The American Psychiatric Association (APA) has released an updated guideline for preventing and treating delirium, providing clinicians with evidence-based strategies to improve detection, management, and patient outcomes for a condition that affects tens of thousands of hospitalized adults each year.
Delirium — a sudden decline in attention, awareness, and mental function — develops rapidly, often over hours, and typically lasts 2-3 days. It can arise from numerous factors, including advanced age, prior episodes of delirium, medical conditions such as pneumonia or urinary tract infection, psychiatric conditions like cognitive impairment, medications with anticholinergic properties or opioids, metabolic disturbances, vitamin deficiencies, sensory impairments, and sleep disruption.
The condition affects roughly 1 in 4 hospitalized adults and up to three quarters of ventilated ICU patients. Often underrecognized, delirium can prolong hospital stays, increase complications, and impose significant costs and psychosocial burdens on patients and their families.
However, these estimates are likely inaccurate because delirium is frequently underdiagnosed.
“Clinicians don’t always acknowledge it, sometimes for fear it may reflect poorly on the quality of care,” said Mark A. Oldham, MD, a member of the APA Practice Guideline Writing Group and immediate past president of the American Delirium Society. He added that because delirium is classified as a complication or comorbidity, the Centers for Medicare and Medicaid Services provides no financial incentive for clinicians to diagnose it.
Regardless of the reasons for underdiagnosis, delirium takes a significant toll on patients and their families. It can prolong hospital stays, cause psychosocial distress such as anxiety and fear, and worsen cognitive outcomes, particularly in older adults or those with preexisting cognitive impairment.
Up to 40% of delirium cases are preventable through multicomponent nonpharmacologic interventions, Oldham noted. “There’s growing awareness that such prevention strategies are effective, but unfortunately, they’re not implemented consistently across institutions, and that’s a real concern,” said Oldham, immediate past president of the American Delirium Society and associate professor of psychiatry at the University of Rochester Medical Center, Rochester, New York. He also cautioned that there is growing evidence that antipsychotics don’t reverse delirium.
The updated APA guideline includes 12 evidence-based recommendations across clinical settings and also includes three suggestions covering assessment, nonpharmacologic and pharmacologic interventions, and transitions of care, providing clinicians with a practical framework to improve patient outcomes.
The executive summary was published online on September 1 in the American Journal of Psychiatry.
Expanded Scope
The previous delirium guideline was published in 1999, with a minor revision in 2010, and was primarily aimed at psychiatrists. The updated version has a broader scope, targeting not only psychiatrists but also specialists in internal medicine, family medicine, and critical care nursing.
“The delirium field has expanded by leaps and bounds since 1999, and it includes stakeholders across a broad range of specialties, disciplines, and professions,” said Oldham.
An updated guideline was needed because so much progress has been made in recent years in clinical research, interventions, and our understanding of delirium, Catherine Crone, MD, chair of the Guideline Writing Group, told Medscape Medical News.
“The new guideline goes beyond detection and treatment and includes steps aimed at prevention,” added Crone, clinical professor in the Department of Psychiatry and Behavioral Sciences at The George Washington University School of Medicine, Washington, DC.
The new guideline goes beyond detection and treatment of delirium and includes steps aimed at prevention, added Crone.
The new guideline includes evidence-based recommendations and suggestions, with the strength of evidence rated as high (A), moderate (B), or low (C).
One key recommendation is that patients with, or at risk for, delirium undergo regular, structured assessments using validated tools. These tools measure factors such as awareness, language comprehension, and confusion, and their use varies by clinical setting.
“For example, patients in the ICU who are intubated and cannot speak will require different tests than those on the medical floor,” said Oldham.
Guidance on Antipsychotic Use
The APA also recommends that patients receive baseline neurocognitive testing and a detailed review of potential contributing factors. Clinicians are further advised to conduct thorough medication reviews, particularly for patients with cognitive impairment.
While medication reviews are routinely performed, the guideline emphasizes that they should specifically focus on drugs that can cause or worsen cognitive status. This targeted attention is a new component of the guideline, Crone noted.
