Delirium

Understanding Delirium

A Whole-Brain Phenomenon

Delirium reflects a global disturbance of brain function rather than damage to any single area. Multiple neurotransmitter systems — cholinergic, dopaminergic, GABAergic, serotonergic — fall out of balance, while neuroinflammation, oxidative stress, and disruption of neural network connectivity contribute. The result is the breakdown of attention and awareness that defines the syndrome, along with fragmented thinking, perceptual disturbances, and a disordered sleep-wake cycle.

This brain-wide dysregulation explains why so many different triggers — infections, drugs, electrolytes, hypoxia, withdrawal — can produce a remarkably similar clinical picture. The brain has a limited repertoire for expressing acute distress, and delirium is its loudest expression.

Acute and Fluctuating

What distinguishes delirium from other causes of cognitive impairment is its sharp time course. The onset is over hours to days rather than months to years, the level of impairment varies through the day, and lucid intervals can alternate with periods of severe confusion. A patient may converse clearly at one moment and fail to recognize a family member an hour later, only to recover orientation by evening. This fluctuation is itself diagnostically useful, particularly when distinguishing delirium from established dementia.

The Hypoactive Form

The stereotype of delirium is an agitated, hallucinating, restless patient. In reality, the more common presentation, especially in older adults, is the opposite: quiet withdrawal, reduced responsiveness, slowed movement, and apparent calm. Hypoactive delirium can be mistaken for fatigue, depression, or simply being "out of it," and it is missed in a majority of cases unless clinicians actively screen for it. Its prognosis is at least as poor as the hyperactive form.

Delirium Versus Dementia

The two conditions can look similar, particularly when delirium is superimposed on existing dementia. Key distinctions include the acute onset and fluctuation of delirium versus the chronic gradual decline of dementia, the predominant inattention of delirium versus the predominant memory impairment of Alzheimer's-type dementia, and the presence of an identifiable medical trigger in delirium. Both can coexist — delirium superimposed on dementia is one of the most challenging clinical scenarios — and recognition of the acute change requires baseline knowledge of the person's usual cognitive status.

Who Is Most Vulnerable

• Adults over 65, with risk rising further in the 75 and older age group
• People with preexisting cognitive impairment or dementia
• Hospitalized patients, especially in intensive care and after major surgery
• Those with multiple medical comorbidities or polypharmacy
• People with hearing or visual impairment
• Patients with prior episodes of delirium
• Individuals with alcohol or sedative dependence facing withdrawal
• End-of-life patients, in whom terminal delirium is common

DSM-5 Diagnostic Criteria

The DSM-5 lays out five criteria for the diagnosis of delirium. All must be present.

Criterion A: Disturbance in Attention and Awareness

There is a disturbance in attention — reduced ability to direct, focus, sustain, and shift attention — and in awareness, meaning reduced orientation to the environment. This is the cardinal feature. A patient with delirium often cannot follow a conversation, loses track of questions mid-answer, and may stare blankly or look distracted by external stimuli. Attention can be tested with simple bedside tasks such as digit span backwards, months of the year in reverse, or the Vigilance "A" task (tap when you hear the letter A).

Criterion B: Acute Onset and Fluctuation

The disturbance develops over a short period — usually hours to a few days — represents an acute change from baseline, and tends to fluctuate in severity during the course of the day. Information from family or staff about the baseline level of function is essential here; a patient's apparent confusion in the emergency department means something very different when it represents a sudden change versus a long-standing pattern.

Criterion C: Additional Cognitive Disturbance

There is an additional disturbance in cognition such as memory deficit, disorientation, language difficulty, visuospatial impairment, or perceptual disturbance. These are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.

Criterion D: Not Better Explained by Another Neurocognitive Disorder

The disturbances in attention, awareness, and cognition are not better explained by an established or evolving dementia and do not occur in the context of severely reduced arousal. Crucially, delirium and dementia can coexist; the DSM-5 framework allows for the diagnosis of delirium superimposed on a preexisting neurocognitive disorder.

Criterion E: Evidence of a Direct Physiological Cause

Evidence from history, physical examination, or laboratory findings indicates that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, exposure to a toxin, or multiple etiologies. This criterion grounds delirium in its medical reality — it is always a symptom of something else.

