“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.
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.
For more useful ideas, see this family tip sheet from the Hospital Elder Life Program.
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.
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 2022. As we are now at 200+ comments, the comments section has been closed to new comments. Thank you!
Pam Williamson says
Thanks for this wonderful forum. My Mom is 90 years old and has no dementia other than some sometimes short term memory loss (she is regularly tested and evaluated). However, she has experienced delirium several times that I know of. Twice from meds, which I promptly removed and she immediately returned to normal. Then, when she was about 85 years old, we worked through a bad delirium experience over a period of two years–the result of a broken pelvis and too long on oxycodon. Again we beat the odds. About a year ago, she had a sudden onset from fecal extraction, and she rebounded very quickly. Now we’re at it again, and I am reading everything I can find to make sure I am doing the right thing and to seek additional recommendations. Mom now lives with me. On a Thursday about three weeks ago, she suddenly and out of the blue showed some signs of delirium: thinking a strange man was trying to call her and thinking she was supposed to cook dinner. That same night she fell and broke two ribs and her thumb which landed us in the hospital. She almost immediately developed hyper delirium in spite of all my attempts to prevent it and warn docs of her propensity for it. She was tested for everything–no UTI (evaluated twice at my assistance); BP good, heart good; all bloodwork great; etc. With the exception of Ibuprofen she has had no new drug introductions–she takes no meds other than the few she has been on over the past two years. We tried rehab but I knew we weren’t gonna get through that, so after a few days I brought her home (wish I’d never taken her to the rehab center where the delirium got worse). Between me and others, she has 24/7 care. It’s now been three weeks since the Fall. There are good days and bad days, but the home environment, sunshine, PT, OT, daily slow walks, good food, and constant care seem to be very slowly easing us out of the delirium. BUT she is just not sleeping well at all, and I am left with thinking sleep deprivation is the culprit. Or have I missed something? What would have caused this sudden onset BEFORE she even fell? She was just fine, and then she wasn’t. We are keeping a sleep diary. She tosses and turns, and jerks herself awake. I have tried everything (essential oils, herbal teas, etc) except meds, and I am just not inclined to go there. I have already had her on Melatonin for over a year. I have just ordered an herbal tablet to try. Shorter question: My Mom was fine on Wednesday three weeks ago, developed delirium out of the blue on Thursday, and I have no idea why. Nor can I look for ways to prevent it when I don’t know what “it” is. Could it be the sleep problem? Was it lack of sleep that caused her to fall in the first place? Other ideas?
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s difficulties. It’s wonderful that you’ve been able to support her through so much.
Well, it sounds like on that Thursday, she had a period of confusion or disconnection from reality. If we thought it was due to a new physical illness or medication, we could call it delirium. But if she’s 90 with short term memory problems, it’s also possible that this was just a manifestation of her vulnerable and somewhat damaged brain having a worse moment. (her short term memory problems indicate that her brain has been damaged enough to be symptomatic.) Her fall may or may not have been related.
At this point, I don’t know that it’s productive to keep trying to figure out what was the Thursday trigger. Many problems in people like your mother are “multifactorial”; they result from a combination of lots of underlying vulnerabilities plus one or more little triggers.
I would recommend focusing on where you are at now, which is supporting her and trying to see if you can improve her sleep. Sleep certainly can be disrupted by brain changes. For ideas on how to improve sleep in people with memory and thinking problems, try this article: How to Manage Sleep Problems in Dementia. Good luck!
Linda says
My 91-year-old father just had knee-replacement surgery. Starting the second day after surgery, he is showing significant post-op delirium. He’s combative and hallucinating, just to name a couple of symptoms. He needs 24/7 monitoring to ensure he doesn’t hurt himself. And given his knee, he’s confined to his bed because he’s to weak and it’s too painful for him to stand.
The hospital keeps telling me this is very common and that it will resolve on its own in a few days or a week. From what I’m reading on here, that doesn’t seem to be the case. Plus, their treatment plan is simply to eliminate pain killers aside from Tylenol and to let the anesthesia dissipate. Surely there is more I can do for him to speed his recovery.
Note that he just moved from MN to TX so there are no “home” familiar surroundings to go back to. Plus, given his knee, he will need to go to a skilled nursing facility instead of any type of home environment.
So two questions.
What can I do to speed recovery?
What can I do for myself in this incredibly stressful time. I’m an only child, and I have no family or friends to support me. Getting through the day is incredibly difficult, and I’m not sure I can handle this if it goes on much longer.
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s delirium. Delirium does improve within several days for many older adults, but yes, it can also take much longer than that, especially in people who are your father’s age.
In the article, I list things that can be done to try to bring about recovery. In terms of what you can do for yourself, I would encourage you to find a support group if at all possible. Online groups are often convenient. A very active free online caregiver community is at AgingCare.com; if you post there, you will get lots of ideas and support. We also offer our own Helping Older Parents Membership Community, which combines a support group with guidance from me, geriatric care managers, and other experts.
You need to try to help but also realize that you’ll try your best and you may not get the outcomes you want for him, because much of this is out of your control. So try to not feel guilty or let the worry take over your life. Support him as best you can and hope for the best. Do connect with other family caregivers, almost everyone finds it enormously helpful. Good luck!
