Highlights
In this large retrospective cohort across three diverse emergency departments, delirium was present in 16.0% of adults aged 65 years and older, confirming that delirium is a common ED syndrome rather than an exceptional finding.
Delirium was independently associated with advanced age, dementia, greater comorbidity burden, arrival from a facility, and higher ED acuity. It also independently increased the likelihood of hospital admission.
Management patterns reflected both restrictive and supportive approaches. Patients with delirium were more likely to receive restraints, psychoactive medications, and constant observation, but also more likely to have safety precautions, family involvement, and palliative care input.
Importantly, delirium was not confined to admitted patients: 7.9% of discharged older adults had delirium, and delirium was associated with higher 30-day readmission rates.
Background
Delirium is an acute disturbance in attention, awareness, and cognition that develops over a short period and tends to fluctuate. In older adults, it is often a marker of underlying acute illness, medication toxicity, infection, metabolic disturbance, pain, dehydration, or environmental stress. It is also associated with poor outcomes including functional decline, prolonged hospitalization, institutionalization, and mortality. Despite this, delirium remains underrecognized in routine emergency care, where time pressure, crowding, sensory overstimulation, and limited collateral history can make identification difficult.
The emergency department occupies a particularly important place in the delirium pathway. For many older adults, the ED is the first point of contact during an acute medical event. Delirium may already be present on arrival, may be precipitated or worsened by the ED environment, or may emerge during prolonged boarding. Yet ED practice has historically focused more on stabilization of immediate physiologic threats than on structured cognitive assessment. Existing literature has suggested that delirium frequently goes undocumented in the ED and that missed delirium may lead to unsafe discharge decisions, delayed diagnosis of serious illness, and downstream healthcare utilization.
Against this background, Sinvani and colleagues sought to provide a more rigorous contemporary estimate of delirium prevalence in older ED patients, identify independent risk factors, characterize management strategies actually used in practice, and examine subsequent hospital utilization. The study is clinically relevant because it moves beyond simple prevalence reporting and begins to show how delirium shapes real-world care decisions in a heterogeneous health-system population.
Study Design
This was a multi-site retrospective cohort study conducted across three diverse emergency departments within a single integrated health system in the New York metropolitan area. The cohort included 2,827 adults aged 65 years or older. Delirium was identified by rigorous in-depth chart review using a validated approach that required evidence of an acute change from baseline, an important methodological strength because chart-based delirium ascertainment can otherwise overcall chronic cognitive impairment or nonspecific confusion.
The authors analyzed the cohort during control and intervention periods of a parent delirium screening trial, with results stratified accordingly. Although the abstract does not detail the trial intervention itself, the stratified approach is helpful because it tests whether prevalence and major findings were stable across differing screening contexts.
The principal outcomes included ED delirium prevalence, independent patient characteristics associated with delirium, management strategies used in the ED, hospital admission, and 30-day hospital utilization outcomes such as readmissions. To estimate independent associations, the authors used modified Poisson regression, a reasonable choice when outcomes are common and relative risks are more interpretable than odds ratios.
Key Findings
Delirium prevalence in the emergency department
The headline result is straightforward and clinically important: 16.0% of older adults presenting to the ED had delirium, with a 95% confidence interval of 14.6% to 17.4%. In practical terms, this means about 1 in 6 older ED patients had delirium. That prevalence was consistent across study periods and sites, suggesting that the finding is robust and not simply the result of local workflow or temporal variation.
The burden was higher among hospitalized patients, among whom delirium prevalence reached 27.3%. This aligns with prior evidence that delirium enriches among sicker, more medically complex, and more functionally vulnerable patients. However, one of the most actionable findings is that delirium was also present in 7.9% of all discharged patients. This subgroup is especially important because discharge from the ED may occur without the monitoring, medication review, collateral gathering, or delirium-focused supportive care that an inpatient setting can provide.
Independent risk factors for ED delirium
Several patient and encounter characteristics were independently associated with delirium. Advanced age carried an adjusted relative risk of 1.01, indicating a modest increase in risk with increasing age. Dementia was the strongest baseline clinical predictor, with an adjusted relative risk of 3.10. This is clinically plausible: patients with dementia have reduced cognitive reserve and are highly susceptible to superimposed delirium during acute illness or environmental stress.
Greater multimorbidity also mattered. Each increase in Charlson Comorbidity Index was associated with higher delirium risk, with an adjusted relative risk of 1.06. Arrival from a facility rather than from the community was also independently associated with delirium, with an adjusted relative risk of 1.28. This likely reflects a convergence of frailty, underlying cognitive impairment, dependency, polypharmacy, and acute illness severity.
