Persistent delirium: recognise it, reassess it, support recovery

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Foundations · Module A4

Persistent delirium: recognise it, reassess it, support recovery

Recognise ongoing delirium, take a structured second look, continue rehabilitation, and plan transfer and follow-up.

Why this matters

Delirium does not always resolve when the first trigger has been treated. It may improve only partly, continue to fluctuate, or still be present when a person moves to another ward, rehabilitation setting, care home, or home. Ongoing delirium needs an active plan. Otherwise, remaining causes, distress, loss of function, and follow-up needs can be missed.

About 30 to 35 minutes Adult, non-ICU care 10 formative questions Foundations · Module A4 Content version 1.4 · References updated 8 August 2026

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Learning outcomes8 outcomes

By the end, you should be able to

  • Describe persistent delirium without relying on a fixed number of days.
  • Recognise that partial improvement or a lucid period does not necessarily mean recovery.
  • Compare the person’s current cognition and function with their usual baseline.
  • Monitor recovery across cognitive, psychological, and functional features.
  • Carry out a structured second review of possible causes and contributing factors.
  • Recognise findings that need urgent or targeted further assessment.
  • Continue multicomponent care and rehabilitation while delirium is present.
  • Hand over unresolved delirium with a named review and follow-up plan.
Scope: This module assumes that delirium has already been diagnosed or is strongly suspected. It covers adults in general hospital settings, including emergency and acute assessment areas, and in long-term care. It does not cover children, critical care, the recovery room immediately after surgery, delirium at the end of life, or delirium related to alcohol or drug withdrawal or intoxication. Use the relevant specialist and local pathway in those situations. A person who is acutely unwell or deteriorating needs urgent assessment and treatment. Do not wait for delirium to have lasted a particular number of days.
When delirium is still present, keep recovery work moving
  1. Name itDo not assume a new baseline
  2. Check the whole dayCompare with usual cognition and function
  3. Look againReopen causes, examination and response
  4. Continue careTreatment, comfort and rehabilitation
  5. Share responsibilityName the next review and owner

Transfer or discharge should carry the current diagnosis, remaining risks, review plan and reasons for earlier reassessment.

1. What persistent delirium means

There is no agreed clinical or research duration that defines persistent delirium. It should not be defined for every person as delirium lasting more than five days, seven days, or any other single threshold.

In practice, persistent delirium is a useful description when delirium remains after initial assessment and treatment, particularly when it is still present at transfer, discharge, or later review. The person may be less unwell than at the start and still have delirium. Inattention, altered alertness, disorganised thinking, perceptual disturbance, sleep-wake change, or fluctuation may remain.

A 2022 systematic review defined persistence for research as delirium at follow-up at least one week after the first assessment. That was a study rule, not a universal clinical definition. It included 23 studies and 3,186 older hospital patients outside critical and palliative care. In 13 studies with discharge data, the pooled estimate was that 36% of participants who had delirium initially still had it at discharge (95% confidence interval 22% to 51%). Variation was substantial (all I2 values above 89%), so this is not a rate to apply to an individual service or person (Whitby et al. 2022).

The review’s modelled 12-month estimate was 16% (95% confidence interval 6% to 25%), with low precision and few data beyond six months. Studies were from high-income countries, mostly involved acute illness, varied in delirium assessment, and had substantial loss through death or follow-up. At longer follow-up, they could not always separate uninterrupted delirium from a new episode. The estimate does not mean that one person in six remained continuously delirious for a year.

Persistent delirium has been associated with poorer functional recovery and higher mortality in selected post-acute observational cohorts. These studies do not establish cause and effect or predict the outcome for an individual person. Further recovery may still occur.

Practical point: Ask, “Does this person still have evidence of delirium, and are they back to their usual cognition and function?” Base the plan on the current clinical findings and comparison with usual cognition and function, rather than on the day number.

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2. Decide whether the person is really better

Delirium fluctuates. A clear conversation during a morning review does not erase marked inattention, drowsiness, fear, or disorientation during the night. Likewise, a lower assessment score may represent genuine improvement without showing complete recovery.

