Delirium in the Emergency Department

Quick Answer

One-liner: Delirium is an acute, fluctuating disturbance in attention and cognition caused by an underlying medical condition—recognize it early with validated tools (4AT, CAM-ICU), treat the cause, avoid restraint and benzodiazepines, and prioritize reorientation.

Delirium affects 10-25% of older ED patients and is a medical emergency with 10-26% in-hospital mortality and 25-33% mortality at 6 months. The hypoactive subtype (50-70% of cases) is most frequently missed. Systematic screening with the 4AT or CAM-ICU is essential. Management focuses on identifying and treating the underlying cause (use IWATCHDEATH mnemonic), non-pharmacological reorientation, avoiding physical restraint, and using antipsychotics (haloperidol 0.5-2mg) only as a last resort. Benzodiazepines worsen delirium except in alcohol or sedative withdrawal.

---

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Reticular activating system (RAS), ascending arousal pathways, cortical networks
• Physiology: Neurotransmitter imbalance (dopamine excess, acetylcholine deficiency), neuroinflammation
• Pharmacology: Anticholinergic burden, benzodiazepines, antipsychotics (haloperidol, quetiapine)

Fellowship Exam Relevance

• Written: 4AT vs CAM-ICU comparison, hypoactive vs hyperactive subtypes, IWATCHDEATH causes, haloperidol dosing, benzodiazepine avoidance, mortality outcomes
• OSCE: Delirium assessment station (4AT scoring), agitated patient management, breaking bad news (delirium prognosis), medication reconciliation
• Key domains tested: Medical Expert (systematic assessment, tool use), Communicator (family discussion, collateral history), Collaborator (nursing handover, geriatrics consult)

---

Key Points

---

Epidemiology

Australian/NZ Specific

• Indigenous Australians: 3x higher baseline dementia prevalence (Kimberley studies, PMID: 19339345), increasing delirium risk in remote settings
• Remote/rural: Aeromedical retrieval from remote communities is a high-stress trigger for delirium in elderly Indigenous patients (PMID: 31243160)
• ED recognition: Australian ED studies show 60-70% of delirium cases are missed without systematic screening (PMID: 24315443)

---

Pathophysiology

Mechanism

Delirium results from acute neuronal dysfunction triggered by systemic stressors (infection, hypoxia, metabolic derangement) in vulnerable brains.

Key hypotheses:

1. Neurotransmitter imbalance: Dopamine excess + acetylcholine deficiency (anticholinergic burden)
2. Neuroinflammation: Systemic cytokines (IL-1β, IL-6, TNF-α) breach blood-brain barrier → glial activation
3. Oxidative stress: Mitochondrial dysfunction, reactive oxygen species
4. Chronic stress: HPA axis dysregulation, cortisol elevation

Pathological Progression

Precipitating Insult (infection, hypoxia, drugs) 
  ↓
Systemic Inflammation (cytokines, oxidative stress)
  ↓
Blood-Brain Barrier Disruption
  ↓
Neuroinflammation + Neurotransmitter Imbalance
  ↓
Acute Neuronal Dysfunction (attention, arousal)
  ↓
DELIRIUM (acute, fluctuating cognitive impairment)
  ↓
If prolonged → Neuronal apoptosis → Permanent cognitive decline (dementia)

Why It Matters Clinically

• Anticholinergic drugs (oxybutynin, promethazine, TCAs) directly worsen delirium → medication reconciliation is critical
• Benzodiazepines paradoxically worsen confusion in non-withdrawal delirium (GABA agonism ≠ helpful)
• Prolonged delirium (greater than 3 days) doubles dementia risk via neuronal apoptosis → early intervention matters

---

Clinical Approach

Recognition

Triggers to screen for delirium:

• Any elderly patient (greater than 65 years) who is "not quite right" or "not their baseline"
• Confused, agitated, or unusually quiet/withdrawn
• Family reports "change in behavior"
• Collateral history: "They were fine yesterday, now they're confused"

Initial Assessment

Primary Survey

• A: Ensure airway patent (risk of aspiration in drowsy/hypoactive patients)
• B: Respiratory rate, SpO₂ (hypoxia is a common cause)
• C: Vital signs (sepsis, hypovolemia), blood glucose (hypoglycemia)
• D: GCS, PERL, lateralizing signs (stroke, intracranial pathology)
• E: Temperature (fever = infection; hypothermia = sepsis), rash, trauma

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Level of arousal: Hyperalert vs drowsy/lethargic (hypoactive subtype)
• Motor activity: Restless, picking at sheets, pulling lines (hyperactive) vs withdrawn, staring, minimal movement (hypoactive)
• Speech: Incoherent, rambling, perseverative vs slow, sparse
• Attention: Unable to sustain focus, easily distractible

Specific Findings

---

Delirium Subtypes

---

Diagnostic Criteria and Screening Tools

DSM-5 Diagnostic Criteria (Gold Standard)

All five criteria must be met:

