Delirium is an acute neuropsychiatric syndrome — a sudden deterioration in brain function — characterised by disturbed attention, awareness and cognition, with an acute onset (hours to days) and fluctuating course. It is extremely common in hospitals: approximately 20-30% of all admitted medical patients develop delirium; in the ICU, rates reach 50-80%. There are three subtypes: hyperactive (agitated, combative, hallucinating — the classic "confused patient" that nurses call for help); hypoactive (quiet, withdrawn, reduced movement, sleepy — the most common and most frequently missed); and mixed (fluctuating between the two). Delirium is an emergency — it indicates significant medical stress on the brain and requires immediate investigation and treatment of the underlying cause.

Why is hypoactive delirium so often missed?

Hypoactive delirium — characterised by reduced activity, decreased responsiveness, withdrawal, somnolence and slow speech — is the most common subtype (approximately 50%) but is missed in approximately 70% of cases by clinical staff. The reasons: it doesn't disrupt ward function (the patient is quiet); the reduced activity may be attributed to tiredness, depression, sedation or "the patient's age"; staff may feel reassured by a quiet patient. A patient who is unusually quiet, has stopped participating in conversation, is staring blankly, is slow to respond, or is sleeping more than usual should be assessed for delirium — not assumed to be fine because they're not agitated.

How is delirium prevented?

The Hospital Elder Life Program (HELP) — a multi-component non-pharmacological programme — reduces delirium incidence by approximately 40% in high-risk elderly inpatients. Key components: Orientation: large wall clocks and calendars; daily orientation conversations (name, date, place, reason for admission); familiar photos from home. Early mobilisation: get patients out of bed and walking daily — immobility is a major delirium precipitant. Sleep protocol: avoid unnecessary night-time interruptions; noise reduction; dim lights at night. Hydration: encourage oral fluids; early IV fluids for dehydrated patients. Restore sensory aids: glasses and hearing aids must be returned immediately after admission — their removal is a major preventable delirium trigger. Family presence: familiar faces and voices are orientating.

What causes delirium?

Delirium results from a pathological interaction between predisposing vulnerability (dementia, age >65, functional dependence, sensory impairment, dehydration, multiple comorbidities) and acute precipitating insults. Common precipitants (PINCHME): Pain (unrecognised); Infection (UTI most common in women; pneumonia; surgical wound); Nutrition (malnutrition; B1 deficiency — Wernicke encephalopathy); Constipation/urinary retention; Hydration (dehydration → electrolyte abnormality → confusion); Medication (any new drug should be suspect — anticholinergics, opioids, benzodiazepines, steroids, antihistamines, sedatives are high risk); Environment (sensory deprivation, noise, unfamiliar place); Electrolytes (hyponatraemia, hypercalcaemia, hypoglycaemia).

What is the role of antipsychotics in delirium?

This is critically important: antipsychotics (haloperidol, olanzapine, quetiapine) are commonly prescribed for delirium in clinical practice but have very limited evidence of benefit. Multiple large RCTs have shown: haloperidol does NOT reduce delirium duration or mortality in medical inpatients; quetiapine does NOT significantly improve delirium in ICU patients. Side effects: sedation, falls, QT prolongation (torsade risk), extrapyramidal effects (dystonia, parkinsonism). The only appropriate use: hyperactive delirium causing IMMEDIATE risk of harm to self or others where non-pharmacological approaches have failed — minimum dose, shortest duration possible. Never use benzodiazepines for delirium (except alcohol withdrawal) — they dramatically worsen confusion.

How does GMJ News cover delirium?

GMJ News covers WHO delirium data, the three subtypes (hypoactive — the missed crisis), CAM screening tool, PINCHME causes, HELP programme (40% prevention), ICU delirium ABCDEF bundle, antipsychotic limitations (no routine use), benzodiazepine contraindication, and delirium-dementia long-term link. Delirium — the most common serious brain complication in hospital — is directly relevant to PHIG's hospital accreditation programme and Georgian geriatric care standards.

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Delirium

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Delirium — an acute neuropsychiatric syndrome characterised by disturbed attention, awareness and cognition that develops acutely and fluctuates during the day — is one of the most common, serious and under-recognised complications in hospitalised patients: affecting approximately 20-30% of all medical inpatients, 50-80% of ICU patients and up to 65% of patients after hip fracture surgery, it is independently associated with longer hospital stays, higher mortality, accelerated cognitive decline and higher rates of institutionalisation, yet hypoactive delirium (the quiet, withdrawn, reduced-activity subtype) — the most common form — is missed in approximately 70% of cases (WHO). Prevention through the multi-component HELP (Hospital Elder Life Program) — maintaining orientation, mobility, hydration, sleep-wake cycle, and sensory aids — reduces delirium incidence by approximately 40%, outperforming any pharmacological intervention.

Key messages

20-30% of inpatients — the most common serious brain complication in hospital

Delirium affects approximately 20-30% of all hospitalised medical patients, 50-80% of ICU patients and up to 65% of post-hip-fracture patients — making it the most common serious neuropsychiatric complication in hospital and an independent predictor of mortality, longer stay and accelerated cognitive decline (WHO).

Hypoactive delirium — missed in 70% of cases

Hypoactive delirium — the quiet, withdrawn, reduced-activity subtype — is the most common form yet is missed by clinical staff in approximately 70% of cases because the patient doesn't disturb the ward. Hyperactive delirium (agitated, confused) is more visible but less common. Missed delirium is untreated delirium.

HELP programme — 40% prevention

The Hospital Elder Life Program (HELP) — a multi-component non-pharmacological intervention — reduces delirium incidence by approximately 40%. Components: daily orientation (large clock, calendar, regular communication about date, place, reason for hospital); early mobilisation; sleep protocol; hydration; hearing aids and glasses restored; family involvement. Prevents delirium better than any drug.