Start with the person’s usual baseline. Record what they were normally able to do, who provided the information, and when that baseline was last observed. Family, carers, care-home staff, and previous records may describe changes that are not apparent during a short bedside assessment.

Review the person more than once and use information from the whole day. The 4AT is a brief bedside tool that supports delirium assessment. One 2025 single-centre study assessed 120 hospital patients aged 70 or older two to four times over no more than nine days. Only 18 recovered, so early estimates of specificity were imprecise. A repeated 4AT can support short-term serial assessment in a similar ward, but it has not been validated for long-term or community recovery assessment. No score on its own proves resolution (McCartney et al. 2025).

Track the features that matter to the person and to safe care:
  • attention, alertness, orientation, communication, and fluctuation;
  • distress, fear, hallucinations or suspicious ideas, and sleep-wake pattern;
  • eating, drinking, continence, and ability to take medicines safely;
  • mobility, transfers, self-care, and participation in rehabilitation; and
  • the difference between current ability and the person’s usual baseline.

Document observed features rather than writing only “confused” or “better”. For example: “Still loses the thread after one question, drowsy before lunch, frightened overnight, needs two people to stand; daughter reports this is not usual.”

If dementia is known or suspected, acute fluctuation and change from baseline remain central. If it is difficult to distinguish delirium, dementia, or delirium superimposed on dementia, NICE advises managing delirium first.

Do not write “new baseline” without a plan to reassess. Recovery may continue over weeks or months, although the course differs between people.

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Unscored observation activity

Watch closely: a brief response does not prove recovery

Observation task: Watch the whole clip. What should happen next?

Simulation disclosure: This is a fictional, AI-generated clinical simulation. No real patients or staff appear. Minor equipment imperfections may be present. The clip illustrates observable behaviour only. It cannot establish a diagnosis, cause, level of distress or decision about capacity by itself.

Choose your interpretation before revealing the commentary.

This activity is formative. It is separate from the 10-question knowledge check and does not affect your score.

Reveal the best answer and commentary

Best answer: B.

The clip shows Eileen’s voice fading and her head dropping, followed by reduced responsiveness. It cannot establish the cause. Use the local ABCDE approach, checking airway, breathing, circulation, disability and exposure, along with full observations, and escalate urgently if the reduced alertness is new, marked or worsening. Once immediate safety has been addressed, judge recovery using repeated clinical observations, current function, usual baseline and information from family, carers, familiar staff or records. This brief exchange cannot establish that delirium has resolved.

Read the transcript

A nurse asks Eileen what month it is. After a pause, Eileen replies slowly, “Is it… winter…?” Her voice fades and her head droops towards the pillow. The nurse says, “Eileen?”

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3. Take a structured second look

When delirium is not resolving, reopen the assessment. Check the diagnosis, repeat the clinical examination, review the response to treatment, and look again for common or newly developed contributors. Select further investigations from the findings rather than ordering every possible test.

Review:
  • observations, oxygenation, circulation, and evidence of clinical deterioration;
  • response to treatment of infection, inflammation, or another acute illness;
  • pain, including pain that the person may struggle to describe;
  • hydration, nutrition and relevant blood results, including kidney function, glucose and electrolytes;
  • urinary retention, constipation, continence and evidence that may suggest infection;
  • all medicines, including recent starts, stops, dose changes, medicines with anticholinergic effects, sedatives, opioids, and unintended omission or withdrawal;
  • sleep disruption, repeated ward moves, excessive noise or stimulation, isolation, and unfamiliar routines;
  • hearing, vision, communication needs, and whether sensory aids are present and working; and
  • immobility and complications such as pressure injury, aspiration, loss of strength or function, or a fall.
Do not diagnose urinary infection from delirium or a urine result alone. In adults over 65 and people with a urinary catheter, urine dipsticks do not reliably diagnose or exclude urinary tract infection. Bacteria in the urine without compatible urinary symptoms or signs of systemic infection may be asymptomatic bacteriuria and should not be treated as urinary infection solely because delirium is present. Assess other possible causes. If the person is systemically unwell or sepsis is a concern, assess urgently and follow local infection, sepsis and antimicrobial guidance.
Escalate red flags promptly. If the clinical course does not fit ordinary delirium recovery, consider another diagnosis or an additional neurological or psychiatric condition. New one-sided weakness, facial droop or speech difficulty, seizure activity or episodes of unresponsiveness, a recent head injury, marked or unexplained reduction in consciousness, severe headache, fever with neck stiffness or other signs suggesting meningitis, or rapid unexplained deterioration requires prompt escalation. Brain imaging, an electroencephalogram (EEG, a recording of brain electrical activity), lumbar puncture (sampling fluid from around the brain and spinal cord), or specialist review may be needed when the findings support them. They are not routine tests for every person with persistent delirium.

