To the Editor, Delirium is an acute disturbance of attention, awareness, and cognition that frequently complicates hospitalization, particularly among older adults and critically ill patients. Despite decades of research demonstrating its association with increased mortality, prolonged hospitalization, institutionalization, and long-term cognitive decline, delirium remains under-recognized in routine clinical practice1. The reported incidence of delirium varies by setting, affecting approximately 10–30% of general medical inpatients and up to 50–70% of patients in intensive care units (ICUs)1,2. In mechanically ventilated ICU patients, rates may exceed 80%3. Importantly, delirium is not merely a transient cognitive fluctuation; it is independently associated with increased short- and long-term mortality, longer hospital stays, higher healthcare costs, and persistent cognitive impairment comparable to mild dementia4,5. Despite its clinical impact, delirium remains frequently missed. Hypoactive delirium, characterized by lethargy and reduced responsiveness, is particularly underdiagnosed compared to the hyperactive form, which presents with agitation and behavioral disturbance1. Failure to identify delirium early may delay appropriate management of underlying precipitating factors such as infection, metabolic disturbances, medication effects, hypoxia, or organ dysfunction. Validated screening tools are readily available and feasible for bedside use. The confusion assessment method (CAM) has demonstrated high sensitivity and specificity in general medical settings, while the CAM-ICU and intensive care delirium screening checklist are widely validated in critically ill populations6,7. These instruments can be administered in only a few minutes and are endorsed by multiple professional societies. The 2018 Society of Critical Care Medicine (SCCM) clinical practice guidelines recommend routine delirium monitoring in adult ICU patients using validated tools8. Yet, implementation remains inconsistent. In many institutions, delirium screening is performed irregularly or not at all outside the ICU. Even within critical care settings, compliance with routine assessment varies. Barriers extend beyond knowledge deficits alone and include staffing shortages, competing workflow demands, difficulties integrating screening into routine nursing assessments, limited institutional ownership of delirium prevention, and suboptimal electronic health record support. Recent implementation studies also suggest that sustained uptake is more likely when programs are backed by leadership support, designated clinical champions, standardized documentation pathways, and decision-support tools embedded within existing care processes9,10. The consequences of delayed recognition are substantial. Delirium is often multifactorial and may serve as the earliest clinical manifestation of serious underlying pathology. Early detection facilitates timely investigation and correction of reversible triggers. Moreover, identification of delirium allows implementation of evidence-based non-pharmacologic interventions, including reorientation strategies, sleep optimization, early mobilization, vision and hearing correction, and minimization of deliriogenic medications11. Multicomponent prevention strategies have been shown to reduce delirium incidence in high-risk populations12. Pharmacologic therapy remains limited and should not be considered first-line treatment. Antipsychotics have not consistently demonstrated improved outcomes and should be reserved for severe agitation posing a risk to the patient or staff8. This underscores the importance of prevention and early non-pharmacologic management, both of which depend on systematic recognition. Given the aging global population and rising hospitalization rates among older adults, the burden of delirium is expected to increase. Integrating routine delirium screening into standard admission and daily assessment protocols represents a low-cost, high-yield intervention. Similar to vital signs or pain assessment, delirium evaluation should be normalized as a core component of inpatient care. Standardization of screening protocols, staff education, and institutional quality-improvement initiatives may help close the recognition gap, but durable improvement will likely require system-level redesign rather than isolated educational efforts. Recent quality-improvement work has shown that redesigning delirium documentation workflows, embedding screening prompts into the electronic health record, and linking positive screens to best-practice advisories can improve recognition and communication across teams13. Importantly, the next phase of delirium care requires not only wider use of bedside tools but also smarter implementation. Emerging approaches, such as automated alerts, dashboard-based performance monitoring, and predictive or digitally assisted risk detection, may help hospitals move from intermittent screening to more reliable surveillance models14. Framing delirium recognition as a patient-safety and implementation priority, rather than solely a cognitive assessment task, may better support institutional adoption. In conclusion, delirium remains a common, serious, and frequently underdiagnosed complication of hospitalization. Validated screening tools are widely available, yet underutilized. Routine early recognition offers an opportunity to mitigate morbidity, reduce healthcare burden, and improve patient outcomes. Strengthening institutional commitment to systematic delirium assessment should be regarded not as an optional initiative but as a fundamental component of high-quality inpatient care.
Nour et al. (Mon,) studied this question.