Delirium & Agitation

at the bedside

treat first, these can mimic agitation

recognise delirium

4AT (alertness, AMT4, attention, acute change): ≥ 4 = possible delirium; < 2 min, no training needed
hyperactive: agitation, restlessness, pulling at lines (obvious, over-diagnosed)
hypoactive: withdrawn, drowsy, not engaging (easily missed, higher mortality)
mixed: fluctuates between both
delirium ≠ dementia: delirium is acute + fluctuating; dementia is chronic + stable; can coexist

collateral from staff / family
admission reason; prolonged stay; prior agitation episodes
risk factors: CVA, dementia, psychiatric illness; alcohol use / withdrawal; sensory impairment
review: medications (new / missed); infection / metabolic triggers
differential (DIMS-RAT)
- D: delirium / dementia / depression
- I: infection (UTI, sepsis, meningitis)
- M: metabolic (glucose, Na, CO₂, thyroid, liver)
- S: structural (stroke, seizure, tumor)
- R: retention (urine / stool)
- A: alcohol / drugs
- T: toxins / medications

glucose (if not checked at bedside)
CBC, U&E, creatinine, LFTs, CRP
VBG
urinalysis
ammonia → liver disease or unexplained encephalopathy
TFTs → no obvious precipitant
drug levels (digoxin, lithium, anticonvulsants) if on narrow-index drugs
blood cultures → febrile or sepsis suspected
CXR → chest signs or no clear precipitant
CT brain → trauma, focal neurology, new headache, or anticoagulated
medication reconciliation: print drug chart, compare prescribed vs given vs recently changed

non-pharmacologic first (always)

calm, non-threatening approach; do not argue; reassure
reduce stimuli: noise, bright light, unnecessary alarms
reorient: clock, calendar, familiar objects; explain location + reason
sensory aids: glasses, hearing aids, dentures
sleep hygiene: minimize nighttime observations if safe; reduce noise + light
mobilize early if safe; remove unnecessary tethers (catheters, restraints, IV lines)
family presence or 1:1 sitter

general agitation / delirium, unsafe behavior, no specific cause

haloperidol 0.5–1 mg PO/IV/IM; repeat q30 min if needed (max 5 mg/day)
- ECG first: avoid if QTc > 500 ms; recheck after the dose; watch for EPS
- avoid in Parkinson’s / Lewy body or NMS
alternative: quetiapine 12.5–25 mg PO or olanzapine 2.5–5 mg PO/IM
hypoactive delirium rarely needs antipsychotic: treat cause, not quiet patient
avoid benzodiazepines except in alcohol/benzo withdrawal

alcohol withdrawal, all bands

thiamine 200–300 mg IV before any glucose (Wernicke suspected → 500 mg IV TID)
prefer lorazepam in liver disease; elderly / frail → lower doses, start low, go slow

alcohol withdrawal, mild (CIWA < 15)

alcohol withdrawal, moderate (CIWA 15–20)

severe withdrawal / delirium tremens (CIWA > 20 or poor response)

elderly / frail, high sensitivity

de-escalation and medication failed, persistent danger → call for help
treatable cause (infection / metabolic) → treat it; Geriatrics for elderly delirium; Psychiatry if primary psychiatric disorder suspected
sepsis / hemodynamic instability → shock management
severe withdrawal or unstable → ICU

restraint

physical restraint = last resort: only if immediate danger unmanageable by de-escalation or medication
document indication; set time limit; reassess frequently
restraint does not treat delirium: keep investigating + treating cause

source	type
NICE NG103 · Delirium: prevention, diagnosis and management ↗︎	international guideline
4AT · Rapid clinical test for delirium ↗︎	validated screening tool

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? IM Rapid Review covers delirium in the same format. see the sample chapter.

reviewed Jun 2026updated Sep 2026file complaint/delirium-and-agitation