Low mood, withdrawal, reduced speech or slowed movement can occur in delirium, depression, medicine-related sedation or catatonia, a syndrome involving marked changes in movement, speech and responsiveness. Do not assign one of these diagnoses from a single feature. Review medicines and the whole clinical picture, and seek appropriate specialist assessment when the course or examination suggests another condition.

Clinical consequence: Calling ongoing symptoms “just dementia” can end the search too early. A treatable problem such as urinary retention, constipation, hypoxia, pain, medicine toxicity, or a new neurological event may then be missed.

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4. Continue treatment and rehabilitation

Persistent delirium has no single curative treatment. Continue to treat identified causes and provide the multicomponent care used in ordinary delirium management. The evidence for a dedicated persistent-delirium treatment package is limited, so the plan should be individualised and reviewed against the person’s response (McCartney et al. 2023).

Continue clinical care. Maintain oxygenation and circulation, treat acute illness and pain, support hydration and nutrition, manage bowels and bladder, review medicines, protect sleep, provide hearing and visual aids, and prevent complications of immobility.

Support comfort and communication. Use calm introductions, simple explanations, orientation and reassurance. Ask about distress and respond to hallucinations or frightening beliefs without confrontation. Tell the person they have delirium when appropriate. Explain that recovery can be uneven and that the team will keep reviewing them. Involve family or carers with the person’s agreement where possible, respecting their preferences and confidentiality.

Distress is not the same as agitation. A quiet or drowsy person may be frightened, thirsty, in pain, or unable to make sense of the environment. Ask directly when possible, use accessible communication, and observe facial expression, tears, withdrawal and restlessness. These signs are non-specific. Moving away from staff or refusing care does not by itself prove agitation, distress or lack of capacity; explore the person’s communication, purpose and circumstances.

Rehabilitation should not automatically wait until delirium has cleared. Before each session, check immediate medical stability, alertness, pain and falls risk, and provide the supervision and equipment needed. Use short, repeated sessions adapted to fluctuation. Supported mobility, self-care, eating and drinking, familiar routines, communication support and meaningful activity aim to limit avoidable loss of function. Evidence for a dedicated delirium-recovery programme remains limited. Record what the person can do today and the next realistic goal (Allan et al. 2026).

Medication has a restricted role. Antipsychotic medicines do not hasten delirium recovery. Use de-escalation first. Only consider short-term medication when contributing factors have been addressed as far as possible and significant distress or a risk of physical harm remains. An authorised prescriber must document the indication, risks, review and stop plan (Crone et al. 2025).

Medicine safety

The 2025 American Psychiatric Association guideline gives a strong recommendation based on low-confidence evidence (1C) that antipsychotic medicines should not be used to hasten delirium recovery. Look for and treat causes of distress, and use verbal and non-verbal de-escalation first. Only consider medication for delirium-related symptoms when de-escalation has failed, contributing factors have been assessed and addressed as far as possible, and the symptoms are causing significant distress or creating a risk of physical harm. Follow current national and local guidance.

