Updated October 2025

Hospital Medicine | Geriatrics | Critical Care

Delirium in Hospitalized Adults: Prevention and Treatment

Delirium is common, morbid, and often preventable. The strongest evidence supports multicomponent non‑pharmacologic bundles (e.g., HELP) to prevent delirium, meticulous risk factor modification, and judicious avoidance of deliriogenic drugs. Pharmacologic prophylaxis is not routinely indicated outside select perioperative contexts; antipsychotics are not disease‑modifying and should be reserved for severe distress or dangerous agitation. Early recognition, mobilization, sleep promotion, pain control, and family engagement are core elements.

Clinical question

What evidence-based strategies prevent and treat delirium in hospitalized patients, and how should clinicians operationalize them at the bedside?

DeliriumHospital MedicineGeriatricsCritical CarePerioperativePatient Safety

Key points

Implement multicomponent prevention for all at-risk inpatients

Programs like HELP target orientation, sleep, mobilization, hydration/nutrition, vision/hearing, and medication review; they reduce incident delirium by about one-third and are recommended as standard care.

Screen daily and act on early signs

Use validated tools (e.g., 4AT, CAM/CAM-ICU) and escalate a bundle of non-pharmacologic measures immediately when fluctuations in attention or cognition are detected.

Mobilize early, protect sleep, treat pain

Mobilization, circadian entrainment, and analgesia with opioid-sparing strategies are foundational; evidence for early mobilization in ICU is inconclusive but supports safety and functional gains.

Treat underlying precipitants first

Correct hypoxemia, infection, dehydration, electrolyte disturbances, urinary retention/constipation, and drug effects before considering symptom-directed medications.

Reserve antipsychotics for severe agitation risking harm

They do not shorten delirium duration; use the lowest effective dose for the shortest time with cardiac and EPS monitoring. Consider dexmedetomidine in ICU/postoperative settings with appropriate monitoring.

Evidence highlights

Multicomponent bundles reduce incident delirium by ≈30%

Preventability

Delirium occurs in 35–80% of ICU patients

ICU burden

Dexmedetomidine lowers postoperative delirium risk (RR ~0.33–0.53)

Perioperative signal

Evidence Synthesis

What Works to Prevent Delirium

Prevention centers on multicomponent, non-pharmacologic strategies and selective perioperative sedation choices.

Multicomponent non‑pharmacologic programs

The Hospital Elder Life Program (HELP) and similar bundles address orientation, therapeutic activities, sleep hygiene, early mobilization, hydration/nutrition, and sensory optimization. Contemporary analyses show significant reductions in incident delirium (~30% relative reduction) across general medical and surgical inpatients ^[1], ^[3], ^[5], ^[8], ^[10], ^[12].

Family engagement

Structured family participation focusing on reorientation and appropriate sensory stimulation can further reduce delirium in ICU and ward settings, complementing core bundles ^[2].

Medication stewardship

Regularly deprescribe or minimize deliriogenic agents (anticholinergics, benzodiazepines, sedative hypnotics, high-dose opioids), prefer regional/neuraxial techniques when feasible, and avoid polypharmacy triggers embedded in risk tools ^[3], ^[5], ^[12].

Perioperative/ICU pharmacologic prevention (select patients)

An umbrella review of RCTs indicates dexmedetomidine reduces postoperative delirium: adults overall RR 0.33 (95% CI 0.24–0.45); older adult surgery RR 0.53 (95% CI 0.46–0.67); in older adults with comprehensive geriatric assessment prevention OR 0.46 (95% CI 0.32–0.67). Benefits must be balanced against bradycardia/hypotension and resource needs ^[4]. Routine pharmacologic prophylaxis outside these contexts is not supported ^[5], ^[12].

Early mobilization and sleep

Early mobilization is widely recommended; evidence in ICU remains inconclusive for delirium reduction, though it improves function and is safe with appropriate protocols ^[13]. Implement sleep bundles (lights-noise reduction, daytime light, minimize nocturnal care disruptions) within prevention packages ^[1], ^[5], ^[12].

