Delirium and the Frail Patient

Delirium in a frail older patient is one of the most common IMT clinical station scenarios, and it is won by structure. NICE CG103 wants you to recognise the risk, assess with a named tool, find and treat the cause, and only then think about sedation.

Key takeaways

• NICE CG103 names four risk factors for delirium: age 65 or older, cognitive impairment or dementia, current hip fracture, and severe illness.
• NICE CG103, updated in January 2023, recommends the 4AT for assessment on the ward, and CAM-ICU or ICDSC in critical care or recovery.
• Hypoactive delirium is the form most often missed: withdrawal, slow responses, reduced mobility and reduced appetite.
• First-line management is to identify and manage the underlying cause, then reorientate and reassure, involving family and carers.
• NICE reserves short-term haloperidol, usually for one week or less, for distressed patients where de-escalation has failed or is inappropriate.
• The Mental Capacity Act 2005 applies to a temporary disturbance of the mind or brain, so a delirious patient's capacity is assessed decision by decision.

What is delirium, and why does the panel choose it?

Delirium is an acute change in cognition, perception, physical function or social behaviour that fluctuates over hours or days and has a cause you are expected to find. The panel chooses it because it tests recognition, a differential, safe management and communication in one scenario.

NICE CG103 describes the changes to look for at presentation: worsened concentration, slow responses, confusion, hallucinations, restlessness or reduced movement, sleep disturbance, withdrawal, and altered mood or communication.

Say early that delirium is common and, in NICE's words, usually temporary. That framing matters when you later explain the diagnosis to a frightened family.

Who is at risk, according to NICE CG103?

NICE CG103 says to assess everyone presenting to hospital for four risk factors: age 65 years or older, cognitive impairment or dementia, current hip fracture, and severe illness. Any one of them puts the person at risk.

In practice, a frail 84-year-old admitted with a chest infection has at least two of the four before you have examined her. Say so out loud, because naming the risk is what triggers the rest of the pathway.

How do you assess a confused frail patient on the ward?

Assess A to E first, then use the tool NICE names. CG103 recommends that a competent practitioner carries out an assessment with the 4AT when indicators of delirium are identified, and uses CAM-ICU or ICDSC instead in critical care or the recovery room.

What does the history need to establish?

A collateral history from a relative or carer establishes the baseline, the speed of change and the fluctuation. NICE CG103 says these changes may be reported by the person, a carer or a relative, so ask them directly.

What if it could be dementia?

NICE CG103 is explicit: if it is difficult to distinguish delirium, dementia or delirium superimposed on dementia, manage the delirium first. Document the diagnosis in the hospital record and the primary care record.

What causes should you look for first?

The causes to look for are the same factors NICE CG103 asks you to address in prevention: infection, dehydration and constipation, hypoxia, pain, immobility, polypharmacy, poor nutrition, sensory impairment and disturbed sleep.

• Infection: look for and treat it, and avoid unnecessary catheterisation.
• Dehydration or constipation: encourage fluids and consider subcutaneous or intravenous fluids if needed.
• Hypoxia: check saturations and remember NICE's warning that oximeters can over- or under-estimate at borderline levels.
• Pain: look for non-verbal signs, especially with communication difficulties, and treat what you find.
• Medication: review both the number and the type of drugs.
• Sensory impairment: resolve reversible causes such as ear wax and make sure glasses and hearing aids are in use.

However, do not present this as a checklist you recite. Tie each item to the patient in the scenario: the new opioid, the retention, the sodium, the missing hearing aid.

How do you manage delirium once you have found the cause?

NICE CG103 puts management in a fixed order: identify and manage the underlying cause, then ensure effective communication and reorientation, and provide reassurance. Involve family, friends and carers to help, and keep the patient in a familiar environment.

CG103 also asks you to avoid moving people between wards or rooms unless absolutely necessary, and to make sure a clock and calendar are visible, lighting is appropriate and signage is clear.

When is sedation justified, and what does NICE actually say?

Only when a person with delirium is distressed or a risk to themselves or others, and verbal and non-verbal de-escalation has failed or is inappropriate. That said, the first step is always de-escalation, and NICE CG103 says so in terms.

NICE CG103 then says to consider short-term haloperidol, usually for one week or less, starting at the lowest clinically appropriate dose and titrating cautiously. It cites the MHRA's warnings about cardiac and neurological side effects, especially in Parkinson's disease and dementia with Lewy bodies.

Do not name a milligram dose at the interview unless asked. The panel is listening for the sequence and the caution, not the number.

How does capacity work when the patient is delirious?

The Mental Capacity Act 2005 applies, because section 2 says it does not matter whether the impairment or disturbance of the mind or brain is permanent or temporary. Capacity is decision-specific and time-specific, so you assess it for the decision in front of you.

GMC Decision making and consent 2020 adds a point the panel likes: if the patient may regain capacity and the decision can be delayed, you must consider delaying it. A delirious patient refusing a non-urgent scan is the classic example.

If a decision cannot wait, act in the patient's best interests, consult those close to them and choose the least restrictive option. The full test is set out in the capacity article in this library.

What is the trap in this scenario?

The trap is treating the behaviour instead of the cause. A candidate who reaches for sedation before naming infection, drugs, pain, retention and hypoxia has answered the wrong question, and the panel will score it as unsafe.

The second trap is missing hypoactive delirium. NICE CG103 says to be particularly vigilant for withdrawal, slow responses and reduced appetite, because the quiet patient in the corner is the one who is not assessed.

How would you hand this patient over?

Use SBAR and lead with the concern: an 84-year-old with new fluctuating confusion, 4AT positive, probable urinary sepsis, antibiotics and fluids started, opioid stopped, family aware, and what you want the night team to review and when.

How this comes up at the IMT interview

At the IMT interview, delirium appears in station 2 as a clinical scenario of up to ten minutes, marked on investigations, diagnosis and management, with communication marked throughout and a one-minute handover to close. Two interviewers each score 1 to 5, and the clinical area is weighted 1.2.

Practise it spoken, not written. internalmedicineinterview carries 361 IMT questions with AI-marked spoken practice, and the delirium scenario in the clinical bank is built around exactly this NICE CG103 sequence.