Specifiers

• Etiological subtype: Substance intoxication delirium, substance withdrawal delirium, medication-induced delirium, delirium due to another medical condition, or delirium due to multiple etiologies
• Duration: Acute (hours to days) or persistent (weeks to months)
• Activity level: Hyperactive, hypoactive, or mixed level of activity

Subtypes and Clinical Settings

Hyperactive Delirium

Hyperactive delirium features increased motor activity, agitation, restlessness, mood lability, refusal to cooperate with care, vivid hallucinations, and sometimes aggression. This is the most recognizable form because the behavior demands attention. Patients may attempt to climb out of bed, pull out lines and tubes, or shout at staff. While easier to identify, hyperactive delirium accounts for only about a quarter of cases overall.

Hypoactive Delirium

Hypoactive delirium is the quiet form: decreased motor activity, lethargy, withdrawal, reduced speech, and apparent sedation. Patients appear to be sleeping well or are described as "just tired." They are also disoriented and inattentive on careful examination, but the lack of disruptive behavior means the condition is often missed entirely. Hypoactive delirium is the most common form in older medical inpatients and carries equal or worse prognosis than the hyperactive form.

Mixed Delirium

Many patients fluctuate between hyperactive and hypoactive states across hours, with restless wakefulness at night and lethargy during the day, or sudden swings from withdrawal to agitation. The mixed pattern is common and accounts for a substantial proportion of cases.

Postoperative Delirium

Delirium occurs in 15 to 50 percent of patients after major surgery, with the highest rates after cardiac, vascular, hip fracture, and major abdominal procedures. Risk factors include older age, preexisting cognitive impairment, anemia, electrolyte disturbance, certain anesthetic exposures, postoperative pain, and sleep disruption. Preventive bundles in surgical and orthopedic care have meaningfully reduced incidence in many centers.

ICU Delirium

In the intensive care unit, delirium affects 30 to 80 percent of patients, depending on the population and how carefully it is assessed. Mechanical ventilation, sedative infusions (particularly benzodiazepines), restraints, sleep deprivation, immobilization, social isolation, and the severity of underlying illness all contribute. Modern critical care emphasizes minimizing sedation, daily awakening trials, early mobilization, family presence, and structured delirium assessment as components of the ABCDEF bundle.

Sundowning

Sundowning is a pattern of increased confusion, agitation, or anxiety in late afternoon and evening. It can occur in established dementia or as part of delirium superimposed on dementia. The pattern reflects circadian disruption, fatigue accumulating across the day, and reduced sensory input as light fades. Although sometimes treated as a separate phenomenon, it overlaps significantly with hypoactive or mixed delirium when occurring in hospitalized patients.

Alcohol Withdrawal Delirium

Delirium tremens is the most severe form of alcohol withdrawal, occurring 48 to 96 hours after the last drink in chronic heavy drinkers. Features include profound confusion, vivid hallucinations (often of small animals), severe tremor, autonomic instability with tachycardia and hypertension, and risk of seizures. Untreated, mortality can reach 15 percent. Identification of patients at risk and proactive use of benzodiazepine protocols are central to prevention.

Benzodiazepine and Sedative Withdrawal

Abrupt discontinuation of benzodiazepines, barbiturates, and some other sedatives can produce a similar withdrawal delirium with seizure risk. Hospitalized patients on chronic outpatient benzodiazepines are particularly vulnerable if their home regimen is interrupted.

Terminal Delirium

Delirium is extremely common in the last days of life, occurring in the majority of dying patients. Causes include multiorgan failure, metabolic disturbance, hypoxia, medication accumulation, and pain. Treatment emphasizes comfort, family support, and addressing reversible contributors when consistent with goals of care.

Symptoms and Warning Signs

Attention and Awareness

• Inability to maintain focus on a conversation or task
• Easily distracted by ambient noise or movement
• Difficulty following multistep instructions
• Reduced awareness of surroundings, time, or who is in the room
• Variable level of arousal — drowsy at one moment, restless the next

Disorientation and Memory

• Confusion about time, place, or situation
• Misidentification of familiar people
• Poor recent memory, particularly for the events leading to admission
• Confabulation — filling memory gaps with plausible but inaccurate accounts

Perceptual Disturbances

• Illusions — misperceiving real objects (a coat rack seen as a person)
• Visual hallucinations, often vivid and sometimes frightening
• Auditory hallucinations, less common than visual
• Persecutory or paranoid delusions, often centered on staff intentions