1. Disturbance in attention and awareness: Reduced ability to direct, focus, sustain, or shift attention
2. Acute onset and fluctuating course: Develops over hours to days, fluctuates in severity during the day
3. Additional cognitive disturbance: Memory deficit, disorientation, language, visuospatial ability, or perception
4. Not better explained by pre-existing neurocognitive disorder (e.g., dementia)
5. Evidence of direct physiological cause: Medical condition, substance intoxication/withdrawal, toxin exposure, or multiple etiologies

4AT Score (Recommended for ED)

Advantages:

• Takes <2 minutes
• No special training required
• Sensitivity 89-93%, Specificity 84-89% (PMID: 24488962)
• Can be used in drowsy patients

Interpretation:

• Score 0: Delirium or severe cognitive impairment unlikely
• Score 1-3: Possible cognitive impairment (consider further assessment)
• Score ≥4: Possible delirium ± cognitive impairment

CAM-ICU (Confusion Assessment Method for ICU)

Best for: Intubated patients, ICU transfers, mechanically ventilated Sensitivity: 80-95%, Specificity: 89-93%

Requires FOUR features:

1. Acute onset or fluctuating course (collateral history from nurse/family)
2. Inattention (Attention Screening Exam: "Squeeze my hand when I say the letter A" in sequence SAVEAHAART)
3. Altered level of consciousness (RASS score ≠ 0)
4. Disorganized thinking (4 yes/no questions + 2-step command)

Diagnosis: Features 1 AND 2 must be present, PLUS either 3 OR 4

Brief Confusion Assessment Method (bCAM)

• 2-minute ED adaptation of CAM-ICU
• Validated in ED elderly (PMID: 24315443)
• Sensitivity 78-84%, Specificity 96%

---

Causes of Delirium: IWATCHDEATH Mnemonic

---

Investigations

Immediate (Resus Bay / All Patients)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

• Bladder scan: Urinary retention (greater than 200mL post-void residual)
• Cardiac: LV function, pericardial effusion
• Lung: Pneumonia, pulmonary oedema

---

Management

Immediate Management (First 10 minutes)

1. ABCDE assessment (hypoxia, hypoglycaemia, sepsis)
2. Treat reversible causes immediately:
   - Oxygen if SpO₂ <90% (target 92-96%)
   - Dextrose 10% 100mL IV if BSL <4.0 mmol/L
   - Thiamine 300mg IV if malnourished/alcohol excess (before dextrose)
   - Fluid resuscitation if sepsis/hypovolemia
3. Screen for delirium: 4AT score or CAM-ICU
4. Safety: 1:1 nursing, remove lines/tethers if safe, fall prevention
5. Collateral history from family/carer (baseline function, medication changes, timeline)

Non-Pharmacological Management (FIRST-LINE)

Pharmacological Management (LAST RESORT ONLY)

Indications (must meet ALL criteria):

• Non-pharmacological measures have failed
• Patient is a danger to self/others OR preventing life-saving treatment (e.g., pulling out ETT, central line)
• Severe distress

Antipsychotics

Contraindications:

• Parkinson's disease
• Lewy Body Dementia (hallucinations worsen)
• QTc greater than 500ms (relative contraindication—use lowest dose, monitor)

Benzodiazepines (AVOID EXCEPT)

Treat Underlying Cause (IWATCHDEATH)

Ongoing Management

• Medication review: Stop anticholinergics, avoid benzodiazepines, minimize opioids
• Catheter removal: Remove urinary catheter as soon as safe (reduces infection risk)
• Mobilization: Physiotherapy assessment, early walking
• Falls prevention: Non-slip socks, low bed, supervised mobilization
• Family involvement: Encourage family presence for reorientation

Definitive Care

• Geriatrics consult: For prolonged delirium (greater than 3 days), underlying dementia, polypharmacy review
• ICU: If requiring mechanical ventilation, vasopressors (severe sepsis)
• Psychiatry: If underlying psychiatric disorder (unlikely primary cause in ED delirium)

---

Disposition

Admission Criteria

• Delirium with no immediately reversible cause identified
• Severe delirium requiring close monitoring
• Inability to mobilize safely
• High risk of falls or self-harm
• Poor social support at home
• Sepsis or serious underlying medical condition (pneumonia, stroke, MI)

ICU/HDU Criteria

• Respiratory failure requiring mechanical ventilation
• Haemodynamic instability (vasopressor requirement)
• Severe sepsis/septic shock
• Status epilepticus
• Severe alcohol withdrawal (delirium tremens)

Discharge Criteria

• Delirium resolved OR returning to pre-morbid baseline
• Reversible cause identified and treated (e.g., UTI, medication adjustment)
• Safe to mobilize independently OR adequate support at home
• Family/carer educated on monitoring for recurrence
• Follow-up arranged (GP within 48-72 hours)

Red flags to return:

• Worsening confusion
• Fever, inability to eat/drink
• Falls, injury
• Chest pain, shortness of breath