Treat the underlying cause first

The first step in delirium management is always: FIND AND TREAT THE CAUSE. Common causes: infection (UTI, pneumonia); medication side effects (opioids, anticholinergics, benzodiazepines, sedatives); dehydration; electrolyte abnormalities; urinary retention; constipation; pain; hypoxia; hypoglycaemia; withdrawal. PINCHME mnemonic: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment/electrolytes.

Antipsychotics — very limited role

Antipsychotics (haloperidol, quetiapine) should NOT be used routinely for delirium — they do not reduce delirium duration or mortality, and increase falls, QT prolongation and extrapyramidal side effects. Limited role: hyperactive delirium causing immediate risk of harm to self or others (minimum dose, short duration). Never use benzodiazepines for delirium (except alcohol withdrawal) — they worsen confusion.

Delirium accelerates dementia — not a "temporary" problem

Each episode of delirium accelerates long-term cognitive decline — hospitalised patients who develop delirium have significantly higher rates of new or worsened dementia at 1-5 year follow-up, even when delirium resolves before discharge. Delirium is not just a temporary confusion — it has lasting consequences.

Key statistics

20-30%

of hospitalised medical patients develop delirium

WHO/Lancet

50-80%

of ICU patients develop delirium (especially mechanically ventilated)

WHO/Critical Care

70%

of hypoactive delirium cases missed by clinical staff

WHO/NICE

~40%

delirium prevention by multi-component HELP programme

NEJM/Lancet

2-5yr

higher dementia risk after a delirium episode (long-term brain consequence)

Lancet

Never

benzodiazepines for delirium (except alcohol withdrawal) — they worsen confusion

WHO/NICE

Delirium subtypes — prevalence and clinical recognition rates (WHO/NICE)

Source: WHO/NICE. Hypoactive delirium is the most common, most missed and most clinically significant. Mixed delirium fluctuates between subtypes.

Glossary of key terms

DSM-5/ICD-11 delirium criteria
WHO/APADelirium is diagnosed by: (1) Disturbance of attention (reduced ability to direct, focus, sustain and shift attention) AND awareness; (2) Develops over a short period (hours to days) and fluctuates during the day; (3) Cognitive disturbance (memory impairment, disorientation, language disturbance, visuospatial impairment or perceptual disturbance); (4) Not better explained by pre-existing neurocognitive disorder in a context of severely reduced arousal; (5) Evidence from history, examination or investigations that it is caused by a medical condition, substance intoxication/withdrawal, or medication side effect.

CAM (Confusion Assessment Method)
WHO/NICEThe Confusion Assessment Method (Inouye et al. 1990) is the most widely validated delirium screening tool — used in most clinical settings and research. Four features: (1) Acute onset and fluctuating course (YES/NO); (2) Inattention (YES/NO — cannot count backwards from 20, cannot say months backwards); (3) Disorganised thinking (YES/NO); (4) Altered level of consciousness (YES/NO). Delirium = features 1 + 2 PLUS either 3 or 4. CAM-ICU: adapted version for mechanically ventilated ICU patients; uses non-verbal attention tests.

PINCHME mnemonic
NICE/GeriatricsA clinical aide-mémoire for delirium precipitants to address: P — Pain (unrecognised and undertreated); I — Infection (UTI, LRTI, other); N — Nutrition (malnutrition, vitamin B1/B12 deficiency); C — Constipation (faecal impaction — extremely common in hospitalised elderly); H — Hydration (dehydration — also causes electrolyte abnormalities); M — Medication (new drugs, interactions, polypharmacy — review ALL medications); E — Environment/Electrolytes (unfamiliar environment, noise, poor lighting; Na, K, Ca, Mg, glucose abnormalities).

Hospital Elder Life Program (HELP)
Inouye/NICEA multi-component non-pharmacological delirium prevention programme developed by Sharon Inouye. Six evidence-based protocols: (1) Cognitive orientation: reality orientation 3× daily (date, name, place, reason for hospital); familiar objects from home; (2) Therapeutic activities; (3) Sleep enhancement: sleep hygiene protocols, avoiding unnecessary night-time interruptions; (4) Mobilisation: daily physiotherapy/mobilisation; (5) Vision/hearing: restore glasses and hearing aids promptly; (6) Hydration: encourage oral fluids; IV fluids if insufficient. Reduces delirium incidence by approximately 40% in high-risk elderly inpatients.

ICU delirium and ABCDEF bundle
SCCM/WHOICU delirium management: the ABCDEF bundle (Society of Critical Care Medicine): A — Assess pain; B — Spontaneous Breathing Trial (daily); C — Choice of analgesic/sedative (avoid benzodiazepines — use propofol or dexmedetomidine instead); D — Delirium monitoring (CAM-ICU daily); E — Early mobility and Exercise; F — Family engagement. Implementation of the complete ABCDEF bundle reduces delirium, sedation, duration of mechanical ventilation and ICU mortality.

Delirium vs dementia vs depression
WHO/NICEThree "Ds" of geriatric psychiatry — can coexist: Delirium: ACUTE onset (hours-days); fluctuating course; inattention prominent; usually reversible if cause treated. Dementia: CHRONIC, gradual onset; stable or slowly progressive; attention relatively preserved until late; irreversible. Depression: days to weeks onset; low mood persistent; attention may be poor; treatable. Important: dementia is the strongest single risk factor for delirium — the three conditions frequently coexist in elderly hospital patients, making delirium superimposed on dementia the most common and most missed combination.