Thought and Language

• Disorganized, tangential, or incoherent speech
• Rambling, mumbling, or perseveration
• Trouble naming objects or finding common words
• Loose associations between ideas

Sleep-Wake Disturbance

• Reversed day-night sleep pattern
• Daytime drowsiness with nighttime agitation
• Fragmented sleep punctuated by waking confusion
• Vivid dreams and nightmares

Behavior and Mood

• Agitation, calling out, pulling at lines and tubes
• Withdrawal, refusal to eat, drink, or participate in care
• Emotional lability — sudden tears, anger, or fear
• Combativeness, particularly when feeling threatened or misinterpreting care
• Apparent depression in the hypoactive form

Family-Recognizable Warning Signs

Family members are often the first to notice subtle changes that staff have not yet appreciated, particularly in patients with baseline cognitive impairment. Phrases such as "He's just not himself," "She isn't tracking the way she usually does," or "He keeps drifting off" deserve serious evaluation rather than reassurance.

Causes and Risk Factors

The Predisposing/Precipitating Framework

A useful clinical model separates predisposing factors — characteristics of the person that increase vulnerability — from precipitating factors — the specific triggers that push the brain into delirium. Patients with many predisposing factors can be tipped into delirium by mild precipitants; those with few predisposing factors require more severe insults to develop the syndrome.

Predisposing Factors

• Advanced age
• Preexisting cognitive impairment or dementia
• Multiple medical comorbidities
• Frailty and sarcopenia
• Sensory impairments — vision and hearing
• Polypharmacy
• History of alcohol misuse
• Prior episodes of delirium
• Depression
• Malnutrition and dehydration at baseline

Precipitating Factors: Infection

Infection is one of the most common precipitants in older adults, often presenting with confusion rather than typical infectious symptoms. Urinary tract infection is particularly common in elderly women, although the diagnosis must be made cautiously to avoid attributing delirium to asymptomatic bacteriuria. Pneumonia, sepsis, cellulitis, and intra-abdominal infections also commonly trigger delirium. Treating the infection treats the delirium.

Precipitating Factors: Medications

• Anticholinergics, including many bladder medications, antihistamines, and tricyclic antidepressants
• Benzodiazepines and other sedatives
• Opioids, particularly when newly initiated or at higher doses
• Corticosteroids, especially at higher doses
• Antiparkinsonian medications, particularly dopamine agonists
• H2 blockers in older adults
• Antibiotics with central nervous system penetration, in selected patients
• Cardiovascular medications, especially digoxin toxicity
• Lithium toxicity
• Polypharmacy in itself — interactions are often the trigger

Precipitating Factors: Metabolic and Endocrine

• Electrolyte abnormalities, particularly sodium, calcium, magnesium, and phosphate
• Hypoglycemia or severe hyperglycemia
• Renal or hepatic failure
• Thyroid dysfunction
• Adrenal insufficiency
• Vitamin deficiencies, including thiamine in alcohol users

Precipitating Factors: Hypoxia and Cardiovascular

• Respiratory failure, exacerbations of chronic lung disease, pulmonary embolism
• Heart failure with reduced cardiac output
• Anemia
• Myocardial infarction, sometimes presenting with confusion in older adults
• Arrhythmias with hemodynamic compromise

Precipitating Factors: Neurological

• Stroke and transient ischemic attacks
• Subdural hematoma
• Seizures, including nonconvulsive status epilepticus
• Central nervous system infection (meningitis, encephalitis)
• Autoimmune encephalitis
• Brain tumors

Precipitating Factors: Withdrawal

• Alcohol withdrawal, with risk of delirium tremens
• Benzodiazepine withdrawal
• Opioid withdrawal (less commonly produces frank delirium but can be a contributor)
• Nicotine withdrawal in heavy smokers admitted to the hospital

Precipitating Factors: Environmental and Iatrogenic

• Sleep disruption
• Sensory deprivation (poor lighting, missing glasses or hearing aids)
• Sensory overload (noise, bright lights, constant interruptions)
• Use of physical restraints, urinary catheters, intravenous lines, and other "tethers" that limit mobility
• Inadequate pain control
• Immobilization and bed rest
• Unfamiliar surroundings and frequent room changes

Why Older Adults Are Especially Vulnerable

Aging reduces the brain's reserve capacity to maintain function under stress. Lower acetylcholine availability, reduced cerebral blood flow autoregulation, accumulated white matter disease, and greater medication sensitivity all contribute. Underlying neurodegenerative pathology — even when subclinical — further lowers the threshold. The result is that small medical perturbations that a younger person would tolerate without cognitive change can precipitate full-blown delirium in an older patient.