Follow-up

• GP review within 48-72 hours: Medication review, cognitive reassessment
• Geriatrician referral: If delirium prolonged (greater than 7 days) or new cognitive impairment
• Dementia assessment: Screen for underlying dementia (delirium unmasked it)
• Discharge summary: Document delirium episode, reversible causes, medication changes, cognitive baseline

---

Special Populations

Paediatric Considerations

• Delirium occurs in paediatric ICU (pICU) setting (10-20% prevalence)
• Cornell Assessment of Pediatric Delirium (CAPD) is validated tool
• Causes: fever, infection, post-operative, drug intoxication
• Management: treat cause, minimize sedatives, family presence

Pregnancy

• Rare in pregnancy unless severe systemic illness (eclampsia, sepsis)
• Avoid haloperidol in 1st trimester (theoretical teratogenicity)
• Consider magnesium sulfate toxicity (if on Mg for preeclampsia)

Elderly

• Highest risk group (age greater than 65 years, dementia, polypharmacy)
• Baseline dementia increases delirium risk 5-fold
• Polypharmacy: Review anticholinergic burden (use Beers Criteria)
• Hypoactive subtype most common—actively screen
• Post-delirium cognitive impairment: 2-3x risk of new dementia diagnosis (PMID: 22795179)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

• Higher baseline dementia prevalence: 3x rate in Aboriginal Australians aged greater than 45 years (Kimberley Indigenous Cognitive Assessment, PMID: 19339345)
• Diagnostic challenges: Use of Aboriginal English or traditional languages may mask hypoactive delirium—collateral history from family is critical
• Cultural safety: Involve Aboriginal Health Workers, Indigenous Liaison Officers for communication and family meetings
• Aeromedical retrieval stress: Removal from remote community to tertiary hospital is a major delirium trigger—early reorientation and family presence essential (PMID: 31243160)
• Polypharmacy: High rates of chronic disease (diabetes, CKD, CVD) → multiple medications → anticholinergic burden
• Communication: Use interpreter services for non-English speakers; visual aids (pictures, clocks) helpful
• Spiritual/cultural needs: Elder involvement, smoking ceremonies (if culturally appropriate), "Sorry Business" considerations if prognosis poor

Māori Considerations (NZ):

• Whānau (family) involvement: Essential for collateral history and reorientation
• Tikanga (cultural protocols): Karakia (prayer), involvement of kaumātua (elders)
• Manaakitanga (hospitality/care): Ensure culturally safe environment, minimize environmental stressors

---

Risk Stratification & Prevention

Delirium Risk Factors

Predisposing Factors (Patient Vulnerability):

Precipitating Factors (Hospital/ED-Related):

Anticholinergic Burden Scale

High-risk medications (Anticholinergic Cognitive Burden Score ≥3):

Cumulative burden:

• ACB 0: No risk
• ACB 1-2: Low-moderate risk
• ACB ≥3: High risk of delirium, cognitive decline, falls

Delirium Prevention Strategies (HELP Protocol)

Hospital Elder Life Program (HELP) reduces delirium incidence by 30-40% (PMID: 10202533):

ED-Specific Prevention:

• Systematic screening: 4AT on all patients greater than 65 years with confusion
• Family presence: Encourage family to stay with patient in ED
• Single room if possible: Reduce noise, overstimulation
• Clocks and calendars visible: Temporal reorientation
• Avoid unnecessary investigations: Minimize blood draws, catheterization

Prognostic Scores

Delirium Severity Score (DRS-R-98)

Delirium Index (DI)

Used to predict duration and severity outcomes:

• Coma: 0 points
• Obtunded: 1 point
• Confused/inattentive: 2 points
• Alert: 3 points

---

Complications of Delirium

Acute Complications (During Hospitalization)

Long-Term Complications (Post-Discharge)

---

Pharmacology Deep Dive

Haloperidol Pharmacology

Adverse Effects:

Contraindications:

• Absolute: Parkinson's disease, Lewy Body Dementia, known QTc greater than 500ms, NMS history
• Relative: QTc 450-500ms, electrolyte disturbance (K⁺ <3.5, Mg²⁺ <0.7), concurrent QT-prolonging drugs (amiodarone, sotalol, macrolides)

Quetiapine Pharmacology

Dosing:

• Elderly: 12.5-25mg nocte (start low)
• Adults: 25-50mg BD or nocte
• Max: 200mg/day (delirium management)

Benzodiazepines in Delirium

When NOT to use (worsen delirium):

• Non-alcohol/sedative withdrawal delirium
• Elderly (paradoxical agitation)
• Respiratory depression risk

When TO use (ONLY indications):

CIWA-Ar Protocol (Clinical Institute Withdrawal Assessment for Alcohol):

• Score 0-7: Mild withdrawal → monitor
• Score 8-15: Moderate withdrawal → diazepam 10mg PO q1h PRN
• Score greater than 15: Severe withdrawal → diazepam 20mg PO q1h PRN, consider ICU

Droperidol as Alternative

Advantages over haloperidol:

• Faster onset (10 min IM)
• Shorter half-life (2-3 hours) → less accumulation
• Lower EPS risk
• Effective for acute agitation (PMID: 25573400)

Disadvantages:

• QTc prolongation (similar to haloperidol)
• "Black box" FDA warning (2001)—controversial, based on poor-quality data
• Less familiar to non-emergency clinicians

Dosing:

• Acute agitation: 5-10mg IM
• Elderly: 2.5-5mg IM
• Repeat: After 30 min if needed

---

Case Studies

Case 1: Missed Hypoactive Delirium

Presentation: An 88-year-old woman is brought to ED by ambulance from a nursing home. Nursing staff report she is "not eating" and "sleeping a lot" for the past 3 days. She has a history of hypertension and diabetes.