Debra evans says
Prior to Mar.31,2019 my 89 year old mom was adapting nicely to her independent senior living apt., that she moved into the prior Oct. (after living 29 years in her own home in FL, she had fallen several times in FL , becoming depressed , didn’t want to live with us, but wanted to be closer). She made new friends, participated in lots of activities. She loved having no more yard work, prepared meals and housecleaning taken care of. End of March she fell, taken to ER, no concussion, but sent to hospital with severe sepsis. It took 5 days for the infection to respond to antibiotics, during which she developed and was diagnosed with delerium. They took her off all her regular meds, including Prozac and she ate, nor drank almost nothing . Her speech changed, she became agitated. They put her on halidol and risperidone, she went psychotic. She was ripping her clothes off, screaming, trying to get out of the hospital bed. The doctor ordered a saline to get it out of her system. It took 5 more days for her to become semi lucid. She was discharged to rehab for physical therapy, as she could not longer walk. At rehab she made physical gains, but still had lingering delerium and agitation. After 20 days she went back to her apt, with in home physical therapy, which she often refused. May 23 she fell again, back to ER, no concussion, but goes back to rehab facility. This time she has her skin torn day 1 by CNA trying to help her from chair (she now cannot transfer from chair, bed or walker, not even for toileting). This triggered daily morning crying spells, moaning when moved anywhere, less cooperation with therapy. I was there Sun., watching her ride an exercise bike, talking about moving even closer to us, but still having more aphasia speech. Monday morning she went into another psychotic event, I came and saw her trying to rip off her clothes, screaming, delirious , wild eyed, totally incoherent speech. We though she had a stroke or seizure and back she goes to the hospital. Now 8 days later, (after once again being taken off her reg. meds, put on Valium, Ativan and keeps)…she has eaten or drank little, sleeps most of the time, speech is almost intel liber. What we can understand is that she wants to die. She is totally immobile. We , are dia led and cannot care safely for her at our home and she cannot go back to her apt. As they cannot meet her needs. I hate to move her to assisted living, but there is one within minutes from us. She will have her own furniture there and inhouse therapy. Hopefully counseling. I am her only child. This is heartbreaking to seen her this way. How else can we help her?
Leslie Kernisan, MD MPH says
So sorry to hear of these events. Your poor mother, she has been through a lot. Unfortunately, a serious illness can set off this type of negative spiral. People do sometimes pull out of it, but it’s hard for them; the longer they are ill or delirious or weak, the more time and effort it takes to climb out of it. Some do seem to give up or lose their will to try to recover. It can be hard to tell if this is purely mental or if it reflects some kind of more substantial change going on inside the body. It may well be some of both, since the mind and body are closely connected and influence each other a lot.
In terms of what you can do next: she is certainly going to need a higher level of care for some time, possibly indefinitely. One thing you could inquire about would be a palliative care consultation, to talk about the big picture of her health and also to get advice on how to improve her quality of life and treat distressing symptoms. A related possibility would be to see if she might be eligible for hospice. I have actually seen a certain number of frail older adults RECOVER while on hospice and eventually “graduate” from hospice, because hospice provides lots of TLC and attention to uncomfortable symptoms, and that can help an older person recover! Hospice is also a way to get a nurse and other services to see an older person where they are living, which can be hugely helpful. Last but not least, hospice is designed to provide emotional support to the patient and also to the family.
Good luck, I hope she feels better soon and that you find the support she needs and you need.
Brooke says
Hi there, after reading your article it has really made me question if my grandfather is suffering from this. He has been in and out of the hospital since December 18th 2018 and has now been hospitalized since about April! From April until now he has significantly decreased in health and his cognitive skills. He often forgets things he says or completely forgets entire conversations. The nurses have said he may be “sundowning” which could just be what’s happening. Unfortunately he is under a huge amount of stress as his house is being redone without him there and he has really lost his independence which is really upsetting him. He seems to have given up, he’s refusing to get in the wheelchair and go for walks or even eat his dinner! Could this be delirium?
Leslie Kernisan, MD MPH says
So sorry to hear about your grandfather. Especially with such a long time in the hospital, it wouldn’t be surprising for him to experience some delirium.
We do see some older people seem to “give up” after weeks in the hospital. Sometimes we’re able to identify a specific medical cause, but often I think it’s partly that they are just so worn out by the stress of illness and the hospital. I do sometimes see people recover after a long hospitalization like this, but it can take months and usually requires a lot of tender loving care at home (and also, no longer having whatever serious illness landed them in the hospital).
I hope he starts to improve soon. Getting him to familiar restorative surroundings might help. Good luck!
Helen says
My 64 year old active healthy dad had an accident apr 20. Had heart surgery that night. On a ventilator morphine numerous antibiotics and sedated for 2.5 weeks. Developed pneumonia and infection in lungs. Woke up not great mentally. Moved from icu to general ward early last week and mentally deteriorated. Lungs crashed due to infection last week and was reintubated and back on ventilator for 2 to 3 days in icu. When ventilator was removed last thurs I had a regular conversation where he got all details right names places etc. since then he’s deteriorated again, paranoid that someone is trying to hurt him / steal from him etc. Hes recovering from his physical injuries but mentally deteriorating. Do you think we just need to give it more time? Most articles seem to mention up to 2 weeks but we’re way beyond that at this point….
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s accident. I have often seen it take several weeks or many months for an older person to recover from delirium. Most of those older people are older and less fit than your father, but he did just spend quite a while in the intensive care unit and he’s had infections, so I’m sure he’s been physically quite weakened. He may just need more time to slowly recover.
A small minority of people your father’s age never do completely recover to the way they were before. But I think there’s not much use in worrying about that at this point…better to focus on supporting him as he works on recovering from the accident and hospitalization. Give him and yourselves time and then see where you are at. Good luck!