in medicines, intake, urine, bowel movements, sleep and mobility. Describe pain or distress, including facial expression when speech is difficult. Confusion alone does not establish a urinary infection.
Return to Mrs Ahmed
Her nurse finds fever and a new low oxygen level and seeks urgent medical review. The team assesses possible causes and begins treatment.
The pharmacist reviews medicines. Therapy staff assess her movement and everyday abilities. Her daughter provides the history and brings her hearing aids.
Everyone can notice, report, offer appropriate help and check that a concern has been received. Clinical assessment, investigations and prescribing depend on professional responsibilities and competence.
After you report a new change, no review has happened and the person is getting worse. What should you do?
Explanation
Seek help again and state that the person is deteriorating. Use the emergency response when needed. Record who received the concern, the response and the agreed review.
Sources: NICE CG103; NHS: sudden confusion
Part 5 of 8 · About 3 minutes
Help the person feel safe
A person with delirium may misunderstand their surroundings or an attempt to help. They may feel frightened while still and saying little. Ask how they feel. Watch for discomfort if speech is limited.
Approach within their view and introduce yourself. Check they can hear you. Speak calmly, give one short explanation at a time and allow a response. Explain before touching or beginning care.
“You are in hospital. I’m one of the nurses. You have been unwell, and it has made it harder to think clearly. I’ll explain what we are doing.”
Use words that fit what you know and can offer. If you promise to return, do so.
Acknowledge fear without agreeing that a threat is real. Avoid arguing or repeatedly testing memory. Ask what usually reassures the person. Involve someone familiar if the patient welcomes this.
Check for pain, thirst, hunger, a full bladder, constipation, noise and an uncomfortable position. Help the person use glasses or hearing aids. If there is an immediate risk of harm, get help and use the least restrictive safe approach under local guidance.
Medication has a limited role
Care and treatment of causes continue. Only a clinician authorised to prescribe should decide whether a medicine is appropriate. A short course of haloperidol may be considered for distress or risk when calm communication and other measures to reduce distress have failed or are inappropriate.
Haloperidol must not be used in Parkinson’s disease or dementia with Lewy bodies. It can cause heart rhythm and movement problems. The prescriber checks individual risks, uses the lowest appropriate dose for the shortest possible time, and records monitoring, review and stopping plans. Follow current prescribing guidance.
Report distress or risk, what was tried and the response. Assess distress separately from movement or noise.
Which is the most useful response to a frightened person who believes staff will hurt them?
Explanation
Acknowledge the person’s fear and provide calm explanation and practical help. Look for pain and other needs. Seek clinical help if distress or risk persists.
Sources: MHRA haloperidol advice; NICE CG103
A survivor’s account
Listen to what Dr S says about staff spending time with a person who has delirium.
Written alternative
Dr S describes the value of staff spending time with someone who has delirium. Listening to the person’s experience is part of care throughout the illness. Consider what you could ask before beginning a procedure.
Part 6 of 8 · About 3 minutes
Provide care that reduces risk
People are more vulnerable to delirium when they are older, have dementia or another cognitive impairment, have a hip fracture or are severely ill. Support should begin before delirium develops.
Several measures together can reduce the risk of delirium in hospital. Choose measures for the person’s needs and review whether staff have been able to provide them. The same everyday needs require attention during delirium.
Food, fluid and comfort
Offer appropriate help with meals and drinks. Follow swallowing advice and any fluid restriction. Check pain, bowel and bladder needs. Report reduced intake or difficulty swallowing.
Hearing and vision
Help the person use their glasses and hearing aids. Check that the aids work and are within reach. Adapt communication to their needs.
Movement and sleep
Support movement and mobility appropriate to the person’s condition, with the assistance and equipment they need. Reduce avoidable interruptions at night while continuing necessary observations and treatment.
Familiar contact and medicines
Offer explanation, familiar contact and orientation. Avoid unnecessary moves. Ask for medicines to be reviewed by a qualified clinician or pharmacist.
A drink, a walk or a hearing aid alone does not guarantee prevention. The team needs to address the relevant problems together. A person may develop delirium despite appropriate care.
Mrs Ahmed is drowsy and has hardly drunk today. What is the safest next action?
Explanation
Follow the swallowing and fluid plan. Do not test swallowing yourself unless this is part of your training and role. Drowsiness and reduced intake need assessment; do not force oral fluids.
Sources: NICE CG103; Burton and colleagues, Cochrane review (2021)
Part 7 of 8 · About 2 minutes
Explain, record and support recovery
Explain delirium to the person and family using plain words. Describe what has changed, what the team is treating and how the person is being supported. Invite questions and reports of further changes.
Many people improve as the causes are treated. Recovery varies: some people have symptoms for weeks or months and need continuing support. A new deterioration still needs prompt assessment. Do not assume that it is an expected part of recovery.