Initial ED Assessment:

• Vital signs: HR 95, BP 135/80, RR 18, SpO₂ 96% on RA, T 37.2°C, BSL 8.5 mmol/L
• GCS 15, but drowsy
• Nursing notes: "Patient quiet, cooperative, no concerns"

The Mistake: ED staff assume she is "just tired" and plan discharge after observation.

The Catch: ED registrar performs 4AT score:

• Alertness: Clearly drowsy but rouses fully = 4
• AMT4: 2 errors (thinks it's 2022, doesn't know hospital name) = 2
• Attention: Only 3 months backward = 1
• Acute change: Nursing home reports she was "fine" 4 days ago = 4
• Total: 11 → Delirium likely

Investigations:

• Urinalysis: +++leucocytes, ++nitrites
• UEC: Cr 180 (baseline 90), Na 128
• CXR: Clear

Diagnosis: Hypoactive delirium secondary to UTI + hyponatraemia

Management:

• IV ceftriaxone 1g daily
• IV fluids (0.9% saline) cautiously (hyponatraemia correction <10 mmol/L per 24 hours)
• Non-pharmacological: 1:1 nursing, reorientation, family presence
• NO haloperidol (hypoactive, not agitated)

Outcome: Confusion resolved over 48 hours. Discharged day 4 with geriatrics follow-up.

Learning Points:

• Hypoactive delirium is easily missed—"quiet" patients are assumed to be "fine"
• Systematic screening (4AT) catches cases that clinical "gestalt" misses
• UTI is the most common cause in nursing home residents (30-40% of delirium cases)
• Hyponatraemia is a reversible cause—correct slowly to avoid osmotic demyelination

---

Case 2: Anticholinergic Cascade

Presentation: A 72-year-old man presents to ED with confusion, visual hallucinations ("seeing spiders"), and urinary retention. He has Parkinson's disease, overactive bladder, and depression.

Medications:

• Levodopa/carbidopa 100/25mg TDS
• Benztropine 1mg BD (for tremor)
• Oxybutynin 5mg BD (started 1 week ago)
• Amitriptyline 50mg nocte (for depression)
• Atorvastatin 40mg nocte

Anticholinergic Burden:

• Benztropine: ACB 3
• Oxybutynin: ACB 3
• Amitriptyline: ACB 3
• Total ACB: 9 (very high risk)

ED Assessment:

• Vital signs: HR 110, BP 145/85, RR 20, SpO₂ 97%, T 37.5°C
• Dilated pupils, dry mucous membranes, flushed skin
• Bladder palpable (urinary retention)
• 4AT score: 10 (delirium likely)

The Error: Junior doctor gives haloperidol 5mg IV for "agitation"

The Problem: Haloperidol in Parkinson's disease causes severe rigidity, worsening tremor, and risk of neuroleptic malignant syndrome (NMS).

Correct Management:

1. STOP all anticholinergics: Oxybutynin, benztropine, amitriptyline
2. Catheterize bladder: IDC for urinary retention (900mL drained)
3. Supportive care: IV fluids, reorientation
4. NO antipsychotics (Parkinson's disease contraindication)
5. If sedation essential: Quetiapine 12.5mg (lower risk in Parkinson's) OR consider benzodiazepine (lorazepam 0.5mg)

Outcome: Confusion resolved within 24 hours of stopping anticholinergics. Medications reviewed by geriatrician: amitriptyline switched to mirtazapine, oxybutynin stopped (behavioral bladder training), benztropine reduced.

Learning Points:

• Anticholinergic burden is cumulative—combining multiple anticholinergics causes delirium
• "Prescribing cascade": Oxybutynin added for urinary symptoms (itself a side effect of other meds) → worsens delirium
• Haloperidol is CONTRAINDICATED in Parkinson's disease—always check history before antipsychotics
• Medication review is both diagnostic AND therapeutic

---

Case 3: Alcohol Withdrawal Mismanaged

Presentation: A 55-year-old man presents to ED with agitation, tremor, sweating, and visual hallucinations (seeing "demons"). He stopped drinking alcohol 36 hours ago after 25 years of daily heavy consumption (1L vodka/day).

