SGEM#507: Till Everybody Got Delirious – Geriatric Patients in the Emergency Department

Date: April 2, 2026   Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in EM. She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. Case: An 82-year-old woman with hearing impairment and mild baseline dementia is brought to the emergency department (ED) by her daughter because she became “not herself” over 24 hours. She is more sleepy, intermittently agitated, keeps losing the thread of conversation, and cannot say the months backward. She arrived by ambulance from home after nearly falling twice. Vitals show fever and mild tachycardia. The daughter reports foul-smelling urine and poor oral intake for two days. On examination, there is no head trauma and no focal neurologic deficit. The question in the ED is not simply “Is she confused?” but “Does she have delirium, how do we confirm it efficiently, and does she need a head CT as part of the workup?” Background: Delirium is an acute brain dysfunction: a disturbance in attention and awareness that develops over hours to days, fluctuates, and is accompanied by additional cognitive disturbances such as memory, language, orientation, or perceptual changes. In older adults, it is common, dangerous, and often goes unnoticed. The latest GED Delirium Guidelines indicate that delirium occurs in about 6% to 38% of older ED patients, increases mortality, contributes to functional decline, and imposes a significant burden on health systems. ED-based geriatric screening tools also highlight that delirium is frequently under-recognized by emergency clinicians and that hypoactive delirium is most common, making bedside detection even more challenging.  For emergency physicians, delirium matters because it is rarely the final diagnosis. Delirium is usually a clue that something else serious is also wrong. The practical ED task is to identify the syndrome, search for precipitants, and avoid worsening the situation. But one reason the new guideline is so useful is that it is honest about the evidence gap. Prior reviews found no consistent ED-based strategy to prevent incident delirium or to treat prevalent delirium, so this guideline appropriately focuses on the parts of care for which there is sufficient evidence to guide bedside decisions now. It addresses risk stratification, diagnosis, and brain imaging.  This delirium guideline is also notable because it was built using the newer GED 2.0 model for subspecialty guideline development [1].  The Geriatric Emergency Department initiative moved beyond the older consensus-based 2014 framework and adopted a transparent GRADE process: multidisciplinary working groups, explicit PICO questions, systematic reviews and meta-analyses, Evidence-to-Decision frameworks, attention to feasibility, equity, and stakeholder values, plus external stakeholder review. This SGEM episode highlights the first EM subspecialty guideline effort to fully adopt GRADE, and this delirium guideline shows that process in action.  Clinical Questions: Which older ED adults are at the highest risk on walking in, and who should then be further assessed for delirium? (or CLS addition, should have special prevention measures or expedited treatment or bed placement). Which tools should be used to identify ED delirium? Should acutely confused older ED patients undergo head CT as part of the delirium evaluation? Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Authors’ Conclusions: “Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes  An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to value the relative importance of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes Has the guideline been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlike