Introduction
Delirium is a common, serious, and under-diagnosed neuropsychiatric syndrome, representing a clinical and economic challenge to the NHS. For UK clinicians, two key national guidelines inform best practice: the National Institute for Health and Care Excellence (NICE) Clinical Guideline CG103 (published 2010, last updated 2023) and the Royal College of Physicians (RCP) National Clinical Guideline for Delirium (published 2023). While both aim to improve patient outcomes, their scope, structure, and specific recommendations differ. This comparison provides a factual analysis for clinicians, highlighting key differences and practical takeaways for implementation in everyday practice.
See how this translates to practice: Explore our Clinical governance features, visit the Patient Safety Hub, or review Clinical Safety & Assurance for enterprise rollout.
Diagnosis and Assessment
NICE CG103
- Core Tool: Recommends the Confusion Assessment Method (CAM) as the standard for diagnosis in patients aged 65 and over. For those under 65, clinical judgement based on DSM or ICD criteria is advised.
- Risk Assessment: Strong emphasis on proactive risk assessment upon admission. Recommends considering 4 key risk factors: age 65+, cognitive impairment, current hip fracture, and severe illness.
- Process: Diagnosis should be made by a healthcare professional trained and competent in delirium diagnosis.
RCP Guideline (2023)
- Core Tool: Also endorses the 4AT (Assessment Test for Delirium and Cognitive Impairment) as the primary rapid assessment tool. It highlights the 4AT's advantages in also detecting cognitive impairment and being usable in patients who cannot engage deeply.
- Risk Assessment: Promotes a broader, more formalised approach. Recommends using a structured risk factor checklist as part of initial assessment for all adult patients.
- Process: Provides a more detailed assessment pathway, including the use of the Single Question in Delirium (SQiD) ("Do you think [patient's name] has been more confused lately?") to engage carers and family in screening.
Key Differences & Practical Takeaway
Difference: The primary difference lies in the recommended first-line assessment tool: NICE champions the CAM, while the RCP advocates for the 4AT. The RCP guideline is more recent and provides a more granular, step-by-step assessment algorithm that incorporates family/carer input via the SQiD.
Takeaway: The 4AT's speed and ability to test even when patient engagement is limited make it highly practical for busy acute settings. Many NHS trusts have now adopted the 4AT as their standard. Clinicians should be proficient in both CAM and 4AT, but follow their local trust policy, which is increasingly likely to be aligned with the RCP's 4AT recommendation.
Treatment and Management
NICE CG103
- Non-Pharmacological First: The cornerstone of management is multicomponent non-pharmacological intervention delivered by a multidisciplinary team. This includes addressing orientation, ensuring adequate hydration/nutrition, managing pain, and promoting sleep.
- Pharmacology: Pharmacological treatment should only be considered for patients in distress or where behaviour poses a risk of harm. Haloperidol or olanzapine are suggested, starting at the lowest dose for the shortest time. Antipsychotics are not recommended for patients with Parkinson's disease or Lewy body dementia.
- Environment: Focuses on creating an optimal environment (calm, well-lit, familiar faces).
RCP Guideline (2023)
- Structured Interventions: Similarly prioritises non-drug approaches but structures them more explicitly around addressing the underlying cause(s). It emphasises a "treat the cause" approach alongside supportive care.
- Pharmacology: Provides more nuanced guidance. It agrees on using haloperidol first-line but offers clearer dosing strategies (e.g., 0.5 mg initially in older adults) and alternatives (e.g., risperidone if olanzapine is not suitable). It gives stronger warnings regarding antipsychotics in Lewy body dementia.
- De-escalation: Places greater emphasis on verbal and non-verbal de-escalation techniques as a first step before considering medication.
Key Differences & Practical Takeaway
Difference: Both guidelines agree on the fundamental principle of "drugs last." The RCP guideline offers more detailed, practical advice on pharmacological dosing and alternatives, reflecting its more recent publication and clinical feedback on the practical challenges of implementing NICE's broader recommendations.