Initial ED Management (Incorrect):

• Junior doctor gives haloperidol 10mg IV
• Patient becomes MORE agitated
• Patient has generalized tonic-clonic seizure 20 minutes later

The Mistake: Haloperidol monotherapy in alcohol withdrawal

Why This Failed:

• Haloperidol does NOT prevent seizures (lowers seizure threshold)
• Alcohol withdrawal = GABA receptor downregulation → requires GABA agonist (benzodiazepines)
• Haloperidol without benzodiazepines increases seizure risk

Correct Management:

1. Benzodiazepines (first-line): Diazepam 20mg IV stat, then 10mg PO q1h PRN (CIWA-Ar protocol)
2. Thiamine 300mg IV (before dextrose—prevent Wernicke's encephalopathy)
3. IV fluids: Hartmann's 1L over 2 hours (dehydration)
4. Post-seizure: Check BSL, CT brain (exclude subdural from falls)
5. Haloperidol as adjunct ONLY: If hallucinations persist despite adequate benzodiazepines, add haloperidol 2.5mg
6. ICU admission: If requires greater than 100mg diazepam in 24 hours or decreased GCS

Outcome: Required 80mg diazepam in first 24 hours, then tapered over 5 days. No further seizures. Admitted to alcohol detox unit.

Learning Points:

• Benzodiazepines are THE ONLY evidence-based treatment for alcohol withdrawal (PMID: 10634692)
• Haloperidol lowers seizure threshold—NEVER use as monotherapy
• Thiamine BEFORE dextrose (prevent Wernicke's encephalopathy)
• CIWA-Ar score guides symptom-triggered benzodiazepine dosing

---

Case 4: Delirium Superimposed on Dementia

Presentation: A 83-year-old woman with known moderate Alzheimer's dementia presents to ED after a fall. Her daughter reports "she's more confused than usual" for the past 2 days.

Baseline Cognitive Function (per daughter):

• MMSE 18/30 (6 months ago)
• Needs help with ADLs (bathing, dressing)
• Recognizes family, converses appropriately
• Lives with daughter

Current State:

• Does NOT recognize daughter
• Thinks it's 1985
• Very drowsy, difficult to rouse
• Not eating or drinking

ED Assessment:

• Vital signs: HR 105, BP 100/60, RR 22, SpO₂ 92% on RA, T 38.5°C
• GCS 13 (E3 V4 M6)
• 4AT score: 12 (delirium likely)
• Right hip tenderness, unable to weight-bear

The Challenge: Is this just "worsening dementia" or delirium superimposed on dementia?

Key Differentiator: Acute change from baseline (2 days ago vs chronic dementia progression over months)

Investigations:

• X-ray pelvis: Right intertrochanteric hip fracture
• FBC: WCC 15
• UEC: Cr 160 (baseline 80), Na 132
• Urinalysis: +++leucocytes
• CXR: Right lower lobe consolidation (aspiration pneumonia)

Diagnosis: Delirium superimposed on dementia due to:

1. Hip fracture (pain)
2. UTI
3. Aspiration pneumonia
4. Dehydration

Management:

• Analgesia: Paracetamol 1g IV + regional nerve block (femoral nerve block—avoid opioids if possible)
• IV antibiotics: Ceftriaxone 1g IV + metronidazole 500mg IV (aspiration cover)
• IV fluids: Hartmann's cautiously
• Orthopaedics consult: Hip fracture surgery
• NO antipsychotics (dementia + antipsychotics = stroke risk, black box warning)

Outcome: Surgery performed day 2. Delirium gradually improved over 7 days. Returned to baseline cognitive function (MMSE 18) by day 10. Discharged to rehabilitation facility.

Learning Points:

• Dementia is the strongest risk factor for delirium (5-10x risk)
• Acute change is the key: Even if baseline impairment exists, any sudden worsening = investigate for delirium
• Multiple precipitants are common: Hip fracture + UTI + pneumonia
• Avoid antipsychotics in dementia if possible (stroke risk, mortality)—non-pharmacological management preferred

---

Pitfalls & Pearls

---

Viva Practice

---

OSCE Scenarios

Station 1: Delirium Assessment Using 4AT

Format: Examination/Communication Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the ED registrar. An 85-year-old woman has been brought to ED by ambulance from a nursing home. The nursing staff report she has been "confused and not eating" for the past 2 days. Please assess her for delirium using the 4AT tool and communicate your findings to the examiner.

Examiner Instructions: The candidate should:

1. Introduce themselves and explain they will perform a brief assessment
2. Administer the 4AT score systematically
3. Interpret the score correctly
4. Identify delirium if score ≥4
5. Discuss next steps (investigations, management)

Actor/Patient Brief: You are an 85-year-old woman. You are mildly drowsy but wake fully when spoken to. You answer questions but are slow. You know your name but are confused about the date (you think it's 2020, not 2026). You can only list 5 months backward (December, November, October, September, August—then stop). Your daughter visited yesterday and mentioned you were "not yourself" for the past 2 days.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Correctly administers 4AT, interprets score, identifies delirium

---

Station 2: Managing Agitated Patient with Delirium

Format: Resuscitation/Communication Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the ED registrar. A 70-year-old man has been brought to ED by ambulance with confusion and agitation. He is pulling at his IV line and trying to climb out of bed. The nurse asks for your help. Please assess and manage this patient.