Any short-term antipsychotic used in this narrow situation should have a clear indication, careful risk assessment, frequent review and stop plan. For an older person receiving haloperidol, follow Medicines and Healthcare products Regulatory Agency (MHRA) advice: check contraindications, obtain a baseline electrocardiogram and correct electrolyte disturbances before treatment, use the lowest possible dose for the shortest possible time, and monitor cardiac effects, movement-related adverse effects and swallowing difficulty. Haloperidol is contraindicated in Parkinson’s disease and dementia with Lewy bodies. Benzodiazepines are not routine treatment for delirium unless there is a specific indication, and an established benzodiazepine should not be stopped abruptly by accident. Prescribing decisions must be made by an authorised prescriber working within local policy.

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5. Make recovery a shared responsibility

Ongoing delirium often crosses professional and organisational boundaries. One team treats the acute illness, another provides rehabilitation, and family or care staff notice the fluctuations. Information is easily lost unless the current diagnosis and review plan are explicit.

Agree who is responsible for the next clinical review and when it will happen. The frequency should reflect the person’s condition and care setting. In acute hospital care this may mean review every day and sooner if the person changes. In rehabilitation, long-term care, or the community, it still needs a named date rather than an open-ended instruction to “monitor”.

The multidisciplinary plan should cover:
  • remaining possible causes, outstanding investigations and medicine changes or stop plans;
  • cognition, distress, sleep, mobility, nutrition, continence and self-care;
  • rehabilitation and safety needs, including falls, pressure injury, aspiration, dehydration and ability to summon help;
  • information from family or carers and agreed involvement that respects the person’s preferences and confidentiality; and
  • the next review, responsible clinician or team, and reasons for earlier reassessment.

Registered nurses contribute serial clinical and physiological assessment and escalate deterioration. Care staff record and report observations within their role. The responsible medical or advanced-practice clinician reassesses the diagnosis, physiology, causes and treatment. Pharmacists can identify medicine burden or unintended continuation. Physiotherapists and occupational therapists can distinguish current function from baseline and adapt rehabilitation. Dietitians and speech and language therapists may be needed where nutrition, swallowing or communication is affected.

Family, carers and familiar staff may have essential information about baseline and change. Check when and how directly they last observed the person. Ask the person whom they want involved where possible, respect confidentiality, and check the carer’s willingness and ability to help. Never transfer professional responsibility to family or carers.

A usable plan names the next decision and the person responsible for it.

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Fictional multidisciplinary case

6. Putting it together: better, or just leaving?

Mrs Patel, aged 83, lives with her daughter. She usually manages her personal care, walks indoors with a stick, makes tea, and enjoys long conversations. She is admitted with pneumonia, hypoxaemia, and delirium. At first she is markedly inattentive, drowsy at times, and frightened by people she thinks are in the room.

Six days later, her fever has settled and she no longer needs oxygen. The ward note says “confusion improving”. During the morning round she answers several questions correctly. Her daughter and the night nurse give a different picture: Mrs Patel still loses track of conversation, sleeps for much of the day, becomes frightened after dark, eats little, and needs two people to stand. None of this is usual for her.

Recognise and measure

The team records that Mrs Patel still has an acute, fluctuating change from baseline. A repeat 4AT remains positive, and clinical assessment confirms that delirium remains. They document attention, alertness, distress, intake, mobility and sleep rather than relying on the phrase “improving confusion”.

Take a second look

The review finds several plausible contributors rather than one dramatic new diagnosis. Mrs Patel has urinary retention after catheter removal, has not opened her bowels for five days and has clinical findings that support constipation, has had little to drink, and has received a sedating medicine on three nights. Her hearing aids are in a bedside drawer. There are no new one-sided neurological findings or seizure features.

The team manages the retention and constipation, supports fluids and meals, reviews and safely stops the recently started sedating medicine because it is no longer indicated, returns her hearing aids, explains what is happening, and continues supported mobility and self-care practice. With Mrs Patel’s agreement where possible, her daughter helps with familiar conversation and food preferences.

