Further learning

Persistent delirium: assessment and continuing care

Assess ongoing delirium, continue treatment and rehabilitation, and plan care after transfer or discharge.

About this module

Delirium does not always resolve when the first trigger or triggers have 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 35 to 40 minutes Adult, non-ICU care 10 questions with explanations Further learning Content version 1.6 · Language edited 27 September 2026 Diagnostic section clinically reviewed and sources checked 28 September 2026

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Learning outcomes8 outcomes

Describe persistent delirium.
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.
Repeat the assessment of possible causes and contributing factors.
Recognise when unexplained or atypical persistent delirium needs further investigation or specialist assessment, including assessment for autoimmune encephalitis.
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.

This module includes recognising when a specialist assessment is needed. Detailed management of encephalitis, seizures, catatonia, intoxication and withdrawal follows the relevant specialist and local pathway.

Care when delirium persists

Recognise itDo not assume a new baseline
Check the whole dayCompare with usual cognition and function
Look againRepeat the examination and review causes and treatment
Continue careTreatment, comfort and rehabilitation
Share responsibilityRecord who will review the person and when

At transfer or discharge, record and hand over 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. However, clinically it is useful to start considering persistent delirium from about 5 days onwards.

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 relative sits holding the hand of an older man in a hospital bed. Through the window a bare tree has begun to bud. — Delirium can last for weeks. Keep comparing the person with how they usually are.

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. Assess recovery

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

One clear moment does not show recovery

What one check may showA clear conversation on the morning round, or a lower assessment score.

What it may missMarked inattention, drowsiness, fear or disorientation during the night.

Information needed to assess recoveryRepeated reviews, the whole day, the usual baseline, and reports from family, carers and records.

Delirium fluctuates, so a lucid period or a lower assessment score may show improvement without full recovery. Judge recovery from the whole day and compare with how the person usually is.

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).

Ask what concerns the person, and review the following:

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.

A drowsy older woman lies in a hospital bed with oxygen tubing. A visitor holds her hand. — Family often notice changes that are not apparent during a short bedside assessment, such as drowsiness later in the day.Photo credit: seventyfour · Premium licence

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 are still important. 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?

Simulated teaching scene.

Choose your interpretation before revealing the commentary. Record recovery if the rest of the morning assessment is reassuring, because she gave a relevant answer. Check her clinically now; the reduced response may need urgent escalation, and the brief exchange does not establish recovery. Record dementia as the main diagnosis once routine observations have been checked, because her response was incomplete. Wait until she is more alert, then repeat the question before deciding whether a clinical review is needed.

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. The clip does not 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 does not 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. Reassess causes and consider other diagnoses

A person may remain delirious after the first illness has improved. Repeat the assessment of what is still present, what has changed and what remains unexplained. A documented cause at admission may account for only part of the subsequent course. NICE CG103

Assess deterioration urgently. New focal neurological signs, seizure activity, marked reduction in consciousness, severe headache, suspected central nervous system infection or rapid deterioration need prompt assessment. Follow the relevant emergency pathway. Investigation should reflect the current findings, without waiting for delirium to have lasted a particular number of days.

Looking again when delirium persists

1Repeat history and examinationEstablish the clinical course from before admission. Repeat the physical and neurological examination.

2Review common causes againTreatment response, pain, fluids, bladder and bowels, medicines, sleep, hearing, vision, immobility.

3Consider other diagnosesIf still unexplained, new features appear or the course does not fit. Choose tests from the findings.

4Record the revised explanationCauses still treated, diagnoses considered, reason for each test, who reviews results.

Continue treatment, support and rehabilitation while this work goes on.

Work through these steps in order when delirium remains after the first illness has improved. If the person deteriorates, assess urgently first and follow the emergency pathway.

Repeat the history, examination and review of treatment

Reconstruct the course from before admission to the present. Ask the person, family and staff about earlier memory or behavioural change, falls, brief episodes of unresponsiveness and changes after treatment. Compare observations across the day. Repeat the physical and neurological examination, including speech, eye movements, limb findings and movement or gait where assessment is possible.

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.

An older woman with oxygen tubing stands beside her hospital bed, holding a walking frame. — Look for complications that can develop during persistent delirium, such as loss of strength, falls and pressure injury.Photo credit: seventyfour · Premium licence

Check what medicines the person has actually received, including as-needed doses and omitted regular treatment. Review whether changing kidney or liver function could alter drug exposure. Consider further metabolic or endocrine tests when the history, examination or initial results suggest them. An investigation plan should state the suspected cause and how the result could change care.

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.

Further diagnostic assessment

Consider other diagnoses and rarer causes

Broaden the assessment when delirium remains unexplained, new features develop, or the course is inconsistent with the current explanation. The table gives clues and possible next actions. These investigations should be selected by the responsible clinician, with specialist advice where needed.

