American Psychiatric Association Publishes Updated Comprehensive Guideline for the Prevention and Treatment of Delirium

September 02, 2025

Washington, D.C. — The American Psychiatric Association (APA) has published its updated comprehensive "Practice Guideline for the Prevention and Treatment of Delirium." Delirium is a common but often underdiagnosed condition that significantly impacts patient health, recovery, and health care costs. The new guideline, which is designed for any clinician who may encounter patients with delirium, includes evidence-based recommendations to improve its detection, prevention, and treatment.

Delirium involves reduced attention and awareness and problems with mental function that develop quickly. It can result from a medical condition, toxins, medications, or alcohol or drug use. Estimates of its prevalence vary significantly depending on the location and population. For example, delirium is estimated to affect about 23% of adults in inpatient medical units, 31% of adults in intensive care units (ICUs), and 75% of mechanically ventilated patients in ICUs. Despite its prevalence, delirium is frequently not recognized. It can lead to longer hospital stays, greater risk of complications, increased strain on patients and caregivers, and significant additional health care costs.

The goal of the guideline is to prevent at-risk individuals from developing delirium and to improve the quality of care and treatment outcomes for those who have it. The practice guideline includes 12 clinical recommendations and three suggestions, depending on the level of scientific evidence.*

Guideline Statements

Assessment and Treatment Planning

APA recommends (1C) that patients with delirium or who are at risk for delirium undergo regular structured assessments for the presence or persistence of delirium using valid and reliable measures.
APA recommends (1C) that a patient’s baseline neurocognitive status be determined to permit accurate interpretation of delirium assessments.
APA recommends (1C) that patients with delirium or who are at risk for delirium undergo a detailed review of possible predisposing or contributing factors.
APA recommends (1C) that a detailed medication review be conducted in patients with delirium or who are at risk for delirium, especially those with preexisting cognitive impairment.
APA recommends (1C) that physical restraints not be used in patients with delirium, except in situations when injury to self or others is imminent and only:
- After review of factors that can contribute to racial/ethnic and other biases in decisions about restraint;
- With frequent monitoring; and
- With repeated reassessment of the continued risks and benefits of restraint use as compared with less restrictive interventions.
APA recommends (1C) that patients with delirium have a documented, comprehensive, and person-centered treatment plan.

Nonpharmacological Interventions

APA recommends (1B) that patients with delirium or who are at risk for delirium receive multicomponent nonpharmacological interventions to manage and prevent delirium.

Pharmacological Interventions

APA recommends (1C) that medications, including anti-psychotic agents, be used to address neuropsychiatric disturbances of delirium only when all of the following criteria are met:
- Verbal and nonverbal de-escalation strategies have been ineffective;
- Contributing factors have been assessed and, as far as possible, addressed; and
- The disturbances cause the patient significant distress and/or present a risk of physical harm to the patient or others.
APA recommends (1C) that antipsychotic agents not be used to prevent delirium or hasten its resolution.
APA recommends (1C) that benzodiazepines not be used in patients with delirium or who are at risk for delirium, including those with preexisting cognitive impairment, unless there is a specific indication for their use.
APA suggests (2B) that dexmedetomidine be used rather than other sedating agents to prevent delirium in patients who are undergoing major surgery or receiving mechanical ventilation in a critical care setting.
APA suggests (2C) that when patients with delirium are sedated for mechanical ventilation in a critical care setting, dexmedetomidine be used rather than other sedating agents.
APA suggests (2C) that melatonin and ramelteon not be used to prevent or treat delirium.

Transitions of Care

APA recommends (1C) that in patients with delirium or who are at risk for delirium, a detailed medication review, medication reconciliation, and reassessment of the indications for medications, including psychotropic medications, be conducted at transitions of care within the hospital.
APA recommends (1C) that when patients with delirium are transferred to another setting of care, plans for follow-up include:
- Continued assessments for persistence of delirium;
- Detailed medication review, medication reconciliation, and reassessment of the indications for medications, including psychotropic medications;
- Assessment of consequences of delirium (e.g., post-traumatic symptoms, cognitive impairment); and
- Psychoeducation about delirium for patients and their care partners.

Development of the Guideline

The guideline was developed by the APA Practice Guideline Writing Group, chaired by Catherine Crone, M.D., and approved by the APA Board of Trustees in November 2024. The Writing Group conducted an extensive review of research evidence and used a process consistent with the recommendations of the Institute of Medicine (2011) and the Council of Medical Specialty Societies (2017) in developing the guideline. A detailed description of the process and research evidence are included in the guideline and accompanying appendices. Members of the multidisciplinary writing group included experts from psychiatry, internal medicine, family medicine, and critical care nursing.

“All too often, clinical guidelines come across as two-dimensional documents that are intellectual exercises,” said Dr. Crone, “rather than what they truly are: carefully considered, evidence-based guides that can be applied to direct patient care, quality improvement efforts, as well as the education of colleagues and trainees in psychiatry and other disciplines, with the end result being improvement in patient care.”

Delirium Guideline Resources

The full "Practice Guideline for the Prevention and Treatment of Delirium," executive summary and appendices are available free online and as a printed copy for purchase from APA Publishing. APA is also developing related resources to facilitate understanding of the guideline and its implementation, including training slides, clinician guide, patient/family guide, webinar and case vignettes. All of these materials will be available to practitioners and the public.

Notes

*A recommendation (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh the harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Although the benefits of the statement are still viewed as outweighing the harms, the balance of benefits and harms is more difficult to judge, or either the benefits or the harms may be less clear. With a suggestion, patient values and preferences may be more variable, and this can influence the clinical decision that is ultimately made. Each guideline statement also has an associated rating for the strength of supporting research evidence. Three ratings are used: high, moderate, and low (denoted by the letters A, B, and C, respectively) and reflect the level of confidence that the evidence for a guideline statement reflects a true effect based on consistency of findings across studies, directness of the effect on a specific health outcome, precision of the estimate of effect, and risk of bias in available studies (Agency for Healthcare Research and Quality 2014; Balshem et al. 2011; Guyatt et al. 2006).