“How should delirium be managed in the hospital?”
This question came up during a Q & A session, as we were discussing the Choosing Wisely recommendation to avoid tying down older adults who become confused during a hospitalization.
Delirium is a common and very important problem for all older adults in the hospital. It doesn’t just happen to people with Alzheimer’s or a dementia diagnosis. (And, it’s not the same thing.)
But many family caregivers have hardly heard of hospital delirium. This is too bad, since there’s a lot that family caregivers can do to prevent this serious complication, or at least prevent an older loved one from being physically restrained if delirium does occur.
In this post, I’ll review what older adults and families absolutely should know about hospital delirium. And, we’ll cover some of the things you can do if it happens to your loved one.
Why hospital delirium is so important to know about
Delirium is a state of worse-than-usual mental function, brought on by illness or some kind of stress on the body or mind.
It is sometimes referred to as “hospital confusion” or “hospital sundowning.” And if it happens in the intensive care unit (ICU), it is sometimes referred to as “ICU psychosis.”
Although people with dementia are especially prone to develop delirium, delirium can and does affect many aging adults who don’t have Alzheimer’s or another dementia diagnosis. Here are some facts that all older adults and family caregivers should know:
- Delirium is very common during hospitalization. Delirium can affect up to half of older patients in a hospital. Risk factors include having pre-existing dementia and undergoing surgery. Having had delirium in the past is also a strong risk factor.
- Delirium is strongly associated with worse health outcomes. Short-term problems linked to delirium include falls and longer hospital stays. Longer-term consequences can include speeding up cognitive decline, and a higher chance of dying within the following year.
- Delirium is often missed by hospital staff. Busy hospital staff may not realize that an older person is more confused than usual, especially if the delirium is of the “quiet” type. (Although many people are restless when delirious, it’s also common for people to become quiet and “spaced out.”)
- Delirium is multifactorial. There often isn’t a single cause for delirium. Instead, it tends to happen due to a combination of triggers (illness, pain, medication side-effects) and risk factors (dementia, or pre-dementia). This means that treatment — and prevention — often require a multi-pronged approach.
To summarize, delirium is common, serious, and often missed by hospital staff.
Fortunately, there’s a lot that you can do as a family caregiver. In particular, you can help your loved one more safely get through a hospitalization by:
- Taking steps to prevent delirium;
- Keeping an eye out for any new or worse-than-usual mental states that might signal delirium;
- Making sure hospital staff address the problem if it does happen;
- Questioning things if the hospital resorts to tying a person down, before all other options have been tried. (This last one is a Choosing Wisely recommendation.)
How to prevent hospital delirium
Now, not all hospital delirium can be prevented. Some people are very sick, or very prone to delirium, and it’s certainly possible to develop delirium even when all triggers and risk factors have been addressed. Furthermore, many older adults are already delirious when they first get hospitalized.
Still, there are steps that can be taken to reduce the chance of a bad delirium. Experts estimate that about 40% of delirium cases are preventable.
The ideal is to be hospitalized in a facility that has already set up a multi-disciplinary delirium prevention approach, such as the Hospital Elder Life Program. Other hospitals have Acute Care for Elders units (also called “ACE” units) which also provide a special environment meant to minimize the hospital stressors that can tip an older person into delirium.
For elective surgeries, such as joint replacements, look for a hospital that has set up a geriatric co-management program for orthopedics, such as this one.
Here are some specific interventions that help reduce delirium, and how you can help as a caregiver:
- Minimize sleep deprivation. Consider asking the nurses if it’s possible to avoid blood pressure checks in the middle of the night. A quieter room can help. Do NOT ask for sleeping pills, however! Even a mild sedative, such as diphenhydramine (brand name Benadryl) increases the risk of developing delirium. Sleeping pills can also make delirium worse in someone who is already affected.
- Minimize vision and hearing impairments. Make sure the older person has glasses and hearing aids available, if they usually need them.
- Provide familiar objects and reassuring companionship. A few family photos can bring some soothing cheer to an older person’s hospital stay. Family or friends at bedside are also often very helpful, especially since they can help gently reorient an older person to where he is, and what’s been going on.
