Sedation and Delirium assessment and management (including Mental Capacity) 

1. Sedation: Assessment 

Goals of Sedation 
Ensure comfort, safety, and anxiety control 
Enable procedures or mechanical ventilation 
Avoid over-sedation (↑ delirium, ventilation time, mortality) 

Common Sedation Scales 
Use regularly and document frequently 

RASS – Richmond Agitation–Sedation Scale (most common) 
+4 Combative 
+3 Very agitated 
+2 Agitated 
+1 Restless 
0 Alert & calm 
−1 Drowsy 
−2 Light sedation 
−3 Moderate sedation 
−4 Deep sedation 
−5 Unarousable 
Target in most ICU patients: RASS −2 to 0

Others 
Ramsay Sedation Scale 
Sedation-Agitation Scale (SAS) 

2. Sedation: Management 

General Principles 
Use the lightest effective sedation 
Daily sedation interruption or “sedation vacation” (unless contraindicated) 
Treat pain first (analgosedation) 
Common Sedative Agents 

Avoid benzodiazepines unless indicated (alcohol withdrawal, seizures) 

3. Delirium: Assessment 

What Is Delirium? 

Acute, fluctuating disturbance of consciousness and cognition 
Often under-recognized 
Associated with ↑ mortality, LOS, long-term cognitive decline 

Types 
Hyperactive: agitation, restlessness 
Hypoactive (most common): lethargy, withdrawal (often missed) 
Mixed 

Delirium Screening Tools – Use at least once per shift 

CAM-ICU (gold standard in ICU) 

Positive if: 
Acute onset or fluctuating course 
AND 
Inattention 
AND 
Disorganized thinking OR altered level of consciousness 

Other tools 
ICDSC (Intensive Care Delirium Screening Checklist) 
4AT (commonly outside ICU) 

4. Delirium: Risk Factors 

Predisposing 
Age >65 
Dementia 
Sensory impairment 
Frailty 

Precipitating 
Infection, sepsis 
Hypoxia 
Metabolic disturbances 

Sedatives (especially benzodiazepines) 
Sleep deprivation 
Pain 
Restraints 

5. Delirium: Management 

First-Line = Non-Pharmacologic (MOST IMPORTANT) 
ABCDEF Bundle 

A – Assess & manage pain 
B – Both spontaneous awakening & breathing trials 
C – Choice of analgesia/sedation 
D – Delirium assess, prevent, manage 
E – Early mobility & exercise 
F – Family engagement 

Other key strategies: 

Reorientation (clocks, calendars) 
Sleep promotion (lights off, reduce noise) 
Vision/hearing aids 
Early mobilization 
Hydration and nutrition 

Pharmacologic Treatment (Use Sparingly) 
Remember: Medications do NOT treat delirium itself…. 

When to consider medication: 

Severe agitation threatening safety 
Failure of non-pharmacologic measures 

Options 


Avoid benzodiazepines (except in alcohol/benzo withdrawal) 

6. Key Points 

Assess sedation and delirium separately 
Aim for light sedation 
Screen for delirium daily 
Non-pharmacologic prevention is most effective 
Benzodiazepines = delirium risk 
Delirium is often hypoactive and missed 

7. Sedation Holds (Daily Sedation Interruption) 

What is a Sedation Hold? 

Temporarily stopping continuous sedatives (propofol, dexmedetomidine, midazolam) in ventilated ICU patients 
Usually once daily, under close monitoring 
Goal: lighten sedation, assess neurological function, and minimize complications 
 
Why Sedation Holds Are Important 



How Sedation Holds Are Performed 

Pre-check 
Haemodynamic stability 
No ongoing seizures or severe agitation 
Adequate oxygenation 
Stop sedative infusion (hold opioids unless indicated) 

Monitor patient closely 
RASS or sedation scale every few minutes 
Watch closely for agitation, desaturation, or pain 

Restart sedation if needed 
If patient becomes unsafe or excessively agitated (usually RASS > +1) 

Safety Notes 

Contraindications: uncontrolled seizures, active myocardial ischemia, raised ICP, or severe hypoxemia 
Often paired with spontaneous breathing trial (SBT) for ventilator weaning 

Key Points 

Sedation holds are a core part of the ABCDEF bundle 
Evidence shows they improve outcomes without increasing adverse events 
Helps distinguish sedation-related unconsciousness vs true delirium 

8. Mental Capacity Act (MCA) Assessment (UK context) 

When to Assess Capacity 
Assess whenever there is doubt about a patient’s ability to make a specific decision, especially in patients with: 
Delirium 
Sedation 
Dementia 
Acute illness (e.g. sepsis, hypoxia) 
Fluctuating consciousness 

Capacity is always decision-specific and time-specific 

The 5 Key Principles of the Mental Capacity Act 

Presume capacity unless proven otherwise 
Take all practicable steps to support decision-making 
A person can make an unwise decision and still have capacity 
Any act done for someone lacking capacity must be in their best interests 
Choose the least restrictive option 

The Two-Stage Test of Capacity 

Stage 1: Diagnostic Test 
Is there an impairment or disturbance of the mind or brain? 
Delirium 
Effects of sedation 
Dementia 
Mental illness 
Intoxication 
If yes, proceed to Stage 2 

Stage 2: Functional Test 
Can the patient do all four of the following? 
Understand 
The relevant information about the decision 
Retain 
The information long enough to make the decision 
Use or weigh 
The information as part of decision-making 
Communicate 
Their decision (verbal, written, sign, etc.) 
Failure of any one = lacks capacity for that decision 

MCA in Sedation & Delirium Context 

Sedation 
Deep sedation (RASS −3 to −5) → no capacity 
Light sedation → may have capacity; reassess frequently 
Capacity often returns quickly → reassess once sedation reduced 

Delirium 
Capacity often fluctuates 
Hypoactive delirium = high risk of false assumption of capacity 
Reassess during lucid periods if possible 

What If the Patient Lacks Capacity? 

Check for: 
Advance Decision to Refuse Treatment (ADRT) 
Lasting Power of Attorney (LPA) for health & welfare 

If none: 
Make a Best Interests Decision 
Consider patient’s values, beliefs, prior wishes 
Involve family / carers 
Multidisciplinary discussion 
Document clearly 

Life-saving treatment can proceed immediately under best interests 

Documentation: 
Always record: 
Why capacity was questioned 
The decision being assessed 
Findings of the two-stage test 
Outcome (has / lacks capacity) 
Best interests reasoning if applicable 
Plan to reassess capacity