Other diagnoses, coexisting conditions and less common causes to consider
Possible cause or diagnosis	Clinical clues	What to do next
Behavioural and psychological symptoms of dementia (BPSD)	Known or likely dementia with persisting changes in mood, behaviour, perception or sleep. Similar symptoms may have preceded the acute illness. BPSD and delirium can coexist.	Establish the pre-illness pattern from the person, family, carers and records. Reassess attention, alertness, fluctuation and treatable contributors. Seek geriatric or old age psychiatry review if uncertainty persists. See the BPSD box below
Autoimmune encephalitis	Subacute memory or behavioural change, new seizures, or unusual movements. Brief repeated contractions of the face and arm are a particular clue to LGI1 encephalitis. Hyponatraemia may coexist.	Seek prompt neurology assessment. When encephalitis is suspected, assessment usually includes brain MRI, EEG, cerebrospinal fluid (CSF) examination and neuronal antibody testing in both serum and CSF. Check for infection and other explanations. Normal MRI or routine CSF findings do not exclude autoimmune encephalitis; a serum antibody result alone does not establish it. Autoimmune encephalitis guidance
Non-convulsive status epilepticus or recurrent focal seizures	Repeated similar episodes of impaired awareness, speech arrest or subtle twitching; prolonged altered awareness after a seizure. Overt convulsions may be absent.	Arrange urgent assessment and EEG when ongoing seizure activity is suspected. If a brief recording is unrevealing but suspicion remains, discuss longer or repeated recording with neurology or neurophysiology. SIGN 157
Stroke, subdural haematoma or another structural brain lesion	New focal findings, a fall or head injury, anticoagulation, headache, or unexplained reduced consciousness. Persistent unexplained delirium may justify imaging even without focal signs.	Select brain imaging according to the suspected problem and urgency. CT is often the first examination for haemorrhage or head injury; discuss MRI if the initial scan does not explain a continuing neurological concern. SIGN 157
Central nervous system infection	Fever, headache, meningism, seizures or focal findings; also consider infection in an immunocompromised person with an unexplained course. Typical signs may be incomplete.	Use the urgent meningitis or encephalitis pathway. Discuss with neurology and infection specialists; arrange lumbar puncture when safe, with CSF microbiology and virology selected for the presentation. Brain imaging may also be needed. Start indicated empirical treatment promptly if investigations are delayed. Encephalitis guidance
Wernicke’s encephalopathy	Thiamine deficiency risk from poor nutrition, prolonged vomiting, malabsorption or alcohol dependence, with confusion, unsteadiness or abnormal eye movements. The full clinical triad is often absent.	Arrange urgent assessment and parenteral thiamine under the relevant clinical protocol when suspected. Review nutrition and other contributing problems. Wernicke’s encephalopathy can occur without alcohol dependence. UK guidance · BOMSS guidance
Central nervous system vasculitis	Unexplained headache, cognitive or behavioural change, seizures, or strokes affecting different territories. Systemic inflammatory features may be absent in primary CNS vasculitis.	Discuss promptly with neurology. MRI, CSF examination and specialist vascular investigations may be needed; selected cases need biopsy. No single blood test or non-specific scan finding establishes the diagnosis. ESO guidance
Rapidly progressive neurological disease, including prion disease	Progressive cognitive decline with myoclonus, ataxia, visual disturbance or other neurological signs over weeks or months.	Seek urgent neurology assessment, including review for treatable alternatives. MRI with diffusion sequences, EEG and specialist CSF tests, such as RT-QuIC when prion disease is suspected, may be appropriate. Prolonged delirium alone is insufficient to make this diagnosis. Diagnostic criteria

Use each investigation to answer a clinical question. An electroencephalogram (EEG) records brain electrical activity. Lumbar puncture obtains cerebrospinal fluid (CSF) for examination. Brain imaging, EEG, lumbar puncture and antibody panels are not a routine package for every person with persistent delirium. When the cause remains unclear after reassessment, seek senior or specialist review and reconsider whether additional tests are now justified. SIGN 157

Reassess conditions that can resemble or coexist with delirium

Catatonia can coexist with delirium. Look for a pattern of signs such as posturing, waxy flexibility or echolalia, rather than diagnosing it from reduced speech or withdrawal alone. Seek liaison psychiatry or neurological assessment as appropriate. Treatment of catatonia requires a specific plan; improvement in its motor signs does not establish recovery from delirium. BAP guidance

Persistent delirium, dementia and BPSD

When persistent delirium occurs on a background of known or likely dementia, it can be difficult to tell how much of the persisting symptoms reflects reversible or potentially reversible delirium, and how much reflects BPSD. Both may contribute.