ED acuity showed a particularly strong relationship. Patients in the highest acuity category had an adjusted relative risk of 3.85 for delirium. This is one of the most clinically intuitive findings in the study: delirium in the ED often tracks with illness severity, although it should not be dismissed as merely an epiphenomenon of being sick. In many cases, delirium itself is a critical manifestation of severe physiologic stress and should be treated as a high-risk clinical sign.
Management strategies in the ED
The study offers a valuable window into how delirium is actually managed in emergency practice. Patients with delirium were more likely to receive physical restraints, psychoactive medications, and constant observation. These findings indicate that ED teams often respond to delirium as a behavioral and safety emergency, particularly when agitation, wandering, or interference with treatment occurs.
At the same time, delirious patients were also more likely to receive supportive measures including safety precautions, family involvement, and palliative care consultation, with all reported p values below 0.001. This mixed pattern is revealing. It suggests that many clinicians recognize delirium as a syndrome requiring more than sedation or containment, yet supportive approaches remain inconsistently applied.
The distinction between restrictive and supportive strategies has major clinical significance. Restraints and psychoactive medications can sometimes be unavoidable when a patient poses immediate danger to self or others, but both may worsen confusion, impair mobility, and increase complications if used without careful indication and reassessment. By contrast, nonpharmacologic strategies such as reorientation, mobilization when feasible, minimizing tethers, optimizing hearing and vision aids, reducing nighttime disruption, encouraging family presence, and clarifying goals of care are more consistent with current geriatric best practice. The present study does not establish whether the observed management patterns improved or worsened outcomes, but it does make clear that supportive measures were not yet routine.
Hospital admission and 30-day utilization
Delirium independently predicted hospital admission, with an adjusted relative risk of 1.54. This association persisted after accounting for other measured factors, indicating that delirium itself meaningfully influences disposition. That finding is not surprising clinically: delirium complicates diagnostic assessment, increases concern for occult serious illness, raises safety issues, and often makes independent self-care after discharge less reliable.
The study also found higher 30-day readmissions among patients with delirium compared with those without delirium: 19% versus 13%, with p = 0.002. This suggests that delirium identifies a high-risk transition-of-care phenotype. Readmission may reflect unresolved precipitating illness, medication-related harm, persistent cognitive vulnerability, caregiver strain, or insufficient post-ED support. Although the abstract does not provide adjusted readmission estimates, the unadjusted difference is still clinically meaningful and reinforces the need for stronger discharge planning and follow-up in this population.
Clinical Interpretation
This study provides three messages that are directly relevant to emergency and inpatient clinicians.
First, delirium in the ED is common enough that opportunistic recognition is insufficient. A syndrome affecting 16% of older ED patients warrants systematic screening or at least structured cognitive surveillance in older adults with high-risk features. The prevalence estimate here is also credible because the authors used rigorous chart review requiring evidence of acute change from baseline, a critical distinction when differentiating delirium from dementia.
Second, the data reinforce that delirium should be considered both a neurologic emergency and a systems-of-care problem. The strongest associations, particularly dementia and high acuity, fit existing pathophysiologic models of delirium as the interaction of vulnerability and precipitating insult. Older age, chronic disease burden, and preexisting neurodegeneration lower the threshold at which acute illness triggers brain dysfunction. In practical terms, the more vulnerable the patient, the less severe the acute trigger may need to be.
Third, the fact that nearly 8% of discharged older adults had delirium should prompt reflection on ED discharge safety. Not every patient with delirium requires admission, especially if symptoms are mild, rapidly reversible, or clearly explained. Still, delirium at discharge should be unusual enough to trigger deliberate documentation of decision-making, family communication, medication review, and follow-up planning. For some patients, what appears to be transient confusion may instead signal evolving sepsis, intracranial pathology, medication toxicity, dehydration, urinary retention, or other reversible but dangerous conditions.
How These Findings Fit With Existing Evidence and Guidance
Prior studies have shown that delirium in older ED patients is often underdetected and associated with adverse outcomes. Clinical guidelines from the American Geriatrics Society and other expert bodies emphasize prevention and treatment strategies centered on identifying underlying causes and prioritizing nonpharmacologic management. Common recommendations include avoiding deliriogenic medications when possible, limiting restraints, promoting orientation and sleep, and involving caregivers in care planning.
The current study is consistent with that broader literature, but it contributes several practical advances. It reports prevalence in a large, racially and clinically diverse health-system sample, includes management-process data rather than outcomes alone, and highlights a discharged delirium subgroup that may be underappreciated. It also illustrates the tension between ideal delirium care and emergency realities. In a crowded ED, constant observation, family presence, quiet space, and careful reorientation are resource-intensive. This likely helps explain why restrictive measures remain common even when clinicians understand their limitations.