Medical Complications and Long-Term Consequences

Acute Complications

• Falls and injuries during agitation or attempts to leave bed
• Self-extubation, removal of central lines, or other treatment interruptions
• Aspiration during reduced level of arousal
• Pressure injuries from immobilization
• Dehydration and malnutrition from refusal of food and fluids
• Acute kidney injury from inadequate intake or medication accumulation
• Prolonged hospital length of stay
• Increased need for ICU transfer or readmission

Mortality

Delirium is associated with significantly increased in-hospital and post-discharge mortality, even after accounting for severity of illness. The relationship is strongest for hypoactive delirium and for episodes lasting longer than three days, but it is present across subtypes and settings.

Functional Decline

Patients who experience delirium are more likely to lose functional independence during a hospitalization, to require discharge to a facility rather than home, and to experience prolonged rehabilitation. Recovery to prior baseline function is often slower than for matched patients who do not develop delirium.

Cognitive Decline and Dementia Risk

Each episode of delirium is associated with increased risk of subsequent cognitive decline and incident dementia. The relationship appears bidirectional: preexisting cognitive impairment increases delirium risk, and delirium episodes appear to accelerate underlying neurodegeneration or unmask it. Persistent cognitive deficits — sometimes called post-ICU cognitive impairment in critical care survivors — can last months to years.

Psychological Consequences

Patients who experience delirium often retain fragmented and frightening memories of the episode. Distorted recollections of staff as threatening, of hallucinatory experiences, or of physical restraint can persist long after recovery. Post-traumatic stress symptoms, depression, and anxiety are recognized sequelae, particularly after ICU delirium.

Family and Caregiver Impact

Watching a loved one experience delirium is distressing. Families may worry that the change is permanent, may feel helpless, and may carry their own anxiety symptoms after the episode resolves. Honest information about what is happening, why it occurs, and what to expect during recovery reduces caregiver distress and supports recovery.

Assessment and Diagnosis

Recognition

The first challenge of delirium is recognizing it. Routine screening of older inpatients improves identification rates substantially. Several validated tools exist:

• CAM (Confusion Assessment Method): The most widely used bedside tool; requires acute onset and fluctuation plus inattention, with either disorganized thinking or altered level of consciousness
• CAM-ICU: Adapted for use in mechanically ventilated and nonverbal patients
• 4AT: A brief screening tool that does not require formal training
• Delirium Rating Scale (DRS-R-98): A more detailed instrument used in research and complex cases

Establish Baseline

An accurate baseline is essential. Information from family, primary care records, or nursing home documentation about the patient's usual level of cognitive function is sometimes more important than any test performed at the bedside. A patient who appears mildly confused may be at baseline or may be acutely changed; only collateral information can tell the difference.

Workup for Underlying Cause

Once delirium is recognized, the search for triggers begins. A typical evaluation includes:

• Medication reconciliation, with attention to anticholinergics, benzodiazepines, opioids, and recent medication changes
• Vital signs, including oxygen saturation, temperature, and orthostatic measurements when feasible
• Targeted physical and neurological examination
• Basic labs: complete blood count, comprehensive metabolic panel, calcium, magnesium, phosphate, liver function, thyroid function
• Urinalysis with culture if symptoms suggest infection
• Chest imaging when respiratory symptoms are present
• Electrocardiogram
• Blood cultures and lactate when sepsis is suspected
• Arterial blood gas when hypoxia or significant acid-base disturbance is suspected
• Drug levels for digoxin, lithium, or other relevant medications
• Toxicology screening when ingestion or withdrawal is possible

Brain Imaging

CT or MRI is reserved for patients with focal neurological signs, recent fall or head injury, anticoagulant use, severe headache, or delirium that fails to respond to expected treatment of identified triggers. Routine head imaging is not necessary in straightforward cases of delirium with a clear systemic cause.

Lumbar Puncture and EEG

Lumbar puncture is indicated when central nervous system infection or autoimmune encephalitis is suspected. EEG can be useful when nonconvulsive status epilepticus is a consideration or when the diagnosis is uncertain — delirium typically shows generalized slowing, while a normal EEG raises the possibility of alternative diagnoses such as functional disorders.