The guideline recommends that antipsychotics be used only for severe agitation or psychosis in delirium — after de-escalation strategies have failed, contributing factors have been addressed, and the behavior poses a risk for harm.
“There may be a role for antipsychotics in managing some of the severe, distressing, dangerous neuropsychiatric disturbances of delirium,” said Oldham. But he added, “There’s no reason to just give antipsychotics to all comers with delirium.”
All too often, antipsychotics are used “reflexively” in people with delirium, Oldham added. “We wanted to make clear that there are no compelling data that antipsychotics either clearly prevent delirium or hasten its resolution.”
He also noted that antipsychotics carry significant risks, including increased all-cause mortality when used for dementia-related psychosis, as well as movement disorders and heart rhythm abnormalities.
The guideline recommends that benzodiazepines not be prescribed for patients with, or at risk for, delirium unless there is a specific indication. This also applies to individuals with preexisting cognitive impairment.
Benzodiazepines may cause sleepiness and confusion and can actually worsen delirium, said Oldham. He added that they can also affect balance, potentially increasing the risk for falls.
A Better Sedative
The new guidance also recommends using the intravenous sedative dexmedetomidine to prevent delirium in patients undergoing major surgery or receiving mechanical ventilation. Evidence suggests this agent works differently than other sedatives and is superior, said Oldham.
While other sedatives adversely affect sleep architecture, some data indicate that dexmedetomidine can help facilitate a more natural and physiologically restorative sleep, he added.
The guideline authors advise against using melatonin or ramelteon — a sedative commonly prescribed for insomnia — to prevent or treat delirium.
“Melatonin, which is the only hormone available over the counter, is often used like water in the hospital setting,” said Oldham. However, a review of the data found “no compelling evidence that melatonin — or ramelteon — can prevent or treat delirium.”
He added that because melatonin is considered a supplement, “you really don’t know what’s in the pill. There isn’t an FDA-approved and formally regulated formulation.”
Another key recommendation is that at-risk patients receive multicomponent nonpharmacologic interventions.
“I like to think of this as good, humanistic care,” said Oldham. “If somebody can’t see, we make sure they have their glasses, and if they can’t hear, we make sure that they have their hearing aids. We’re talking about providing ambulatory support, so making sure patients get up and walk, and about ensuring patients remain hydrated, have cognitive stimulation, and have the support they need if they’re unable to eat.”
Judicious Use of Physical Restraints
The APA recommends against using physical restraints except when a patient poses an imminent risk for harm to themselves or others. Crone noted that most patients with delirium do not become severely agitated or psychotic and generally do not attempt to leave bed or remove medical lines.
When agitation does occur, it is often linked to disorientation, delusions — such as believing staff intend to harm them — or visual and auditory hallucinations, Crone said.
“Staff may misinterpret the patient’s behavior as a primary psychotic disorder and turn to using physical restraints,” she added. “They may miss that the patient is delirious.”
Oldham noted that this can easily happen in a busy hospital environment but emphasized the importance of “using the least restrictive option that addresses any acute safety concerns that are present.”
The guideline recommends that patients being discharged or transferred to another health care setting receive “a detailed medication review, medication reconciliation, and reassessment of the indications for medications.” A medication reconciliation ensures, for example, that the pharmacy has updated prescriptions with no duplicates and correct dosages, said Oldham.
Almost all of the recommendations are based on evidence considered “low” quality. “It’s unfortunate there are no better data,” said Oldham, though he stressed, “We have definitely made strides” in recent years.
Crone noted that clinical guidelines often rely on expert consensus and indirect evidence from observational studies rather than randomized clinical trials. “While such trials would be ideal, they are difficult and can be unethical to perform,” she said.
Patients being released or transferred to another healthcare setting should get “a detailed medication review, medication reconciliation, and reassessment of the indications for medications,” according to the guideline. A medication reconciliation involves, for example, ensuring the pharmacy has updated prescriptions with no duplicates and correct doses, said Oldham.
The full guideline is available on the APA website. The APA is also developing supporting resources to help clinicians understand and implement the recommendations, including training slides, a clinician guide, a patient and family guide, webinars, and case vignettes.
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