Takeaway: The core message is unchanged: multicomponent care is essential. The RCP's enhanced detail on de-escalation and drug dosing provides valuable, immediate clinical support. The "treat the cause" mantra should be the daily focus of the ward round.
Special Situations
Palliative Care
NICE has a separate guideline for palliative care (NG31) which should be consulted, but CG103 notes that the general principles of delirium management still apply. RCP integrates specific advice for end-of-life care, acknowledging that in the last days of life, sedation may be necessary for distressing delirium that is refractory to treatment, and this should be part of a broader plan agreed with the patient and family.
ICU and Post-Operative Care
NICE mentions the high risk associated with these settings but does not provide extensive specific guidance. RCP dedicates significant attention to these areas, recommending the use of the CAM-ICU (a variant of the CAM for ventilated patients) and emphasising preventive bundles and early mobilisation post-surgery.
Key Differences & Practical Takeaway
Difference: The RCP guideline is more comprehensive in covering special clinical scenarios, particularly critical care and post-operative settings, reflecting a growing evidence base in these areas since the original NICE publication.
Takeaway: For managing delirium in ICU, post-operative, or complex palliative care situations, the RCP guideline offers more targeted, contemporary advice. Clinicians in these specialties should familiarise themselves with these sections.
Practical Clinical Flow: A Synthesis
Combining the strengths of both guidelines, a pragmatic clinical pathway for an adult in an acute hospital would be:
- Identify Risk: On admission, conduct a formal risk assessment using a checklist (per RCP).
- Screen/Diagnose: For any patient with risk factors, new confusion, or a positive SQiD from a relative, perform a rapid assessment using the 4AT (aligning with RCP).
- Investigate Causes: Immediately initiate a search for underlying causes (infection, metabolic disturbance, medication side effects, etc.).
- Implement Multicomponent Care: Instigate non-pharmacological interventions involving the MDT and family (core to both guidelines).
- Manage Distress: For agitation or distress, use de-escalation techniques first (RCP emphasis). If medication is necessary, consider low-dose haloperidol (e.g., 0.5 mg) as per RCP's specific guidance, avoiding in Lewy body dementia/Parkinson's.
- Review & Prevent Harm: Regularly review the patient, taper and stop antipsychotics as soon as possible, and ensure measures are in place to prevent falls and pressure ulcers.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow, NICE or RCP?
Your local NHS trust policy is paramount. However, the RCP guideline (2023) is more current and offers greater practical detail for acute hospital settings. It can be seen as complementing and updating the foundational principles of NICE CG103. For the most up-to-date, practical advice, the RCP guideline is the primary reference.
2. The NICE guideline is older. Is it still valid?
Yes, its core principles—especially the emphasis on non-pharmacological, multicomponent interventions and caution with antipsychotics—remain entirely valid and are reinforced by the RCP. The RCP guideline builds upon this foundation rather than contradicting it.
3. What is the single most important change in practice recommended by the RCP?
The widespread adoption of the 4AT over the CAM for initial rapid assessment in most clinical scenarios. Its simplicity and speed facilitate earlier and more frequent detection.
4. How should I handle a delirious patient who is refusing treatment?
This is a capacity issue. You must conduct a mental capacity assessment for the specific decision at hand. If the patient lacks capacity, treatment should be provided in their best interests under the Mental Capacity Act 2005. Verbal de-escalation and involving a trusted family member are crucial first steps. Medication should only be used if the patient is a risk to themselves or others.
5. Are there any significant conflicts between the two guidelines?
No major conflicts exist. The differences are primarily in emphasis, detail, and the tools recommended. The RCP guideline provides more granularity and addresses clinical scenarios that have become more prominent since the original NICE publication (e.g., ICU delirium). They are broadly complementary.
Source Links
- NICE Clinical Guideline CG103 (Delirium): NICE CG103
- RCP National Clinical Guideline for Delirium (2023): RCP London delirium guideline
- 4AT Assessment Tool: 4AT delirium screening tool
- Confusion Assessment Method (CAM): Available via various medical resources and trust intranets.