- Avoid overwhelming or overstimulating the person. Try to minimize mental strain or emotional stress for the person. A calm reassuring presence is ideal. If you need to give instructions or discuss something, try to keep things simple.
- Encourage physical activity and mobilization. Although many older people are sick or weak while in the hospital, it’s important to encourage safe activity as soon as possible. Physical therapy and minimizing bladder catheters (which can tether an older person to the bed) can help.
- Avoid sedatives and tranquilizers. Especially if the older person is restless or having difficulty sleeping, it’s not uncommon for sedatives such as diphenhydramine (brand name Benadryl) to be prescribed. But these can increase the risk of delirium, and should be avoided. So instead, try non-drug relaxation therapies such as soothing music, massage, a cup of tea, and familiar companionship.
- Minimize pain and discomforts. Ask the older person if he or she feels bothered by pain or constipation. If so, bring it up to the doctors. It’s not uncommon for pain to go inadequately treated unless family caregivers help an older patient bring it to the doctors’ attention.
If you think your loved one has developed delirium, make sure the doctors and nurses know about it. You may want to ask them what their plan is for evaluating and managing it. This will help you stay up-to-speed on the hospital course.
Some hospitals may even interview families to help diagnose delirium, using something called the FAM-CAM (short for Family Confusion Assessment Method) tool. The Confusion Assessment Method is generally considered the gold standard for diagnosing delirium.
Common causes of hospital delirium
Here are some common causes and triggers of hospital delirium and of “sundowning” symptoms when an older person is in the hospital. (Remember: in most older adults, multiple underlying causes and triggers are present.)
- Blood electrolyte imbalances (e.g. blood sodium being too high or too low)
- Infections, such as pneumonia, sepsis (bacteria in the bloodstream), and urinary tract infections
- General anesthesia and/or surgery
- Dehydration
- Drug toxicities and medication side-effects
- Withdrawal from alcohol, sedatives, or other drugs
- Blood glucose being too high or too low
- Sleep deprivation
- Kidney or liver problems
- Untreated pain or constipation
In people who have Alzheimer’s or another form of dementia, just the stress and unfamiliarity of the hospital setting can be enough to tip them into increased confusion.
Sensory impairments, such as uncorrected vision or hearing, can also help tip a vulnerable older person into delirium.
How hospital delirium is treated
To treat delirium, here’s what the doctors and nurses usually do:
- Identify and reverse as many triggers as possible. Remember, delirium is often multi-factorial. So even if there is a urinary tract infection that seems to have brought it on, the hospital team should try to spot any other factors that could be contributing (such as a medication side-effect, or a lack of glasses).
- Provide supportive care. It’s especially important to provide a calm restorative environment when a person is suffering from delirium. People may do better if they can avoid frequent room changes, and if they have a window allowing orientation to daylight.
- Prevent injury and manage difficult behaviors. This can be very challenging in those patients who become restless when delirious. Some hospitals have special “delirium rooms,” in which trained staff provide non-drug management of disoriented patients. As a last resort, the doctors do sometimes use low doses of medication. Research suggests that a small dose of antipsychotic, such as Haldol, is generally better than using a benzodiazepine (such as Ativan) which is more likely to make an older person’s confusion worse.
What you can do if an older person becomes delirious in the hospital
It can be scary to see an older person confused in the hospital, especially if you know that delirium can have serious consequences.
First and foremost, try not to panic. It’s time to hope for the best. Focus on doing what you can to help the delirium resolve.
As a family caregiver, you can play a very important role in providing a supportive and reassuring presence during an older person’s delirium. You can also:
- Advocate for minimum disruptions, and a quieter more pleasant room if possible.
- Make sure glasses and hearing aids are available, if needed.
- Help your loved one speak up if you think pain or constipation may be a problem.
- Question things if the hospital staff want to physically restrain the older person in bed. (This is a Choosing Wisely recommendation.) In many cases, if a person is dangerously restless, it’s better to start by trying a low dose of anti-psychotic, as mentioned above. Physically restraining a person often increases agitation and can lead to injury.