Bedside Management

Treating Established Delirium

Prioritize cause reversal and non‑pharmacologic management. Use medications only for severe distress or safety threats.

Rapid evaluation and trigger reversal

Screen with 4AT/CAM/CAM‑ICU and correct precipitating factors: hypoxemia, infection/sepsis, dehydration, electrolyte disorders, urinary retention, fecal impaction, pain, withdrawal syndromes, and medication toxicity. Daily medication reconciliation is essential ^[3], ^[12].

Non‑pharmacologic core management

Implement HELP-like measures at therapeutic intensity: continuous reorientation, frequent mobilization with PT/OT, vision/hearing aids, sleep promotion, and family presence. These are first-line and safe across settings ^[1], ^[5], ^[12], ^[14].

Antipsychotics: symptom control only

For severe agitation/psychosis endangering care, consider low-dose haloperidol or atypicals; monitor QTc, EPS, orthostasis. They do not shorten delirium duration and should be time-limited with daily taper consideration ^[12].

Sedation strategy in ICU

Avoid benzodiazepines unless treating withdrawal. Consider dexmedetomidine for patients requiring nocturnal sedation or with agitation impeding extubation; evidence supports reduced delirium in postoperative/ICU cohorts but necessitates hemodynamic monitoring ^[4], ^[11], ^[13].

Rehabilitation and discharge planning

Delirium may persist post-discharge; arrange follow-up for cognition and function, ensure mobility aids/home safety, and communicate delirium episodes to primary care to guide medication review and rehabilitation ^[12], ^[14].

Practical Tools

Risk Factors, Screening, and Order Sets

Use this to build ward and ICU order sets that standardize prevention and early treatment.

Major risk factors

Baseline dementia or cognitive impairment; prior delirium

Advanced age, sensory impairment (vision/hearing)

Acute illness severity, infection/sepsis, surgery (especially hip/cardiac)

Dehydration, electrolyte disorders, hypoxia, anemia

Polypharmacy; psychoactive/anticholinergic meds; alcohol use/withdrawal

Immobility, restraints, sleep disruption; urinary retention/constipation ^[3], ^[5], ^[12]

Screening and monitoring

Daily 4AT or CAM on wards; CAM‑ICU in ICU

Assess arousal (RASS) before attention testing

If positive, initiate bundle and search for precipitants

Document subtype (hyperactive, hypoactive, mixed) to guide safety plans ^[12]

Default prevention bundle (order set)

Orientation: clocks/calendars, windows, staff introductions, cognitive activities

Sleep: lights/noise reduction, daytime mobilization/light exposure, avoid nighttime vitals/labs when safe

Mobility: OOB to chair TID; ambulate with assist; PT/OT consult within 24 h

Sensory: ensure glasses, hearing aids; low-vision/hearing amps

Hydration/nutrition: scheduled fluids, assistance with meals; bowel/bladder protocols

Medication stewardship: stop anticholinergics/benzodiazepines when possible; opioid-sparing analgesia ^[1], ^[5], ^[8], ^[12]

When to consider medications

Imminent risk to self/others or care failure despite non‑drug measures

Haloperidol 0.5–1 mg PO/IV q4–6h PRN (frail older adults: 0.25–0.5 mg); monitor QTc/EPS

Atypicals (e.g., quetiapine 12.5–25 mg PO q12h) if Parkinsonism risk; avoid in marked hypotension/QT prolongation

Dexmedetomidine infusion in ICU/post-op for agitation preventing extubation or sleep-wake restoration; monitor for bradycardia/hypotension ^[4], ^[11], ^[12], ^[13]

De‑escalation and follow-up

Daily attempt to taper/stop antipsychotics; set automatic stop dates

Reassess need for sitters/restraints at least every shift; prioritize alternatives

Communicate delirium episode and high-risk status at transitions of care

Arrange cognitive and functional reassessment within 4–12 weeks ^[12], ^[14]

References

Source material

Primary literature that informs this article.