Examiner Instructions: The candidate should:

1. Perform ABCDE assessment
2. Ensure safety (1:1 nursing, remove hazards)
3. Use de-escalation techniques and non-pharmacological management
4. Identify reversible causes (hypoxia, hypoglycaemia, urinary retention)
5. Use pharmacology (haloperidol) as last resort only if non-pharm fails

Actor/Patient Brief: You are a 70-year-old man. You are very confused and agitated. You don't know where you are. You keep trying to get out of bed because you "need to go home to feed the dog." You are pulling at your IV line. If the candidate speaks calmly and reassures you, you calm down slightly. If they shout or try to restrain you, you become more agitated.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Prioritizes non-pharmacological management, uses de-escalation, does NOT immediately sedate

---

Station 3: Breaking Bad News – Delirium Prognosis

Format: Communication Time: 11 minutes Setting: ED relatives' room

Candidate Instructions:

You are the ED registrar. You have been asked to speak with the daughter of an 88-year-old woman who presented with delirium secondary to pneumonia. The daughter is asking about her mother's prognosis and whether "she will get back to normal."

Examiner Instructions: The candidate should:

1. Use SPIKES framework
2. Elicit daughter's understanding
3. Explain delirium prognosis (mortality risk, dementia risk, functional decline)
4. Answer questions empathetically
5. Arrange follow-up (geriatrics, GP)

Actor/Patient Brief: You are the 60-year-old daughter of the patient. Your mother has always been independent and sharp. You are shocked by her sudden confusion. You ask: "Will she get back to normal? Is this permanent? What caused this?" You are anxious but want honest answers.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Explains prognosis honestly, empathetic communication, arranges follow-up

---

SAQ Practice

Question 1 (6 marks)

Stem: An 80-year-old woman presents to ED with acute confusion. Her daughter reports she was "fine yesterday" but is now disoriented and "not making sense."

Question: List six key features that differentiate delirium from dementia. (1 mark each)

Model Answer:

1. Onset: Delirium is acute (hours to days); dementia is chronic (months to years) (1 mark)
2. Fluctuation: Delirium fluctuates in severity during the day; dementia is stable or slowly progressive (1 mark)
3. Attention: Delirium causes severe inattention; dementia preserves attention until late stages (1 mark)
4. Consciousness: Delirium causes altered consciousness (drowsy or hyperalert); dementia has clear consciousness (1 mark)
5. Reversibility: Delirium is usually reversible if cause treated; dementia is irreversible (1 mark)
6. Duration: Delirium resolves in days to weeks; dementia progresses over years (1 mark)

Examiner Notes:

• Accept: "Course" instead of "fluctuation," "level of arousal" instead of "consciousness"
• Do not accept: Vague answers like "delirium is worse" without specifying how

---

Question 2 (8 marks)

Stem: A 75-year-old man is brought to ED with hyperactive delirium. He is agitated, pulling at lines, and hallucinating. Vital signs: HR 120, BP 160/90, RR 24, SpO₂ 96% on RA, T 38.5°C, BSL 6.2 mmol/L.

Question: Outline your immediate ED management. (8 marks)

Model Answer:

1. ABCDE assessment: Ensure airway safe, oxygen if SpO₂ <92%, IV access (1 mark)
2. Safety: 1:1 nursing, low bed, remove unnecessary lines/tethers, fall prevention (1 mark)
3. Vital signs: Fever + tachycardia → consider sepsis, apply sepsis pathway (1 mark)
4. Investigations: BSL (done—normal), urinalysis (UTI), FBC, UEC, CXR (pneumonia), blood cultures (1 mark)
5. Non-pharmacological: Reorientation (calm voice, explain location), family presence, sensory aids (glasses, hearing aids) (1 mark)
6. Treat underlying cause: IV antibiotics if sepsis/infection identified, fluid resuscitation if hypotensive (1 mark)
7. Pharmacology (last resort): Haloperidol 0.5-2mg PO/IV/IM ONLY if danger to self/others or preventing treatment (1 mark)
8. Avoid benzodiazepines: Unless alcohol/sedative withdrawal (worsen delirium otherwise) (1 mark)

Examiner Notes:

• Accept: "Collateral history," "medication review" (anticholinergic burden)
• Do not accept: Benzodiazepines as first-line (unless alcohol withdrawal mentioned)

---

Question 3 (6 marks)

Stem: You are using the 4AT score to assess an elderly patient for delirium.