If you are of the really vigilant and proactive type, you may want to double-check that your loved one isn’t getting any sedatives or anticholinergic medications that make confusion worse. Even though these medications are risky for hospitalized older adults, it’s not uncommon for them to be prescribed!
What to expect after delirium: Even when all the right things are done — including getting the person home to a restful familiar environment — it often still takes a while for delirium to get better. In fact, it’s pretty common for it to take weeks — or even months — for delirium to completely resolve in an older adult. In some cases, the person never recovers back to their prior normal.
For more on delirium, see:
- 10 Things to Know About Delirium (includes information on delirium vs. dementia)
- Delirium: How Caregivers Can Protect People With Alzheimer’s (includes a list of helpful online resources that I’ve reviewed)
- A Common Problem That Speeds Alzheimer’s Decline, and How to Avoid It
You can also listen to our podcast episode, featuring leading delirium researcher Dr. Sharon Inouye, the founder of the Hospital Elder Life Program:
062 – Interview: Preventing Hospital Delirium & Maintaining Brain Health
This article was first published in 2014, and was last updated by Dr. K in March 2024.
John says
Hello I am writing this comment because I am lost and depressed with my family situation. Two months ago me and my mother were playing video games. All of a sudden she ran to the bathroom and vomited violently. When she came out she was dazed. She sat down holding her head and said she was feeling fuzzy. Then she didn’t remember who I was or who anyone was. She didn’t even know herself. Concerned we called 911 and she was taken to the hospital. In there they found her potassium was critically low, her sodium was low, her electrolytes were out of balance, severe dehydration and a UTI.
While in the ER she kept repeating herself, “why am I in the hospital, how did I get here” over a hundred times. It was clear she had to stay over night. So they kept her there and treated her medical condiotions for several days. While treating her they looked at her medication where she is taking serequel and prozac for depression, anxiety and sleep.
At first the doctors didn’t know why she was confused and tried to tell us that it maybe permanate. They didn’t beleive me when I told them that her IQ and normal baseline was above average and that she at one point in her life attended college. It wasn’t until a few days later after giving her antibiotics and potassium that her condion improved and she remembered who we were. They took her off of the seroquel because they blamed that on her part of her condition.
Then they released her and told us to continue giving her antibiotics for the infection. However when she got home she was fine for a few hours, but then became confused again. She was laughing a giggling hysterically and acted like she was a child. We had to help her with her hygiene routine.
We were going to go back to the hospital in the morning but when she woke up she was better again. We took her to her doctors office and they did tests on her and said she was fine. However a few days later she became confused again, exactly like she was the first time.
We rushed her to the hospital again this time and she was found to have a UTI. I was angry, how can she have one when her doctor said she was clear? Clearly the infection didn’t clear up.
They kept her for another two days until she was fine again. Since then she was ok however she followed up with the neurologist that saw her and he said her brain activity is sluggish. They want to do more tests and to follow up with him in a month. We also took her to her psychiatrist who was angry about her being taken of her meds and said she worked as a doctor for many years and knows that it wasn’t the medicine.
However what is strange is a few days ago she became confused again out of nowhere. We planned to take her back to the hospital, but she was suddenly fine again after taking her seroquel.
Lately she has been mostly herself, but she had trouble remembering things sometimes or concentrating on tasks. Sometimes she may forget she told us something and tells us again.
I was wondering if her medicine could have been the real cause or perhaps the UTI? Also I was wondering what her sudden confusion could be? It was strange that it suddenly went away after she took her medicine and went to bed and has been fine since. She is post menupause and in her late 4os almost 50.
How long does it take to fully recover from delirium like this and can they or will they have a relapse of it in the future? Is it something that she is going to have to live with?
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s situation. So, if she is under 50, then she is much younger than my own patients and than most parents that people here have written comments about.
People under age 50 can get delirium or otherwise can become confused, but the likely causes are a little different than in much older adults. In particular, it would be unusual for just a UTI to cause delirium in a woman under age 50. So, it’s possible that she has something more unusual going on. Neurology is a good specialty for evaluating confusion and other similar symptoms. I would recommend you keep following up with them and keep asking lots of questions. Your mother’s psychiatrist may also be able to help. Good luck!
