Acute confusional state (delirium) — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 11: Mental disorders in adults · Médecins Sans Frontières, Current online edition (updated July 2022)

Diagnostic and management guidance for delirium in resource-limited settings for clinicians and humanitarian health workers.

In one sentenceDelirium requires hospitalisation to treat underlying organic causes; avoid sedation except low-dose haloperidol (≤5 mg daily, ≤7 days) if essential; delirium tremens needs ICU care with IV diazepam, hydration and thiamine.

Issuer: Médecins Sans Frontières
Edition: Current online edition (updated July 2022)
Audience: Clinicians working in resource-limited and humanitarian settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline addresses the diagnosis and management of acute confusional state (delirium), characterised by rapid onset of disorientation, impaired consciousness, concentration problems and memory impairment that fluctuate during the day. The guideline emphasises that delirium almost always has an organic cause—infectious, metabolic, endocrine, neurological, drug-related or substance-related—and requires hospitalisation.

Management focuses on treating the underlying cause whilst providing supportive care including nutrition, hydration, electrolyte balance and appropriate sensory environment. Sedation should be avoided where possible, but if essential, low-dose haloperidol (0.5–1 mg twice daily orally or intramuscularly) may be used for short periods, not exceeding 5 mg daily. Diazepam may worsen delirium except in the specific case of alcohol withdrawal.

For delirium tremens related to alcohol withdrawal, the guideline recommends intensive care admission with diazepam 10–20 mg intravenously 4–6 times daily under close supervision, IV hydration with 2–4 litres of 0.9% sodium chloride per 24 hours, and thiamine 100 mg three times daily for 3–5 days intramuscularly or by very slow intravenous infusion.

Key points

For clinicians — doses and thresholds as stated in the guideline

Delirium develops rapidly (hours or days) with disorientation, impaired consciousness, concentration problems and memory impairment that fluctuate during the day
Delirium almost always has an organic cause: infectious, metabolic, endocrine, neurological, drug-related or substance withdrawal; all cases require hospitalisation
Treat the underlying cause and provide supportive care: nutrition, fluids, electrolyte balance, bladder function monitoring, adequate sensory environment (low lighting, limit noise)
Avoid sedation where possible; diazepam may increase delirium except in alcohol withdrawal
If sedation essential: haloperidol 0.5–1 mg PO twice daily or 0.5–1 mg IM, repeated after 30–60 minutes if needed, then every 4 hours; maximum 5 mg daily; use for 7 days or less
For alcohol withdrawal delirium (delirium tremens): admit to intensive care; diazepam IV 10–20 mg 4–6 times daily under close supervision with ventilation equipment available
Delirium tremens requires IV hydration 2–4 litres 0.9% sodium chloride per 24 hours
Administer thiamine 100 mg IM or very slow IV (over 30 minutes) 3 times daily for 3–5 days for alcohol withdrawal; monitor vital signs and blood glucose

Haloperidol dosing for agitated delirium

Table extracted from the guideline

Route	Dose	Frequency	Maximum daily dose	Duration
Oral	0.5–1 mg	Twice daily	5 mg	≤7 days
Intramuscular	0.5–1 mg	Repeat after 30–60 min if needed, then every 4 hours	5 mg	≤7 days

Source: Médecins Sans Frontières, Acute confusional state (delirium) — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Delirium almost always has an organic cause”

— Médecins Sans Frontières, Acute confusional state (delirium) — MSF Clinical guidelines, Management section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As we strengthen mental health services across Georgia under our National Mental Health Strategy, this MSF guidance provides practical protocols for managing delirium—a commonly misdiagnosed condition in our hospitals. The emphasis on identifying organic causes is critical: in our setting, we must be vigilant for infectious aetiologies including tuberculosis meningitis and metabolic causes, whilst recognising that alcohol withdrawal remains a significant issue given regional consumption patterns. I would stress to Georgian clinicians the importance of thiamine administration in suspected alcohol-related cases and the counterintuitive guidance that benzodiazepines worsen most delirium except delirium tremens. Implementation challenges include ensuring consistent availability of parenteral thiamine and haloperidol in appropriate low-dose formulations, training emergency department staff to differentiate delirium from primary psychiatric disorders, and establishing clear referral pathways between emergency services and both intensive care and psychiatric consultation services.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus, where alcohol use disorder prevalence is substantial and delirium is commonly encountered in general hospital settings. National programmes would need to ensure availability of haloperidol in appropriate low-dose formulations, train clinicians to recognise the multiple organic causes of delirium (including metabolic and infectious aetiologies common in the region), and establish protocols for intensive care management of delirium tremens with adequate thiamine supplies. Implementation would require integration with existing mental health services under the National Mental Health Strategy and coordination with emergency and internal medicine departments to ensure appropriate triage and supportive care capacity.

Questions this guideline answers

Quick answers

When should sedation be used in delirium?

Sedation should be avoided where possible as diazepam may worsen delirium. Only if absolutely necessary to sedate an agitated patient should low-dose haloperidol be used (0.5–1 mg orally twice daily or intramuscularly), for a maximum of 7 days and not exceeding 5 mg daily total dose.

How is delirium tremens different from other causes of delirium?

Delirium tremens is the exception where diazepam is indicated rather than contraindicated. It requires intensive care admission, IV diazepam 10–20 mg 4–6 times daily under close supervision with ventilation equipment available, IV hydration with 2–4 litres 0.9% sodium chloride per 24 hours, and thiamine 100 mg three times daily for 3–5 days.

What are the main causes of delirium to investigate?

Investigate infectious causes (meningitis, severe malaria, encephalitis, septicaemia, syphilis, AIDS), metabolic causes (hyper/hypoglycaemia, electrolyte imbalance, niacin or thiamine deficiencies), endocrine disorders (thyroid), neurological causes (epilepsy, raised intracranial pressure, head trauma, meningeal haemorrhage, brain tumour), drug effects (opioids, psychotropic drugs, fluoroquinolones) and substance use or withdrawal.

What supportive care is needed for all patients with delirium?

All patients require hospitalisation with attention to nutrition, fluid and electrolyte balance, bladder function monitoring, pain management if needed, appropriate sensory environment (low lighting, limited noise), and ensuring the patient receives only medications appropriate to their needs.

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Acute confusional state (delirium) — MSF Clinical guidelines

What this guideline says

Key points

Haloperidol dosing for agitated delirium

From the guideline