Recognition and diagnostic confirmation #
Establish an acute departure from baseline attention, awareness and cognition with fluctuation. Obtain collateral when the person cannot provide a reliable timeline. A screening result suggests the need for diagnostic assessment; it does not identify the cause. Dementia and delirium can coexist, and reduced activity does not indicate a mild presentation.
Bedside assessment #
Check oxygenation, glucose, circulation, temperature, pain and neurological findings, then reconcile prescribed and non-prescribed medicines. Ask about recent dose changes, interrupted alcohol or sedatives, food and fluid intake, sleep, constipation and urinary retention. Examine hearing and vision access before interpreting poor engagement as psychosis.
Differential clues #
| Alternative / overlap | Discriminating assessment |
|---|---|
| Dementia | Establish baseline function and the abrupt component; do not exclude superimposed delirium. |
| Non-convulsive seizures | Consider EEG for suspicious episodic changes or unexplained persistent altered awareness. |
| Primary mood or psychotic disorder | Look for preserved attention and a syndrome timeline; abnormal physiology still requires medical assessment. |
Targeted investigations #
| Test | When it helps |
|---|---|
| Glucose, blood count, electrolytes, renal/liver profile, calcium | Suspected metabolic, infectious or organ-failure contributors. |
| ECG and electrolytes | Cardiac illness or contemplated QT-active medication. |
| Chest imaging / cultures | Clinical evidence of an infection source. |
| Bladder scan | Suspected retention. |
| Brain imaging, lumbar puncture or EEG | Selected neurological findings, trauma, CNS infection or seizure concern; not a universal delirium panel. |
Cause-directed care and distress management #
Treat the identified illness and reduce avoidable physiological and environmental stress. Use consistent explanations, familiar people, access to glasses/hearing aids, sleep support and assisted mobilisation. Reserve haloperidol for distress or danger when de-escalation is ineffective or inappropriate and contraindications have been checked.
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Haloperidol
Short-term acute delirium symptoms after non-drug measures fail
Adults · Oral solution, 10 mg/5 mL; dose expressed in mg · Oral · UK product label and NICE; this is not an Indian label determination.
- Starting dose
- Lowest adult label dose is 1 mg/day; older adults start at half the lowest adult dose (0.5 mg/day).
- Titration
- Label permits adjustment at 2–4-hour intervals if agitation persists; use cautious smaller increments, especially in older adults.
- Treatment range / target
- Adult label: 1–10 mg/day, once daily or in 2–3 divided doses.
- Maximum / limits
- 10 mg/day for adult delirium; older-adult label maximum 5 mg/day, not a target.
- Trial & duration
- Shortest effective course; NICE usually 1 week or less.
- Monitoring
- ECG, electrolytes, orthostasis, alertness, rigidity, akathisia and swallowing.
- Population & organ-function adjustments
- Hepatic impairment: halve initial dose and titrate more slowly. Severe renal impairment may require a lower start and smaller increments.
- Important cautions
- Contraindicated with Parkinson disease, Lewy body dementia, known QT prolongation, uncorrected hypokalaemia or interacting QT-prolonging drugs. Not a withdrawal-delirium monotherapy.
Persistent or worsening delirium #
Repeat the examination and medication review; reassess unresolved illness, new complications and missed neurological disease. Apparent behavioural improvement after sedation does not establish resolution. In the MIND-USA ICU trial, haloperidol or ziprasidone did not improve the primary outcome of days alive without delirium or coma; that evidence does not justify escalating antipsychotics to “clear” delirium.
Stopping symptom medication #
Document the target symptom and review the need for haloperidol frequently. NICE describes a short course, usually no longer than 1 week. Explicitly reconcile the discharge prescription so a temporary intervention does not become indefinite medication.
Frailty, Parkinsonism and organ dysfunction #
Haloperidol is contraindicated in Parkinson disease and dementia with Lewy bodies. Frail older adults are particularly vulnerable to cardiac and movement-related adverse effects; monitor swallowing as well as rigidity or restlessness. An alternative plan requires specialist clinical reasoning rather than substituting an antipsychotic from a generic list.
Recovery and transfer of care #
Record the delirium episode, identified contributors and residual cognitive or functional deficits in the handover. Explain fluctuation to family and arrange reassessment of persistent problems after the acute illness. Reconsider support needs when cognition, mobility or self-care has not returned to baseline.
Avoidable errors #
Do not equate positive urine testing alone with the cause of delirium. Do not use an antipsychotic prophylactically merely because a person has dementia. Before haloperidol, obtain ECG and correct electrolyte disturbance; review QT-prolonging combinations, blood pressure, dysphagia and extrapyramidal effects.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
A sudden change in attention or behaviour can come from physical illness or medicines. It needs medical assessment even when the person is quiet.
References · 6
- NICE CG103: delirium · United Kingdom · Checked 2026-10-26 · Supports: Recognition and diagnostic confirmation; Cause-directed care and distress management; Stopping symptom medication; Haloperidol — Short-term acute delirium symptoms after non-drug measures fail (Oral solution, 10 mg/5 mL; dose expressed in mg)
- SIGN 157: delirium · Scotland · Checked 2026-10-26 · Supports: Differential clues; Targeted investigations; Persistent or worsening delirium; Recovery and transfer of care; Avoidable errors
- MHRA: haloperidol for delirium in older adults · United Kingdom · Checked 2026-10-26 · Supports: Frailty, Parkinsonism and organ dysfunction; Avoidable errors; Haloperidol — Short-term acute delirium symptoms after non-drug measures fail (Oral solution, 10 mg/5 mL; dose expressed in mg)
- Haloperidol 10 mg/5 mL oral solution SmPC · United Kingdom · Checked 2026-10-26 · Supports: Haloperidol — Short-term acute delirium symptoms after non-drug measures fail (Oral solution, 10 mg/5 mL; dose expressed in mg)
- QUT: delirium cause assessment · Australia · Checked 2026-10-26 · Supports: Bedside assessment; Targeted investigations
- MIND-USA randomized trial: antipsychotics in critical illness · United States; ICU trial · Checked 2026-10-26 · Supports: Persistent or worsening delirium