Peter says
My 67 year old father recently got diagnosed with a bacterial infection at the spine. He was on intravenous Vancomycin for a period before being switched to Clindamycin. After showing signs of improvement in the hospital he was sent home with a month’s course of Oral Clindamycin. He is also on Tramadol as a pain killer. A few days ago he started hallucinating, seeing and speaking to people who were not around. All doses taken as per instruction from the hospital. Physically he seems to be recovering.
I’m not sure if this is classified as delirium and am looking for advise on whether to worry and take him back to the hospital? Many thanks!
Leslie Kernisan, MD MPH says
This does sound worrisome. If he wasn’t hallucinating before and then developed hallucinations and confusion, this certainly could be delirium. I would recommend alerting his usual healthcare providers and asking for assistance. Good luck!
Sandra says
Hello, and thank you for such an informative site.
My 82 year old Mother has had a difficult year. She’s had three general anaesthetics in 9 months for hydrocephalus, a fractured hip and most recently, her gall bladder. After her brain surgery and hip surgery, she experienced severe confusion during her hospital admissions that slowly settled after she came home (-although it took several months). She recently had a short hospital stay for a cholecystectomy, and given her previous history the medical staff were fantastic in ensuring she wasn’t over-medicated. Upon being discharged from hospital nearly 4weeks ago, she was a little ‘muddled’ and very weak, but generally not too bad compared to her previous experiences. But I’ve noticed over the last few days that her confusion seems to be increasing. It’s not immediately apparent, but conversing with her tonight made me realise she actually didn’t know that I lived with her, among other things. I will make an appointment for to see her regular doctor, but is it possible for Post-op confusion to escalate a month after a hospital stay, or fluctuate? Thanks so much for your time, and regards.
Leslie Kernisan, MD MPH says
So, it’s common for symptoms to fluctuate somewhat with delirium, but usually the fluctuation happens over the course of a day. A person might also be worse on one day compared to the other, just because they didn’t sleep well.
However if these days she’s noticeably worse than she was a week ago, or if you’re noticing a trend in the wrong direction, it would be reasonable to be concerned that she’s becoming more delirious again, and hence one should consider evaluating her for a new infection or some other kind of new trigger.
Another possibility to consider is that maybe she had hypoactive delirium after the hospitalization, which makes people quieter. Now that she’s stronger and more verbal, you might be noticing some underlying confusion…this could still be her resolving delirium, and she might also just have developed a worse mental baseline after this year of hospitalizations.
It is possible that a search for triggers won’t uncover anything treatable, but if you think she’s worse than she was a few weeks ago, it’s probably worth bringing this up to her doctors and having her checked. Good luck!
Kevin says
Thanks Doc. He had great progress yesterday, but last night was sleepless and confusing, and today it’s like a step backwards. We’ll keep reassuring him as best as we can, and hopefully once he’s released home to a familiar environment he’ll snap out of it. Thanks again!
Kevin says
My 80 year old father had a heart attack and spent 3.5 days tubed and sedated, 1.5 days after before being moved out of ICU. It’s been a few days since he’s been off sedation drugs, but delirium hasn’t subsided. I assume it takes time, but fear it may delay his recovery. I couldn’t find it mentioned anywhere, but would it be helpful to tell him he’s experiencing delirium, and provide him with reading material on the subject? My hope would be faster recovery, but certainly wouldn’t want to compound the problem.
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s delirium. Yes, it does often take time for people to slowly recover.
Yes, generally it’s recommended to let the older person know they’ve had some delirium. People can be very frightened by their symptoms and may worry that they are going crazy or losing their mind. So it can be a big relief for someone to tell them that it’s ok, they’ve had confusion or hallucinations but that’s because they were sick and now it’s getting better. You can also ask your father’s doctors for help explaining the delirium to him.
That said, don’t insist on explaining delirium, especially while he’s delirious or if trying to explain this makes him more confused, anxious, or distressed. You really want to focus on creating some reassurance. Giving him reading materials might be tiring and confusing. I would think just giving a little brief information and reassurance would be best. Don’t overwhelm with information. People recovering from delirium need rest and reassurance so that their brains can recover.