Strengths and Limitations
Strengths
The study has several notable strengths. The cohort was large, comprising 2,827 older adults across three different ED sites. The population appears heterogeneous, enhancing real-world relevance. The use of validated, in-depth chart review with a requirement for acute change from baseline strengthens confidence that delirium was identified with attention to diagnostic fidelity rather than simply coded confusion. The analytic approach using adjusted relative risks improves interpretability, especially for common outcomes such as admission.
Limitations
As a retrospective cohort study, the analysis is still vulnerable to incomplete documentation and residual confounding. Chart review, even when rigorous, depends on what clinicians recorded. Hypoactive delirium, which is quieter and more easily missed than hyperactive delirium, may still have been underdetected. Management associations should also be interpreted descriptively rather than causally; for example, higher rates of restraints or psychoactive medication may reflect severity of agitation rather than a practice preference alone.
Generalizability deserves careful consideration. All sites were within one integrated health system in the New York metropolitan area. Although the EDs were diverse, practice patterns, staffing models, consult availability, and patient demographics may differ elsewhere. The abstract also does not provide detailed information on race, ethnicity, language, social determinants, delirium subtype, or specific precipitating diagnoses, all of which could influence both delirium recognition and outcomes.
Finally, the 30-day readmission finding is clinically important but incompletely contextualized without fuller adjusted analyses in the abstract. Future work should determine whether delirium independently predicts return visits and readmissions after adjustment for frailty, baseline function, illness severity, and disposition setting.
Implications for Practice
For emergency clinicians, the immediate implication is that older adults with dementia, substantial comorbidity, high triage acuity, or arrival from a facility should be viewed as high-priority candidates for delirium assessment. Brief validated tools may help, but tools alone are not enough. Recognition requires collateral history to establish acute change from baseline, which often means contacting family or staff from a nursing facility early in the ED course.
For hospital and health-system leaders, the study supports investment in delirium-capable emergency care. This may include staff training, routine use of age-friendly workflows, reduction of unnecessary tethers, access to sitters or trained observers, environmental modification, and escalation pathways that prioritize nonpharmacologic management before medications or restraints when safety permits.
For clinicians involved in discharge planning, the data argue for caution when delirium is present or suspected. Safe discharge should include documentation of delirium status, evaluation of reversible causes, medication reconciliation, caregiver education, explicit return precautions, and timely follow-up. In some settings, observation or short-stay pathways may help clinicians avoid both unnecessary admission and unsafe discharge.
Future Directions
This study raises several research priorities. Prospective work is needed to compare screening strategies in the ED, especially for hypoactive delirium. Interventional studies should test whether structured delirium bundles can reduce restraint use, psychoactive medication exposure, admission, and readmission. It will also be important to identify which discharged patients with delirium can be managed safely at home and what post-discharge support is necessary to reduce near-term deterioration.
Another key gap is implementation science. The challenge in delirium care is rarely knowing what ideal management looks like; it is embedding that care in the pace and resource constraints of emergency medicine. Studies that integrate nursing workflows, family engagement, pharmacy review, geriatric consultation, and digital decision support may be especially valuable.
Conclusion
Sinvani and colleagues show that delirium affects about 1 in 6 older adults presenting to the emergency department and more than 1 in 4 of those ultimately hospitalized. The syndrome is strongly associated with dementia, comorbidity, arrival from a facility, high ED acuity, and subsequent hospital admission. Just as importantly, delirium is not limited to patients who stay in the hospital: nearly 8% of discharged older adults had delirium, and delirium was linked to greater 30-day readmission.
The management patterns observed in this study reveal a care gap that is both clinical and operational. Restrictive measures remain common, while supportive strategies are present but underused. The central message is not simply that delirium is prevalent, but that it is a frequent, consequential, and potentially modifiable syndrome at the front door of acute care. Standardized screening, improved recognition of acute cognitive change, and more consistent use of supportive delirium care should now be viewed as core components of high-quality emergency care for older adults.
Funding and ClinicalTrials.gov
The abstract does not report specific funding information or a ClinicalTrials.gov registration number for this analysis. It notes that analyses were stratified by control and intervention periods of a parent delirium screening trial.
Citation
Sinvani L, Nelson S, Perrin A, Islam S, Sison C, Slotnick S, Chua V, Porreca K, Barnaby DP, Kwiatek S, Cary K, Garg N, Sud P, Makhnevich A. Delirium in Older Adults Presenting to the Emergency Department: Prevalence, Risk Factors, Management Strategies, and Hospital Utilization Outcomes. Journal of General Internal Medicine. 2026-06-02. PMID: 42230527. URL: https://pubmed.ncbi.nlm.nih.gov/42230527/
Additional guideline context: American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015;220(2):136-148.e1. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. NICE guideline CG103.