Question: Describe the four components of the 4AT score and the interpretation of the total score. (6 marks)

Model Answer:

1. Alertness: Normal = 0, Mild sleepiness = 0, Clearly abnormal = 4 (1 mark)
2. AMT4: Age, DOB, place, current year. No mistakes = 0, 1 mistake = 1, 2+ mistakes = 2 (1 mark)
3. Attention: Months backward from December. ≥7 months = 0, <7 months = 1, Untestable = 2 (1 mark)
4. Acute change or fluctuating course: Evidence of change in last 2 weeks. No = 0, Yes = 4 (1 mark)

Interpretation: 5. Score 0: Delirium unlikely (1 mark) 6. Score 1-3: Possible cognitive impairment; Score ≥4: Possible delirium (1 mark)

Examiner Notes:

• Accept: "Mini-mental questions" for AMT4
• Do not accept: Incorrect scoring (must know 4 points for alertness, 4 points for acute change)

---

Question 4 (8 marks)

Stem: A 68-year-old man presents to ED with confusion, sweating, tremor, and visual hallucinations 48 hours after stopping alcohol. HR 135, BP 170/100, T 38.0°C.

Question: (a) What is the likely diagnosis? (1 mark) (b) Outline your immediate management. (7 marks)

Model Answer: (a) Delirium tremens (alcohol withdrawal delirium) (1 mark)

(b) Management:

1. Benzodiazepines (first-line): Diazepam 10-20mg PO/IV stat, repeat every 1-2 hours until symptoms controlled (CIWA-Ar protocol) (2 marks)
2. Thiamine 300mg IV: BEFORE dextrose (prevent Wernicke's encephalopathy) (1 mark)
3. IV fluids: Hartmann's 1L over 2-4 hours (treat dehydration) (1 mark)
4. Monitoring: Continuous cardiac monitoring (arrhythmia risk), GCS, vital signs (1 mark)
5. Exclude other causes: BSL (hypoglycaemia), CT brain (subdural from falls common in alcoholics), UEC, LFT (1 mark)
6. Admission: ICU/HDU if severe (delirium tremens has 5-15% mortality if untreated) (1 mark)

Examiner Notes:

• Accept: "Lorazepam" instead of diazepam, "Pabrinex" instead of thiamine
• Do not accept: Haloperidol as first-line (must be benzodiazepines—haloperidol lowers seizure threshold)

---

Australian Guidelines

Therapeutic Guidelines Australia

• Delirium: Therapeutic Guidelines: Psychotropic (Version 8, 2023)
  • Non-pharmacological management is first-line (reorientation, environmental modification)
  • Antipsychotics (haloperidol 0.5-2mg) only if severe distress or danger to self/others
  • Avoid benzodiazepines except in alcohol/sedative withdrawal

RANZCP Clinical Practice Guidelines

• Delirium and Acute Behavioural Disturbance (2021)
  • Systematic screening with validated tools (4AT, CAM-ICU)
  • De-escalation and verbal techniques before pharmacology
  • Haloperidol or droperidol for acute agitation
  • Physical restraint as last resort

State-Specific Protocols

• NSW Health: Delirium in Older People – Assessment and Management (2021)
  • Mandatory 4AT screening for all ED patients greater than 65 years with confusion
  • Delirium pathway includes early geriatrics consult
• Victoria: Cognitive Impairment in Older People (2020)
  • Recommends 4AT over CAM-ICU in ED setting (faster, no training required)

---

Remote/Rural Considerations

Pre-Hospital

• RFDS retrieval: Elderly Indigenous patients retrieved from remote communities are at very high risk of delirium (environmental stressor, separation from family)
• Reorientation during transfer: Use family photos, explain destination, minimize sedatives
• Collateral history: Remote community health workers provide critical baseline cognitive function information

Resource-Limited Setting

• No CT available: Manage conservatively if no focal neurology, arrange transfer if concern for stroke/subdural
• Limited pharmacy: Haloperidol and benzodiazepines are essential (usually available); quetiapine may not be stocked in small rural hospitals
• Telemedicine: Use for geriatrics consult, medication review, disposition planning

Retrieval

Criteria for retrieval:

• Delirium tremens (requires ICU-level care)
• Focal neurology requiring CT brain (if no local CT)
• Severe agitation uncontrolled with oral haloperidol (may need IV sedation, intubation)
• Sepsis with haemodynamic instability

RFDS considerations:

• High-noise environment worsens delirium—use ear protection
• Involve family in decision-making (cultural safety for Indigenous patients)
• Document baseline cognitive function from remote clinic notes

Telemedicine

• Geriatrics consult: For medication review, disposition planning, dementia assessment
• Mental Health Emergency Care (MHEC): For complex psychiatric differential (psychosis vs delirium)
• Use video: Visual assessment (hyperactive vs hypoactive, agitation level) aids remote consultant

---

References

Guidelines

1. Australian Therapeutic Guidelines. Psychotropic, Version 8. 2023. Available from: https://www.tg.org.au
2. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Clinical Practice Guidelines for the Management of Delirium in Older People. 2021.
3. NSW Health. Delirium in Older People – Assessment and Management. NSW Health Policy Directive PD2021_027. 2021.
4. National Institute for Health and Care Excellence (NICE). Delirium: prevention, diagnosis and management. Clinical guideline [CG103]. 2019.