Every person is an individual, so you may have to do a little trial and error to find out what works best for your father. Good luck!
Sharon says
I am so relieved to find that this is real!! I had knee surgery with complications and had an episode where I thought I was being held captive on the psychiatric floor of St Luke’s Hospital in Houston. Called the police, EMS, my son etc. It was horrible and REAL. I still cannot believe that it was not. They said it was due to severe blood loss.
Leslie Kernisan, MD MPH says
Yes, this is definitely a real phenomenon. Sounds like you recovered, glad to hear it.
Unfortunately, having had delirium in the past puts you at increased risk for having it in the future. So if you are planning another elective surgery, you may want to talk to the doctors proactively about how to minimize your risk for delirium when you have the surgery. Some hospitals have better programs or facilities for this than others do. Good luck!
John B says
Thanks for the informative article, it should be required reading at all hospitals. My father-in-law is 80 and was recently diagnosed with Multiple Myeloma. He was undergoing treatment at home and while he was very fatigued, he was eating well and moving around on his own. His bloodwork numbers were improving, but unfortunately he had to go to the hospital for fluid in the lungs and they inserted a chest tube.
He has since recovered from that (tube has been removed) but is now in a skilled nursing center due to the inability to sit up or stand on his own. He is not getting good rest or eating well and is very confused. Prior to going into the hospital he had been diagnosed with the very initial stages of dementia, but I can tell you he was clearer than most eighty-year old men.
We feel strongly he would be much better at home and are trying to set up 24/7 home healthcare to make that happen. However his facility says he is too weak for that. Our concern is the longer he stays in the worse he will get. We are thinking about hiring a patient advocate to ensure he gets the best treatment possible.
My question is wouldn’t it be worth it getting him home with full-time care for a period of time to see if he responds any better? Is weakness a medical reason to keep us from doing that?
Thank you in advance.
Leslie Kernisan, MD MPH says
It’s true that many older adults find it more restful to recuperate at home, provided that the family is able to provide enough assistance with managing daily tasks, if necessary. If a family prefers to take someone home, it’s often possible to manage any needed skilled nursing care or therapy via home health services. Weakness, in of itself, isn’t necessarily a contraindication to going home, provided there will be enough help at home.
A patient advocate can help sort these issues out, so that might indeed be a good avenue to pursue. You can also learn more about your family’s rights via these resources:
Medicare Part A coverage—skilled nursing facility care (Medicare.gov)
Next Step in Care: Rehab Facility to Home
Good luck!
CoffeeIV says
My entire family is exhausted. Nothing works with my MIL. She is 92 post stroke with dementia. She was in rehab and then a nursing home but kept falling by trying to get out of her wheelchair. Of course, the no restraints policy meant that if someone was not right in front of her the entire day just taking care of her alone, she would fall. She was only in the nursing home for a week and fell 5 times. This was with me going every day for two hours and a sitter for two hours every day. The fifth fall broke her hip, so she is now in the hospital trying to yank out her IV. We are desperately trying to find sitters so someone can be with her 24 hours a day. My SIL has already been to the ER for stress-related heart problems, my husband’s IBS is flaring, so guess who will soon be taking 16 hour shifts with a screaming, flailing, crying MIL? The overworked nurses act as if they have never dealt with this before, the hospitalists have too many patients and may visit every other day. But it’s rarely the same doc, not her internist, and you never know when he or she will be there. They refuse to give her Clonapin for her anxiety, which in the past is the only thing that has worked so both she and we can get relief. If this situation continues, we will ALL be in the hospital together. Whoever wrote the new guidelines obviously never had an elderly parent. The nurses, doctors, nursing home staff’s hands are tied. There is no help, though everyone cares. Nothing can be done. I guess it will be like this until she dies. We have tried all your suggestions many many times just on our own before I even read this, but she is simply inconsolable. She never sleeps except 5 minutes at a time. This is HELL.
Leslie Kernisan, MD MPH says
Yikes. That does sound pretty bad and extremely stressful.