During recovery, offer an opportunity to talk about frightening experiences. Discuss any continuing difficulty with thinking, sleep, movement or everyday activities. Persistent symptoms need clinical review, further assessment of possible causes and a follow-up plan.
Record the usual baseline and its source; the new changes and when they began; observations and assessment results; who was informed and when; actions and response; and who will review the person next and when.
At transfer or discharge, record a confirmed delirium diagnosis, its course, remaining difficulties, treatment changes and follow-up. Hand over review and stopping plans for medicines started for delirium-related distress. Explain the plan to the person and those supporting them. Give a named contact or service for concerns and clear advice about urgent help.
Family information is available at Delirium Support. Offer it alongside a conversation and the person’s care plan.
Sources: NICE CG103; Academy: persistent delirium
Assessment and feedback
Use the interactive assessment to check your answers and create a certificate. The requirement is at least 8/10, including urgent-action questions 2 and 10, followed by review of all feedback.
1. A person with dementia becomes drowsy, withdrawn and less able to follow a conversation over one day. What is the best interpretation?
- This needs assessment for possible delirium
- This is an expected daily consequence of dementia
- Delirium is unlikely without agitation
Answer and explanation
This needs assessment for possible delirium
A sudden change from usual needs assessment. Hypoactive delirium may cause drowsiness, reduced activity and poor attention. Dementia increases vulnerability.
2. A person is very difficult to wake and is breathing abnormally. What should happen first?
- Finish the 4AT before calling for help
- Use the emergency response and begin assessment within your role
- Repeat observations, then decide whether to request review
Answer and explanation
Use the emergency response and begin assessment within your role
Urgent assessment and treatment take priority. A delirium tool must not delay emergency care.
3. Which information is most useful when establishing baseline?
- Whether the person is over 65
- Their score on one memory question
- How they usually think, communicate and function, and when this changed
Answer and explanation
How they usually think, communicate and function, and when this changed
Ask the person and people who know them, and use records. Establish both the usual state and the time course of the change.
4. What does a 4AT score of 4 or more mean?
- Delirium is confirmed without further assessment
- Possible delirium requiring clinical diagnostic assessment
- The person has dementia
Answer and explanation
Possible delirium requiring clinical diagnostic assessment
The result supports assessment for possible delirium. The diagnosis is clinical, using the history, examination and wider information.
5. After a 4AT score of 0 is recorded, a relative reports a marked mental change beginning yesterday and still present today. What is appropriate?
- Disregard the concern because the score is normal
- Wait for agitation to develop
- Assess the concern and review the clinical findings
Answer and explanation
Assess the concern and review the clinical findings
The new history meets Item 4, which scores 4. Review the recorded total and arrange clinical assessment. Pass the history to the clinician if assessment is outside your role.
6. Which response to distress is most appropriate initially?
- Check physical needs, explain calmly and offer reassurance
- Use an antipsychotic for every restless person
- Ask repeated orientation questions until all answers are correct
Answer and explanation
Check physical needs, explain calmly and offer reassurance
Look for pain, discomfort and other causes. Help the person feel safer. Medication decisions require an authorised prescriber and an individual assessment.
7. Which plan best reflects delirium prevention?
- Use the same food, fluid, movement and sleep plan for everyone
- Choose several measures for the person’s food, fluid, movement, sensory and sleep needs
- Start a prevention plan only after a positive delirium assessment
Answer and explanation
Choose several measures for the person’s food, fluid, movement, sensory and sleep needs
Prevention uses several measures together, adapted to the person and setting. Continue necessary monitoring and follow swallowing, fluid and mobility advice.
8. Which statement about causes is most accurate?
- One plausible cause means no other problems need checking
- Confusion alone establishes a urinary infection
- Several contributors may coexist and need assessment
Answer and explanation
Several contributors may coexist and need assessment
Look for acute illness and other contributors, such as medicine effects, pain, dehydration, constipation and urinary retention.
9. What is the most useful handover?
- Usually alert; new drowsiness today; findings and actions recorded; urgent review agreed
- Dementia documented; drowsiness noted today; continue routine observations overnight
- 4AT recorded in the chart; assessment requested; no time or next review agreed
Answer and explanation
Usually alert; new drowsiness today; findings and actions recorded; urgent review agreed
The next team needs enough information to understand the change and act. Record who has been informed and who will review the person and when.
10. Someone recovering from delirium becomes suddenly much worse. What should the family or staff do?
- Assume this is a normal bad day
- Seek prompt clinical assessment and emergency help if seriously unwell
- Wait until the routine follow-up appointment
Answer and explanation
Seek prompt clinical assessment and emergency help if seriously unwell
Recovery can vary, but a new deterioration needs assessment. Give families clear contact details and urgent-help advice.