Delirium Prevention — Preventing Confusion in the Hospital Before It Occurs

Delirium is rarely the result of a single event. It arises from the interaction of two groups of factors:

• Predisposing factors: those that make the patient susceptible—advanced age, preexisting cognitive impairment, visual and hearing impairment, polypharmacy, frailty, and previous episodes of delirium.
• Triggering factors: those that provide the acute tipping point—surgery, infection, pain, medication changes, dehydration, unfamiliar surroundings.

It is important to understand this model: The more vulnerable the patient, the smaller the triggering stimulus needs to be. A robust 75-year-old often survives hip surgery without developing delirium. A frail 88-year-old with early-stage dementia and eight medications can develop delirium from as little as a simple urinary tract infection—without surgery, without trauma, and without a new medication.

It is precisely this insight that forms the starting point for any prevention strategy: If the predisposing factors remain unchanged, managing the triggering factors is the key to prevention.

→ For a detailed overview of delirium: Delirium in Older Adults.

The Hospital Elder Life Program (HELP), developed by Sharon Inouye at Yale University and first published in 1999, is the most extensively studied delirium prevention program in the world. It addresses six key risk factors through structured interventions:

• Structured, regular conversation with the patient
• Orientation aids: clock, calendar, personal photos, familiar objects
• Involvement of support persons (family members, volunteers)
• Activities that fit the patient’s previous lifestyle—reading the newspaper aloud, listening to music, discussing life stories

• Nighttime routine checks (blood pressure, temperature) only when clinically necessary
• Reduce noise and light at night
• Non-pharmacological aids for falling asleep (warm milk, tea, relaxing music)
• Avoid using benzodiazepines and Z-drugs as sleep aids in the hospital

• Initiate mobilization on the day of surgery or on Day 1 if possible—particularly important for preventing immobility in older adults
• Getting up, walking, and sitting daily, even in cases of severe illness
• Empowering care—helping patients help themselves rather than taking over completely
• Avoid unnecessary restraints and access points that hinder mobility

• Keep glasses handy and clean
• Adequate lighting, especially at night
• Large, easy-to-read orientation aids

• Hearing aid by the bed, turned on, with fresh batteries
• Speak clearly, calmly, and at a moderate volume
• Maintain eye contact and make your mouth movements visible

• Monitor adequate fluid intake—1.5 to 2 liters per day, more in case of fever or hot weather
• Make meals accessible; provide assistance if needed
• Provide a protein-rich diet to prevent malnutrition in older adults

Scientific data: HELP has been shown to reduce the incidence of delirium by 30 to 40 percent, shorten the length of hospital stay, and improve the rate of return to one’s own home. International studies in 17 countries confirm its effectiveness.

Other effective interventions

For every older adult patient upon admission: Which medications increase the risk of delirium? Are there alternatives? The main candidates for reduction:

• Benzodiazepines and Z-drugs (lorazepam, diazepam, zolpidem, zopiclone)
• Strongly anticholinergic agents
• Tricyclic antidepressants
• High-dose opioids — a lower-dose combination regimen is preferable
• Certain antibiotics with neuropsychiatric side effects

→ How structured deprescribing works in practice: Reducing medications — Deprescribing.

→ The big picture on polypharmacy: Polypharmacy in older adults.

Severe, untreated pain triggers delirium—as do excessive opioid doses. The middle ground: combined therapy with acetaminophen, non-opioid analgesics (if renal function permits), regional procedures, and targeted, low-dose opioid administration. Consistent pain management for hip fractures—for example, using a fascia iliaca block—significantly reduces the risk of delirium.

The most important point: What is not looked for will not be found. Structured screening tools (CAM, 4AT, Nu-DESC) enable detection within a few minutes. Ideally, these should be administered by nursing staff at least once per shift. A negative screening result in the morning does not predict the evening’s result—delirium fluctuates throughout the day. A frailty screening is also recommended to assess risk.

• Detect urinary tract infections and pneumonia early in older adults and treat them with antibiotics
• Correct electrolyte imbalances
• Prevent hypoxia—ensure adequate oxygen supply
• Systematically address constipation
• Recognize and treat urinary retention — also relevant for urinary incontinence in older adults

The presence of familiar caregivers is one of the most effective factors in preventing delirium. Studies consistently show that the more time family members spend at the patient’s bedside, the lower the rate of delirium. This isn’t just a way to lighten the nursing staff’s workload—it’s evidence-based medicine.

???? When visiting an older family member in the hospital: Bring their glasses, hearing aid, a photo from home, and a calendar showing the current date. And stay longer than you think is necessary. Your mere presence measurably reduces the risk of delirium.

Preoperative Delirium Prevention — Prehabilitation

For scheduled procedures, delirium prevention doesn’t begin in the hospital, but weeks beforehand:

• Cognitive and physical baseline assessment — ideally through a geriatric assessment
• Medication optimization, including discontinuation of substances that increase the risk of delirium
• Targeted strength training before surgery—also to prevent sarcopenia
• Nutritional optimization, particularly protein intake
• Treatment of anemia and vitamin D deficiency
• Psychological preparation — informed consent, realistic expectations
• Planning post-discharge care

→ On preoperative risk assessment and prehabilitation: Surgical risk in older adults.

Special situations

The incidence of delirium in intensive care units ranges from 60 to 80 percent—the highest in the entire hospital. Specific prevention strategies:

• Keep sedation to a minimum (e.g., ABCDE bundle)
• Daily attempts to rouse patients and assessment of the depth of sedation
• Early mobilization, even for intubated patients
• Actively maintain a day-night rhythm, even in the intensive care unit
• Allow family members to be present whenever possible

Patients with dementia have the highest risk of delirium and the greatest difficulty in undergoing standard screening (because cognitive deficits are already present even without delirium). Here, ongoing observation by familiar people is helpful: “Mom was different yesterday than she is today” is a valuable clinical observation that should be noted in the medical record.

The risk of delirium does not end at the hospital door. Residual symptoms may persist during the first few weeks at home—or a new episode of delirium may develop, especially in the event of infections or changes in medication. Follow-up visits with the primary care physician during this phase are mandatory. Early geriatric rehabilitation can also have a stabilizing effect during this transition phase.

What family members can do specifically

• Ensure glasses, hearing aids, and dentures are available: labeled, accessible, and in working order.
• Bring familiar items: a photo of the spouse, a small pillow, a favorite mug.
• Provide a current list of medications: Including over-the-counter and herbal supplements.
• Be present: Visit regularly, even if only briefly. A familiar voice and face have therapeutic benefits.
• Speak up if something seems different: “My mother seems different today than she did yesterday. Has she been screened for delirium?” This isn’t being a know-it-all—it’s part of providing care.
• Do not accept benzodiazepines as sleep aids: If offered, ask for alternatives.
• Encourage mobility: Get up together, take a few steps, sit in a chair instead of the bed.
• Stay vigilant after discharge: Changes in the first few weeks may be aftereffects of delirium.

When should you involve a geriatrician?

In many hospitals—especially in geriatric trauma centers and certified geriatric centers—delirium prevention is part of the standard process. Where this is not the case, it makes sense to specifically request it:

• For planned major surgeries in patients over 75
• In cases of pre-existing cognitive impairment or a history of delirium—especially mild cognitive impairment (MCI)
• In cases of polypharmacy and multimorbidity
• In cases of current delirium with no clear cause
• Following repeated episodes of delirium during previous hospital stays
• When considering medication optimization before and after discharge

→ For a systematic geriatric assessment that categorizes delirium risks in a structured manner: Geriatric Assessment.

→ For a comprehensive overview of delirium: Delirium in Older Adults.