Differential Diagnosis

• Dementia — chronic, gradual, attention relatively preserved early
• Acute psychiatric disorders (mania, psychotic depression, schizophrenia) — typically without the global cognitive disturbance
• Nonconvulsive status epilepticus
• Stroke, particularly involving thalamus or right parietal cortex
• Wernicke encephalopathy — confusion, ataxia, and ophthalmoplegia in alcohol users or others with thiamine deficiency
• Autoimmune encephalitis
• Functional cognitive disorders

Treatment Approaches

Treat the Underlying Cause

The primary treatment for delirium is identifying and reversing the precipitating factors. Antibiotics for infection, correction of electrolyte abnormalities, oxygen for hypoxia, adequate hydration, removal or substitution of offending medications, treatment of pain — these are the actual treatments. Sedating medications do not treat delirium; they only manage behavior, and inappropriately used, they prolong the syndrome and worsen outcomes.

Supportive and Environmental Care

Around the medical workup and treatment, supportive measures matter enormously:

• Reorient gently and frequently — date, time, location, situation, who is in the room
• Provide eyeglasses, hearing aids, and dentures consistently
• Encourage daytime mobilization out of bed
• Protect nighttime sleep — minimize unnecessary interruptions, support normal light/dark cues during the day
• Ensure adequate hydration and nutrition, with appropriate assistance
• Address pain proactively but cautiously
• Minimize "tethers" — remove urinary catheters, intravenous lines, telemetry leads, and restraints as soon as feasible
• Avoid restraints when possible — they often worsen agitation and increase injury risk
• Welcome family presence; familiar faces are profoundly reorienting
• Use a single quiet room where possible, with familiar objects from home

Communication With the Patient

• Speak slowly, clearly, and one idea at a time
• Make eye contact and use the person's name
• Avoid arguing with delusions or hallucinations
• Acknowledge fear without confirming or denying its content
• Redirect to safe activities when possible
• Avoid sudden movements or unexpected procedures without explanation

Pharmacological Management

Medications have a limited and specific role in delirium care. They are not first-line treatment, and they do not shorten the syndrome. They are reserved for situations in which behavior threatens the safety of the patient or staff and nonpharmacological measures have failed.

• Antipsychotics: Low-dose haloperidol historically used for severe agitation, with atypical agents such as olanzapine, quetiapine, or risperidone increasingly preferred. Effect on delirium duration is modest at best. Black-box warnings for increased mortality in older adults with dementia apply. Use the lowest effective dose for the shortest necessary time.
• Benzodiazepines: Generally to be avoided because they can worsen delirium. The major exception is alcohol or sedative withdrawal, where benzodiazepine protocols are the treatment of choice.
• Dexmedetomidine: Used in the ICU in place of benzodiazepines for sedation, with lower rates of delirium.
• Melatonin or ramelteon: Some evidence supports use for sleep-wake regulation and possible reduction in delirium incidence.

Alcohol Withdrawal Delirium

Treatment requires specific protocols: benzodiazepine therapy (often diazepam or lorazepam) titrated to symptom severity using tools such as the CIWA-Ar, thiamine before any glucose to prevent Wernicke encephalopathy, magnesium supplementation, multivitamin support, careful fluid and electrolyte management, and monitoring for seizures and cardiovascular complications. Severe cases require ICU-level care.

Special Population: Lewy Body Dementia

Patients with Lewy body dementia or Parkinson's disease dementia are extremely sensitive to antipsychotics. When pharmacological management of delirium-related agitation is unavoidable, quetiapine or, less commonly, clozapine is preferred over higher-potency agents, and doses should be very conservative. The risk of severe antipsychotic reactions in these patients should be flagged prominently in the medical record.

Family Involvement

Family members are uniquely effective in reorienting and reassuring a delirious patient. Their presence reduces fear, supports cooperation with care, and helps staff understand the patient's baseline and preferences. Hospitals and ICUs increasingly recognize that liberal family visitation is part of delirium care, not an obstacle to it.

Prevention and Caregiving

Prevention Is the Best Treatment

A substantial proportion of delirium episodes are preventable. Multicomponent prevention programs have demonstrated reductions in incidence of approximately one-third in older medical and surgical patients. The most studied program, the Hospital Elder Life Program (HELP), uses trained volunteers and staff to implement specific interventions targeting common risk factors.

