Last Updated on by frcemuser


Precipitating factors for delirium

The mnemonic SMASHED is a useful aide memoir when assessing the possible causes or precipitants of acute confusion:

S Substrates: hyperglycaemia, hypoglycaemia, thiamine
M Meningitis and other CNS infections
Mental Illness, functional psychoses
A Alcohol intoxication or withdrawal
S Seizures: Seizure activity, post-ictal states
Stimulants: anticholinergics, hallucinogens, cocaine
H Hyper: hyperthyroidism, hyperthermia, hypercarbia
Hypo: hypothyroidism, hypothermia, hypoxia, hypotension
E Electrolytes: hypernatraemia, hyponatraemia, hypercalcaemia
Encephalopathy: hepatic, uraemic, hypertensive, others
D Drugs of any sort


  • Management of a person with delirium includes:
    • Correcting any precipitating factors e.g. infection, drugs, constipation, urinary retention, dehydration and electrolyte imbalance, pain
    • Optimising treatment of comorbidities
    • Managing behaviour change
      • Trying reorientation strategies e.g. regular cues, continuity of care from carers and staff
      • Maintaining safe mobility e.g. avoiding physical restraint, encouraging walking
      • Normalising the sleep-wake cycle e.g. discouraging napping and encouraging uninterrupted sleep at night
    • Managing challenging behaviour (such as aggression, agitation or shouting)
      • Addressing any underlying causes for the behaviour (such as discomfort, thirst, or need for the toilet).
      • Moving the person to a safe, low-stimulation environment (such as a quiet room).
      • Using verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, pictures, and symbols).
    • Pharmacological measures
      • Specialists may suggest pharmacological measures as a last resort for severe agitation or psychosis if:
        • Verbal and non-verbal de-escalation techniques are inappropriate or have failed, and
        • The person is a danger to themselves or others, and
        • The cause of delirium is known and being treated, and
        • The benefit outweighs the risk to the person, and
        • There is enough care in place for the person to be continually monitored.
      • The following medication may be suggested:
        • Short-term (for 1 week or less) low-dose haloperidol (off-label indication).
        • Low-dose lorazepam (off-label indication) as an alternative if haloperidol is contraindicated (for example in people with Parkinson’s disease/parkinsonism, Lewy-body dementia, or a prolonged QT interval).
      • Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms. The aim of drug treatment is to calm (not sedate) the person.
      • Most people with delirium should be admitted to the hospital for urgent assessment, close monitoring, and treatment. The decision as to whether to admit a person with delirium depends on the person’s specific clinical and social situation, and should also take into account the views of family members or carers. If the person is deemed to not have the capacity to consent, decisions should be made in the best interests of the person using the Mental Capacity Act 2005. If the person with delirium refuses admission ask carers or family (if appropriate) to help persuade the person. If this fails, consider admission under the Mental Capacity Act (2005).

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