Is it appropriate to discharge a patient with delirium to their home?

Should You Ever Send a Delirious Patient Home?

No, you should not discharge a delirious patient home until the delirium has resolved or substantially improved, and only after ensuring adequate supervision, environmental safety measures, and close follow-up are in place. Delirium is associated with increased mortality, prolonged hospitalization, and development of long-term cognitive impairment, making premature discharge potentially dangerous 1.

Why Delirium Requires Continued Care Before Discharge

Delirium represents an acute medical emergency that signals underlying physiological derangement requiring identification and treatment 2, 1. The condition occurs in approximately 25% of hospitalized geriatric patients and carries serious consequences including increased mortality and lasting functional decline 2. Discharging a patient while still delirious exposes them to substantial risk of harm, falls, medication errors, inability to care for themselves, and progression of the underlying medical condition causing the delirium 2, 1.

Essential Steps Before Any Discharge Consideration

Identify and Treat Reversible Causes

Before discharge can even be contemplated, you must systematically evaluate and address underlying precipitating factors 2, 1:

• Infections (urinary tract infection, pneumonia, bacteremia) - though notably, treating asymptomatic bacteriuria in delirious patients does not improve outcomes and may cause harm through antibiotic-associated complications 2
• Medications - review all drugs and discontinue those with anticholinergic properties, benzodiazepines, or other delirium-inducing agents 2, 1
• Metabolic derangements - evaluate electrolytes, glucose, calcium, hypercalcemia (particularly in cancer patients where it is reversible in 40% of cases) 2
• Hypoxia - ensure adequate oxygenation 1
• Dehydration - clinically assisted hydration may be indicated if dehydration is a precipitating factor 2
• Pain - manage effectively, preferably with nonopioid medications 1
• Alcohol or drug withdrawal - requires specific treatment with benzodiazepines 2

Implement Multicomponent Nonpharmacologic Interventions

Approximately one-third of delirium cases can be prevented or reversed through these interventions, which must be in place and showing effect before discharge 1, 3:

• Reorientation strategies - regular use of visible clocks, calendars, familiar objects 1
• Environmental modifications - adequate lighting, reduced noise, minimized room changes 1
• Sensory optimization - ensure hearing aids and eyeglasses are available and functioning 1
• Early mobilization - promote physical activity and rehabilitation 1
• Sleep hygiene - maintain normal day-night cycles, avoid interruptions during sleep hours 1

Specific Discharge Criteria When Delirium Has Improved

Discharge can only be considered if ALL of the following conditions are met 2:

1. Mental status has stabilized - the patient's level of suicidality (if applicable) or confusion has substantially improved 2
2. Safety assessment passed - patient can rise from bed, turn, and steadily ambulate (perform "get up and go test") 2
3. Adequate supervision confirmed - a responsible adult has agreed to provide continuous monitoring over the next several days 2
4. Environment sanitized - the responsible adult has explicitly agreed to secure or dispose of potentially lethal medications and remove firearms from the home 2
5. Third-party information obtained - you have spoken with family or caregivers to verify the discharge plan is realistic 2
6. Close follow-up arranged - an appointment is scheduled for fuller evaluation, ideally before leaving the emergency department, or telephone contact established with procedures for clinical staff to initiate contact if family doesn't follow up 2

Common Pitfalls to Avoid

• Do not rely on "no-harm contracts" - the delirious patient may not be in a mental state to accept or understand such agreements, and both family and clinician should not relax vigilance just because a contract has been signed 2
• Do not discharge based solely on patient or family reassurance - delirium causes patients to feel they are not being listened to or understood, and families often lack knowledge about delirium's serious nature 2
• Do not treat asymptomatic bacteriuria - if the delirious patient has positive urine cultures but no fever or UTI symptoms, treating with antibiotics worsens functional outcomes and increases risk of Clostridium difficile infection without improving delirium 2
• Do not use benzodiazepines routinely - these are sedating, deliriogenic, and increase fall risk except in cases of alcohol or benzodiazepine withdrawal 2

When Hospitalization Is Mandatory

You must admit patients who express persistent wish to die or have clearly abnormal mental states 2. Inpatient treatment should continue until mental state or level of suicidality has stabilized 2. This applies even if the apparent severity seems mild, as delirium can fluctuate and worsen unpredictably 2.

Special Considerations for End-of-Life Patients

In cancer patients or those with advanced illness where delirium may not be fully reversible, discharge decisions must align with the patient's goals of care and illness trajectory 2. Even in palliative settings, significant improvements in delirium management are possible and should be pursued to reduce distress for patient, family, and staff 2.