Hand over the recovery plan

Mrs Patel improves, but she is not back to baseline when she transfers to a community hospital for rehabilitation. The transfer document states that delirium is still present. It includes her usual and current function, remaining symptoms, treated and possible contributors, medicine changes, distress plan, mobility and nutrition needs, what her daughter has been told, and the date and owner of the next review.

Clinical consequence: Because ongoing delirium was named, the receiving team did not treat Mrs Patel’s current cognition or function as a permanent new baseline. Contributing problems were addressed, rehabilitation continued and the next review was booked. Further recovery remained uncertain.

Example handover

Situation: “Mrs Patel still has delirium. Attention, alertness, and distress fluctuate, and she is not back to her usual cognition or function.”

Background: “Before admission she managed personal care, walked indoors with a stick, made tea, and held long conversations. Her daughter last saw her at this baseline the day before the pneumonia began.”

Assessment: “Pneumonia and hypoxaemia have improved. Urinary retention, constipation, reduced intake, sedating medication, and absent hearing aids have been addressed. She still eats less than usual and needs two people to stand.”

Recommendation: “Continue delirium care and graded rehabilitation. [Named clinician or team] will review attention, alertness, distress, intake, bowel and bladder function, and mobility on [date/time]. Nursing and therapy staff will record changes during each shift or session. Reassess sooner for deterioration, new neurological features or recurrent acute illness. The receiving service has accepted responsibility for this plan and can provide the care described.”

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7. Transfer, discharge, and follow-up

Transfer is a change of treatment setting, not proof of recovery. If delirium remains, document this explicitly. “Delirium is still present” is safer than “confused” because it prompts continued assessment and cause management.

A transfer or discharge plan should include:
  • the diagnosis and whether delirium is resolved, improving but present, unchanged, or worsening;
  • usual cognition and function, with the source and date of the baseline information;
  • onset, course, fluctuation, and current cognitive and psychological features;
  • current mobility, self-care, eating, drinking, continence, communication, and sleep;
  • causes and contributors identified, treatments given, response, and outstanding concerns;
  • a complete medicine reconciliation, including reasons for changes and stop plans for short-term medicines;
  • distress, safety, supervision, equipment, and rehabilitation needs;
  • the person’s wishes, relevant decision-specific capacity assessment and any lawfully authorised representative;
  • what the person and, with their agreement where possible, family or carers have been told;
  • the next review date, the responsible clinician or team, and clear reasons for earlier reassessment or re-referral; and
  • confirmation that the receiving service has accepted responsibility and can deliver the plan.

Persistent delirium does not by itself decide whether discharge is safe. The decision depends on medical stability, current function, distress and risk, the support and supervision available, the receiving team’s ability to continue care, and a workable follow-up plan.

Delirium does not by itself show that a person lacks capacity. Support communication and assess capacity for the specific treatment or discharge decision at the time it must be made. Reassess if the person’s condition fluctuates. Respect a valid refusal. Family members are not automatically authorised to decide for the person. If the person lacks capacity, follow the applicable legal best-interests or benefit framework, involve the appropriate people, and use the least restrictive proportionate option.

Explain that recovery may be uneven and may continue after discharge. Give the person accessible written information and local contact details. With the person’s agreement where possible, include family or carers while respecting preferences and confidentiality. Use a professional interpreter where available if this would support communication. They should know how to seek urgent help for deterioration, a new one-sided weakness or other neurological change, marked reduction in alertness, a seizure, breathing difficulty, fever or other signs of acute illness, a fall or head injury, inability to drink, or another immediate concern.

If delirium does not resolve, NICE advises re-evaluating possible underlying causes and following up to assess for possible dementia where indicated. Ensure that the delirium diagnosis is recorded in the person’s primary care record. Follow-up should also consider ongoing anxiety, low mood, sleep disturbance, frightening memories or other post-traumatic symptoms, and functional recovery. There is no universal time interval for post-delirium cognitive assessment. Arrange a named review when the acute delirium has been managed and the clinical picture is sufficiently stable to interpret, then repeat or refer if uncertainty remains.