Components of HELP and Similar Programs

• Daily reorientation and cognitive engagement
• Early and frequent mobilization
• Sleep enhancement protocols — quiet hours, warm drinks, relaxation techniques, minimal nighttime interruptions
• Vision and hearing optimization — making sure glasses and hearing aids are in place
• Adequate hydration and nutrition assistance
• Medication review to minimize delirium-promoting drugs
• Pain management protocols that reduce opioid burden where feasible
• Family education and involvement

Preoperative Optimization

For elective surgery, prehabilitation programs improve fitness, address malnutrition, optimize chronic medical conditions, review medications, and educate patients and families about delirium risk. Specific anesthesia choices, multimodal analgesia to reduce opioid requirements, careful intraoperative fluid management, and prompt postoperative mobilization all reduce risk.

Critical Care: The ABCDEF Bundle

In the ICU, the ABCDEF bundle organizes evidence-based delirium prevention and treatment:

• A: Assess, prevent, and manage pain
• B: Both spontaneous awakening and spontaneous breathing trials
• C: Choice of analgesia and sedation, favoring nonbenzodiazepine approaches
• D: Delirium assess, prevent, and manage
• E: Early mobility and exercise
• F: Family engagement and empowerment

Bundle implementation is associated with reduced delirium, shorter length of stay, fewer days on mechanical ventilation, and lower mortality.

Outpatient and Long-Term Care

Delirium also occurs at home and in residential care facilities. Periodic medication reviews — particularly targeting anticholinergic burden, benzodiazepines, and opioids — pay large dividends. Treating sensory impairments, addressing sleep apnea, supporting hydration, ensuring early treatment of infections, and avoiding sedating over-the-counter products such as diphenhydramine all reduce risk in older adults.

Recovering at Home After Delirium

Recovery from an episode of delirium can take days to months. Many patients return to baseline; others have persistent symptoms or accelerated cognitive decline. Home strategies during recovery include:

• Consistent daily routines
• Reorientation cues — calendars, clocks, daily schedule visible
• Good lighting during the day and reduced lighting at night
• Hearing aids and glasses available
• Avoiding sedating medications when possible
• Encouraging walking and activity within tolerance
• Gentle social engagement
• Patience — cognition may fluctuate for weeks before stabilizing

Supporting Family Caregivers

Family members are central to recognition, reorientation, and recovery, and they often need support themselves. Honest education about delirium — that it is not "going crazy," not deliberate, and frequently reversible — relieves both patient and family. Caregivers may benefit from acknowledgment of their own emotional response to seeing a loved one acutely confused, and from connection with patient advocacy organizations or memory clinics.

Long-Term Follow-Up

After a delirium episode, cognitive reassessment several weeks to months later is reasonable, particularly if symptoms persist. Some patients show recovery to baseline; others reveal underlying cognitive impairment that had been masked. Identifying any new neurocognitive disorder allows appropriate evaluation, planning, and treatment.

When to Seek Help

Acute Situations

New confusion or any abrupt change in mental status in an older adult warrants urgent medical evaluation. Calling emergency services or going to an emergency department is appropriate, particularly when the change is accompanied by fever, shortness of breath, chest pain, severe headache, focal weakness, or seizure activity.

Suspected Withdrawal

If a person with a history of heavy alcohol or sedative use develops tremors, sweating, anxiety, confusion, or hallucinations after stopping or cutting back, urgent medical evaluation is essential. Alcohol withdrawal delirium can be fatal but is highly treatable when caught early.

In the Hospital

• Speak up to clinicians if a hospitalized loved one seems unlike themselves
• Ask the medical team directly whether delirium is being considered
• Provide a clear description of baseline function before admission
• Bring eyeglasses, hearing aids, and any usual orientation aids such as photographs or familiar objects
• Advocate for medication review and mobility
• Stay present when possible, especially during evenings when sundowning is most likely

After Discharge

• Continue monitoring for symptoms during recovery
• Bring the discharge medication list to a follow-up appointment for review
• Schedule cognitive reassessment if symptoms persist beyond a few weeks
• Watch for new mood symptoms, distressing memories, or anxiety that may reflect post-delirium psychological effects

Where to Start

• Primary care for postdischarge follow-up and medication reconciliation
• Geriatrician or geriatric psychiatrist for complex care
• Neurologist for evaluation of persistent cognitive deficits or new neurological signs
• Memory clinic for cognitive reassessment several weeks after recovery
• Mental health support for patients and families struggling with post-delirium psychological effects