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Delirium: screening (CAM), prevention and nursing care

  • Assessment

Watch daily for sudden changes in attention, thinking and alertness, screen with a validated tool (CAM, 4AT), prevent with the basics and report it.

Updated

What it is

Delirium is a sudden, fluctuating disturbance of attention, awareness and thinking that often signals a serious medical problem. It can be hyperactive or hypoactive (quiet and often missed). Nurses are the first to notice it, because they see the person around the clock. The nurse assesses risk factors on admission, looks daily for recent changes, screens with a validated tool, records and reports the findings, and leads a multicomponent prevention plan: orientation, hydration, oxygenation, mobility, pain control, sleep, nutrition, glasses and hearing aids, and family presence. The Confusion Assessment Method (CAM) checks for the core features of delirium; NICE recommends the 4AT on general wards and the CAM-ICU in critical care.

Reference values

  • Onset over hours or days; symptoms often come and go and are usually worse at night.
  • Alertness changes: drowsy or hyper-alert; attention and short-term memory fail.
  • Common causes: infection, dehydration, electrolyte imbalance, medicines, alcohol or drug withdrawal, pain, sleep loss, organ failure.
  • The screening tool and its scoring are those your institution has adopted.

What you need

  • The validated screening tool of the unit and training to use it.
  • A clock, a calendar, good lighting and clear signage.
  • The person's glasses, hearing aids and dentures.
  • Baseline information from the family about the person's usual thinking and behaviour.

How to measure it (and why)

  1. On admission, record risk factors and ask the family about the person's usual memory and behaviour — a baseline is needed to recognise change.
  2. Each shift, look for recent changes or swings in attention, thinking, perception, mobility, appetite, sleep and engagement — delirium starts fast and swings.
  3. When changes appear, screen with the unit's validated tool and record the result — a structured tool detects delirium that observation alone misses.
  4. Report a positive screen at once and help look for causes: vital signs, oxygen, glucose, pain, urine, bowels, new medicines — delirium signals illness.
  5. Reorient often: say who you are, where the person is and the time of day; keep a clock and calendar in view — this reduces disorientation.
  6. Encourage drinking, early walking, nutrition and well-fitting dentures; avoid unneeded catheters — dehydration, immobility and infection drive delirium.
  7. Protect sleep: no procedures or medicine rounds during sleeping hours if possible, low noise at night — sleep loss worsens delirium.
  8. If the person is distressed, de-escalate first with words and gestures, invite family to help and avoid restraints; give medicines only as prescribed.

How to read it

  • A positive screen means probable delirium: an urgent medical review, not a routine note.
  • Fluctuation is typical: a normal assessment in the morning does not exclude delirium at night.
  • Delirium raises the risk of dementia and death, a longer hospital stay and new admission to long-term care.
  • Explain to the family that delirium is common and usually temporary and ask them to report sudden changes.

Next step: when to call for help

  • Call promptly for any new confusion, drowsiness or fluctuating attention.
  • Call at once if delirium comes with abnormal vital signs, low oxygen saturation, low or high glucose, fever or signs of alcohol withdrawal.
  • Call if the person is a danger to themselves or others despite de-escalation.
  • Call if delirium does not improve, so the team can re-evaluate causes and assess for dementia.

Test yourself

Think of the answer, then tap the question to see it.

Which signs suggest hypoactive delirium?

Withdrawal, slow responses, reduced mobility and movement, worse concentration and reduced appetite; it is often missed.

What should be done if it is unclear whether a person has delirium or dementia?

Manage it as delirium first and look for the underlying cause.

Which three nursing measures help prevent delirium?

For example: reorientation with a visible clock and calendar, adequate hydration and early mobilisation, glasses and hearing aids in use, and protected sleep.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Delirium: prevention, diagnosis and management in hospital and long-term care (CG103), recommendations (National Institute for Health and Care Excellence (NICE), 2023); Nursing: Mental Health and Community Concepts, 11.2: Psychosis and delirium (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations (National Institute for Health and Care Excellence (NICE), 2018).

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