Before transfer, ask: “Who will check whether this person is recovering, what will they measure, and on what date?”

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Further information to use and share

For practitioners: NICE CG103 includes what to do when delirium does not resolve. The official 4AT website provides the assessment, user guidance, translations, FAQs, and cases. The Australian Delirium Clinical Care Standard gives a detailed example of planning for persistent or resolved delirium at transition. Its specific timings are Australian standards; follow the national and local requirements for your setting.

For people who have experienced delirium, families, and carers: Delirium Support provides plain-language information about delirium, recovery, and ways families can help. Share it alongside local advice and contact details.

Open NICE CG103 Open the4AT.com Open Delirium Support

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Before the questions

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Knowledge check

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1. Which statement best describes persistent delirium?
2. A person transfers to rehabilitation with delirium still present. Which plan best makes follow-up a shared responsibility?
3. A person treated for pneumonia is calmer and answers correctly during the morning round, but remains drowsy, inattentive, and frightened at other times. Their family say they are not back to usual. What is the best next step?
4. Which approach gives the most useful picture of delirium recovery?
5. Which is the best second review when delirium is not resolving?
6. A person with ongoing delirium develops new one-sided weakness and episodes of unresponsiveness. What is the best response?
7. A team member suggests postponing all rehabilitation until the delirium has completely resolved. What is the best response?
8. During active delirium, staff suspect that a person may also have previously unrecognised dementia. What is the best approach?
9. An antipsychotic started during an emergency remains on the medication chart as transfer approaches. What is the best action?
10. A person with ongoing delirium refuses a proposed transfer to rehabilitation. Which plan best protects their rights and continuity of care?

Continue learning

  • Review the official 4AT user guide and consider how your service records change from baseline and fluctuation over time.
  • Compare your local transfer or discharge template with the handover fields in section 7.
  • Identify who owns follow-up when a person leaves your service with delirium still present.
  • Keep Delirium Support available to share with people who have experienced delirium, families, and carers alongside local advice.

Research references

Selected peer-reviewed research published within the last five years. Each link opens the verified PubMed record.

  • Whitby, J., Nitchingham, A., Caplan, G., et al. (2022) ‘Persistent delirium in older hospital patients: an updated systematic review and meta-analysis’, Delirium, 1, 36822. Available at: https://pubmed.ncbi.nlm.nih.gov/36936539/.
  • McCartney, H., Noble, E., MacLullich, A.M.J., et al. (2023) ‘A systematic review of studies reporting on neuropsychological and functional domains used for assessment of recovery from delirium in acute hospital patients’, International Journal of Geriatric Psychiatry, 38(6), e5943. Available at: https://pubmed.ncbi.nlm.nih.gov/37294207/.
  • McCartney, H., Noble, E., Thompson, K., et al. (2025) ‘Validation of the 4AT for assessing recovery from delirium in older hospital patients’, Age and Ageing, 54(6), afaf166. Available at: https://pubmed.ncbi.nlm.nih.gov/40586121/.
  • Crone, C., Fochtmann, L.J., Ahmed, I., et al. (2025) ‘The American Psychiatric Association practice guideline for the prevention and treatment of delirium’, American Journal of Psychiatry, 182(9), pp. 880-884. Available at: https://pubmed.ncbi.nlm.nih.gov/40887950/.
  • Allan, L., Um, J., O’Connell, A., et al. (2026) ‘Rehabilitation intervention to improve Recovery after an Episode of Delirium in adults over 65 years (RecoverED): a multicentre, single-arm feasibility study in NHS acute hospitals in the UK’, BMJ Open, 16(4), e102316. Available at: https://pubmed.ncbi.nlm.nih.gov/42020132/.
Clinical guidance and practical resources (6)

References checked and updated on 8 August 2026.

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Original educational text is available under CC BY 4.0. The 4AT has separate terms at the4at.com.

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