The clinical background
Delirium treatment & the 4AT
Recognising delirium is the beginning of a response. Treatment means addressing contributing problems, relieving distress and supporting recovery.
A sudden change in brain function
Delirium is an acute change in mental functioning that develops over hours or days and often fluctuates. A person may have difficulty paying attention, become confused, or be unusually sleepy or agitated.
Some people become quiet and withdrawn rather than restless. Delirium can also occur in someone who already has dementia. Knowing what the person is usually like helps the team recognise a new change.
Background: NICE delirium guideline.
Treatment has several parts
There is no single bedside action that covers all of delirium treatment. The ACE-T paper uses multidomain delirium treatment for the package of actions involved.
Find and address contributing problems
Assess acute illness and other triggers, including pain, hydration, urinary retention, constipation and medicines. Arrange or escalate further assessment within local pathways.
Respond to the person’s experience
Assess distress, offer reassurance and reorientation, support communication, and involve people who know the patient where appropriate.
Support safety, care and recovery
Provide the support the person needs, document delirium, and coordinate a treatment plan with the multidisciplinary team.
Nursing and medical actions work together. ACE-T focuses on the initial nursing response; the full treatment plan continues beyond these first steps.
Why we use the 4AT
Delirium can be missed, especially when a patient is quiet or drowsy. The 4AT gives staff a brief, structured bedside assessment for delirium and cognitive impairment.
Its four items cover alertness, brief orientation questions, attention, and acute change or fluctuation. A score of 4 or more suggests delirium and should prompt clinical assessment and an appropriate response.
Interpret the result in the whole clinical context, including changes from the person’s usual state. The official 4AT user guide explains administration and scoring.
The 4AT supports detection. ACE-T supports the initial response. Document the 4AT score and delirium, communicate the delirium plan, and discuss actions with the team.
Use the assessment tool appropriate to your setting. NICE recommends CAM-ICU or ICDSC in critical care and the recovery room after surgery.
Connect detection to care
After a positive screen or recognition of suspected delirium, begin the applicable ACE-T actions and involve the clinical team. Urgent concerns need immediate action; the four-hour target helps organise the remaining initial response.
Sources: the current ACE-T manuscript, the 4AT user guide, and NICE recommendations on delirium assessment and treatment.