This situation overlaps somewhat with managing agitation and other difficult behaviors in dementia. I write about the various medication options here:
5 Types of Medication Used to Treat Difficult Dementia Behaviors.
The guidelines are meant to provide a sensible starting point. Medicating agitation should not be the first step, but sometimes it’s necessary when all else has failed. Generally, if we have to use medication for this kind of agitation while hospitalized, we would probably try an anti-psychotic rather than a benzodiazepine such as clonazepam. This is in part because benzodiazepines cause paradoxical agitation in some older adults. I suppose if you know benzodiazepines have worked well for her in the past, you could ask that they give it a try, but it might be better to do the trial with a benzo that is shorter acting, such as lorazepam (brand name Ativan). It is also important to ensure that her pain is being adequately managed, so sometimes I try pain medication before a tranquilizer.
Of course pain medication sometimes makes older adults delirious as well…which is why we start with guidelines and then have to proceed with careful and sensible trial-and-error.
You are right that sometimes, everyone cares but a decent solution remains elusive, and this can feel hellish for families. All I can say is keep trying and keep asking the providers for help. You may need to remind them that the sensible first-line approaches have been tried and haven’t worked, in which case it may be reasonable to try second-line or even last-resort approaches.
You could also try requesting a palliative care consultation, if you haven’t already done so. good luck!
Stephanie Duncan says
My 71 year old father has been in hospital with delerium.now for almost 3 weeks wit no sign of improvement or diagnosis. They have ruled out UTI, meningitis, septis, any cancers, and all his vitals are performing well. As well as clear CT scan. He does suffer.from Stage 4 heart failure and has type 2 diabetes. He has experienced foggy moments over the past year and some paranoia BUT nothing to this extreme. Before I admited him he was also vomitting. His mother suffered from dementia and now this is being thrown around. .. Any thoughts?
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s delirium. It does seem to persist in some older adults, even when no obvious infection or trigger can be found. It’s possible that being in the hospital is stressful for him and is affecting his ability to start to recover.
In terms of the possibility of dementia: we do know that many dementia processes damage the brain for 10-20 years before symptoms become obvious. The stress of hospitalization and delirium can “unmask” an underlying dementia. If he’s remaining delirious, it’s certainly quite possible that he has a vulnerable brain that may have some underlying changes or damage. He does need to be given a chance to recover before being diagnosed. But in people like him, there is a fair chance of being eventually diagnosed with dementia over the following few years.
For now, I would recommend you focus on helping him recover. Good luck!
Lynda says
Hi,
My father (age 86) developed delirium following a partial hip replacement the end of March. The wound became infected and he had a second surgery (I&D) the middle of May then went to a Skilled Unit for 6 weeks for IV antibiotics. He discharged home June 25 unable to stand, turn himself,etc. We purchased a stand assist and he has progressively gotten stronger to the point that he was able to use his walker and walk approx. 20 feet this morning!
However, while he is physically stronger, he continues to be confused at times, especially at night, constantly yelling and calling for help, insisting he needs to urinate (he has an indwelling catheter for retention) and saying mean things to those around him. He attempts to get out of bed and becomes angry when attempts are made to reorient him.
We have eliminated medications which are not absolutely necessary ( ie. stool softener,meds for acid reflux, etc) and he is now just taking what he was on prior to his fall and surgery. ( Dig, Keppra, Lopresser, synthroid, etc.) We play soft music at night, adjust the lighting, etc. but he continues to keep everyone awake. He doesn’t remember any of this in the morning and appears to be adequately rested (he naps during the day). Do you, or any of the readers, have ANY suggestions of additional ways of how to deal with the night time issues? No one is getting any rest and I am concerned for my mother’s health (age 84). I keep thinking this has to get better soon but….
Leslie Kernisan, MD MPH says
Hm…what you describe sounds a bit like sundowning and/or the kind of sleep problems that are common in dementia. His circadian rhythm may be a bit off, esp if he is napping during the day. I have an article on sleep and dementia, some of the suggestions there might help…even if he doesn’t have dementia, doesn’t sound like his brain is entirely back to normal.
How to Manage Sleep Problems in Dementia.
In particular, I wonder if it would help to make sure he gets plenty of exposure to light during the day. You might also want to ask his doctor about melatonin, it seems to help some older adults with their sleep schedule. Good luck!