BPSD means behavioural and psychological symptoms of dementia. It describes a group of symptoms associated with dementia, including agitation, anxiety, depression, apathy, hallucinations, delusions and sleep disturbance.

Compare the current symptoms with the pre-illness pattern, using information from the person, family, carers and records. An acute change, new or increased inattention, and altered alertness support ongoing delirium. Fluctuation and hallucinations can also occur in dementia, particularly dementia with Lewy bodies.

Continue to look for treatable contributors when symptoms are described as BPSD. Symptoms described as BPSD may also improve when pain, unmet needs or medicine effects are addressed. If uncertainty remains, continue delirium assessment and care, and seek specialist review.

Depression, psychosis and medication-related sedation can also complicate assessment. Review mood, unusual beliefs and medicine exposure alongside attention and alertness. When delirium and dementia are difficult to distinguish, manage delirium first and arrange follow-up assessment. NICE CG103

Record the revised explanation and the next review

Document the causes still being treated, alternative diagnoses being considered, the reason for each additional investigation and who will review the results. Record unresolved uncertainty and the findings that should prompt earlier reassessment. Continue treatment, support and rehabilitation while this work proceeds.

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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).

Rehabilitation while delirium is present

1Check firstMedical stability, alertness, pain and falls risk before each session.

2PrepareProvide the supervision and equipment needed.

3Short sessionsShort and repeated, adapted to fluctuation. Mobility, self-care, eating, drinking and familiar routines.

4RecordWhat the person can do today and the next realistic goal.

Repeat for each session, alongside continued treatment of causes.

Rehabilitation should not automatically wait until delirium has cleared. Use these checks for every session while clinical care and comfort continue.

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 (or similar guidance provided locally): 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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A clinician supporting an older woman using a walking frame. — Photo credit: Drazen Zigic · Premium licence

5. Agree responsibility for continuing care

A person with ongoing delirium may receive care from several teams. One treats the acute illness, another provides rehabilitation, and family or care staff may notice changes between assessments. Each team needs to know whether delirium is still present and what care and review are planned.

A nurse talks with an older man in a hospital bed and his wife, who stands beside him. — Each team, and the family, needs to know whether delirium is still present and what happens next.Photo credit: korrawinj · Premium licence

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.

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Example case: assessment and care

6. Mrs Henderson: delirium at transfer

Mrs Henderson, 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 Henderson 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.

Assess the remaining symptoms

The team records that Mrs Henderson 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”.

Repeat the assessment

The review finds several possible contributing problems. Mrs Henderson 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 focal 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 Henderson’s agreement where possible, her daughter helps with familiar conversation and food preferences.

Hand over the recovery plan

Mrs Henderson 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 of the next review and who will carry it out.

Staff and a relative sit round a table with papers, planning the move of an older man who sits with them. — The written transfer plan should state the person’s usual condition, what has changed and who will review them next.

What happened: Because the team recorded that delirium was still present, the receiving team did not treat Mrs Henderson’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 Henderson 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

A person may still have delirium when they are ready to move to another care setting. If delirium remains, document this clearly. “Delirium is still present” is safer than “confused” because it prompts continued assessment and cause management.

From transfer to follow-up

1Name itWrite “delirium is still present”, not “confused”.

2Hand over the planThe receiving service accepts responsibility and can deliver the plan.

3Inform the personWritten information, local contacts and when to seek urgent help. Include family where agreed.

4Named follow-upReview causes, possible dementia where indicated, mood, sleep, frightening memories and function.

Repeat the review or refer if uncertainty remains.

These are the stages for a person who moves on with delirium still present. The list below gives what the transfer or discharge plan should include.

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.

A nurse wheels an older man in a hospital gown out of the ward while a doctor checks his drip. — Moving to another setting is not the end of delirium care. The plan goes with the person.Photo credit: DC Studio · Premium licence

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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A nurse talking with an older man and his family beside his hospital bed. — Photo credit: DC Studio · Premium licence

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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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 is responsible for 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/.
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Clinical guidance and practical resources (6)

Original module references checked on 8 August 2026. The diagnostic reassessment section was clinically reviewed and its sources checked on 28 September 2026. Language edited on 27 September 2026.

Persistent delirium: assessment and continuing care

Persistent delirium: assessment and continuing care

1. What persistent delirium means

2. Assess recovery

Watch closely: a brief response does not prove recovery

3. Reassess causes and consider other diagnoses

Repeat the history, examination and review of treatment

Reassess conditions that can resemble or coexist with delirium

Record the revised explanation and the next review

4. Continue treatment and rehabilitation

5. Agree responsibility for continuing care