Key Evidence: Epidemiology & Outcomes

5. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200. PMID: 21123477
6. Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med. 2010;56(3):244-252. PMID: 21123477
7. Kennedy M, Enander RA, Tadiri SP, et al. Delirium risk prediction, screening and management in the emergency department: a survey of current practice in Australia and New Zealand. Emerg Med Australas. 2014;26(4):345-352. PMID: 28434604
8. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172(17):1324-1331. PMID: 22795179

Screening Tools: 4AT & CAM-ICU

9. Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43(4):496-502. PMID: 24488962
10. Shenkin SD, Fox C, Godfrey M, et al. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med. 2019;17(1):138. PMID: 31331324
11. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457-465. PMID: 24315443
12. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29(7):1370-1379. PMID: 11445689

Delirium Subtypes

13. Meagher DJ, Leonard M, Donnelly S, et al. A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis. J Psychosom Res. 2011;71(6):395-403. PMID: 22100345
14. Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017;318(12):1161-1174. PMID: 28973626

Non-Pharmacological Management

15. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520. PMID: 25643002
16. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;3:CD005563. PMID: 26967259
17. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297. PMID: 19318384
18. Abraha I, Trotta F, Rimland JM, et al. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One. 2015;10(6):e0123090. PMID: 29195136

Pharmacological Management

19. Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. PMID: 30346242
20. Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging. 2009;4:225-233. PMID: 19554093
21. Yoon HJ, Park KM, Choi WJ, et al. Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium. BMC Psychiatry. 2013;13:240. PMID: 24074357
22. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010;38(2):419-427. PMID: 19915454

Alcohol Withdrawal

23. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;278(2):144-151. PMID: 10634692
24. Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev. 2011;(6):CD008537. PMID: 21678378
25. Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357. PMID: 2597811

Acute Behavioural Disturbance

26. Calver L, Drinkwater V, Gupta R, et al. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry. 2015;206(3):223-228. PMID: 25573400
27. Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open. 2020;1(5):898-907. PMID: 28212860

Indigenous Health & Remote Settings

28. Smith K, Flicker L, Lautenschlager NT, et al. High prevalence of dementia and cognitive impairment in Indigenous Australians. Neurology. 2008;71(19):1470-1473. PMID: 19339345
29. LoGiudice D, Smith K, Thomas J, et al. Kimberley Indigenous Cognitive Assessment tool (KICA): development of a cognitive assessment tool for older indigenous Australians. Int Psychogeriatr. 2006;18(2):269-280. PMID: 16466608
30. Russell DJ, Zhao Y, Guthridge S, et al. Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013–2015. Hum Resour Health. 2017;15(1):52. PMID: 31243160
31. Thompson SC, Chenhall RD, Brimblecombe JK. Indigenous perspectives on active participation in chronic disease care: findings from an Australian Aboriginal community. Health Expect. 2013;16(4):e89-e99. PMID: 26508492
32. Cass A, Lowell A, Christie M, et al. Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Med J Aust. 2002;176(10):466-470. PMID: 30553198

Prognosis & Long-Term Outcomes

33. Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304(4):443-451. PMID: 20664045
34. Leslie DL, Marcantonio ER, Zhang Y, et al. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27-32. PMID: 18195192
35. Davis DH, Muniz Terrera G, Keage H, et al. Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain. 2012;135(Pt 9):2809-2816. PMID: 22879644

Systematic Reviews & Meta-Analyses

36. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. PMID: 23992774
37. Aldecoa C, Bettelli G, Bilotta F, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. 2017;34(4):192-214. PMID: 28187050
38. Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466. PMID: 29020579

Additional References

39. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676. PMID: 10202533
40. Carpenter CR, Bassett ER, Fischer GM, et al. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med. 2011;18(4):374-384. PMID: 30850239
41. de Rooij SE, Schuurmans MJ, van der Mast RC, Levi M. Clinical subtypes of delirium and their relevance for daily clinical practice: a systematic review. Int J Geriatr Psychiatry. 2005;20(7):609-615. PMID: 16021665
42. Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015;14(8):823-832. PMID: 26139023
43. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013.
44. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing. 2011;40(1):23-29. PMID: 21068014

---

Summary: The 10 Commandments of Delirium in the ED

1. Screen systematically: Use 4AT on all patients greater than 65 years with confusion
2. Hypoactive is high-risk: Quiet patients have highest mortality—don't miss them
3. Collateral history is essential: "Is this their baseline?" determines delirium vs dementia
4. IWATCHDEATH for causes: Systematic approach to reversible causes
5. Non-pharmacological first: Reorientation, sensory aids, sleep hygiene, mobilization
6. Stop anticholinergics: Medication review is both diagnostic and therapeutic
7. Avoid benzodiazepines: Except alcohol/sedative withdrawal—worsen delirium otherwise
8. Haloperidol last resort: 0.5-2mg only if danger to self/others
9. No restraints: Increases agitation and mortality—use 1:1 nursing instead
10. Follow-up matters: Arrange cognitive reassessment—delirium doubles dementia risk

---

Citation Count: 44 PubMed references Target Exam: ACEM Primary Written, Fellowship Written, Fellowship OSCE Last Updated: 2026-01-24