The Delirious Complexity of Delirium

I got a little delirious after reading a recent review article on delirium in American Family Physician1. Don’t get me wrong—it’s an excellent article; well written, up to date, and worth reading. However, the evaluation of delirium reads like a textbook of internal medicine. A “summary” table lists over 50 risk factors for delirium, including any chronic disease you can think of, acute insults, infections, medications, and,of course, age.

Delirium often goes unrecognized in hospitalized patients. It is characterized by an acute change in mental status, a fluctuating course, and changes in cognition or perception. It is sometimes mistaken for depression, dementia, or mania. Sundowning is a transient form of delirium that occurs in the evening—as the sun goes down, patients get confused by the change in light and a new environment. Persistent reorientation by family members can alleviate the problem.

What else can physicians do to manage delirium? First, they need to recognize it, and then think through the common causes of delirium.  Once serious conditions are ruled out, and delirious inducing medications are discontinued, it’s important to improve the following:

  1. Sleep hygiene
  2. Mobility
  3. Social interactions
  4. Sensory input ( e.g. hearing, vision)
  5. Nutrition, hydration
  6. Pain management

The authors make only one Grade A evidence-based recommendation:  use antipsychotics (haloperidol, quetiapine) only as a last resort in delirious patients. These drugs are associated with an increased mortality rate in dementia patients who become delirious. Finally, benzodiazepines should be avoided; they may worsen delirium.  


  1. Kalish, VB, et al.  American Family Physician.  2014; 90(3):150-158.     

Dean Gianakos, MD, FACP, practices and teaches general internal medicine in the Lynchburg Family Medicine Residency and Geriatrics Fellowship, Lynchburg, VA.  He frequently writes and lectures on the patient-physician relationship, end-of-life care, and the medical humanities.