Understanding Delirium in the Prehospital Environment: A Call for Greater Recognition and Action

Understanding Delirium in the Prehospital Environment: A Call for Greater Recognition and Action

Che Bruce Che Bruce

Che Bruce

Advanced Clinical Practitioner/Assistant Professor

Published Apr 28, 2025
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By Che Bruce, University of Birmingham Dubai

Altered mental status (AMS) is one of the most challenging and common presentations encountered by prehospital care providers. Among older adults, AMS is frequently a manifestation of delirium — an acute, fluctuating disturbance in attention and cognition that demands urgent recognition and careful management. As the global population ages, it is increasingly critical that paramedics and other prehospital clinicians develop a structured, patient-centred approach to identifying and responding to delirium.

Recent evidence highlights that up to one-third of Emergency Medical Services (EMS) responses involve adults over the age of 65 (Haussner et al., 2025). Among these patients, approximately 10% experience delirium, a figure that is likely under-recognised and under-treated in the prehospital setting. Yet early identification and intervention are vital to improving outcomes, reducing hospital stays, and preventing associated morbidity and mortality.

The Complexity of Delirium in Older Adults

Delirium is a syndrome characterised by an acute onset of altered awareness, attention deficits, and fluctuating consciousness (Haussner et al., 2025). Its causes are diverse and often multifactorial. Common triggers include infection (particularly urinary tract infections and pneumonia), metabolic disturbances (such as hypoglycaemia, dehydration, or electrolyte imbalances), medication effects, hypoxia, and trauma — including occult head injuries.

Paramedics are uniquely positioned to detect delirium early through careful scene assessment, family interviews, and systematic patient evaluation. However, one of the greatest challenges is that delirium often presents subtly at first, with changes in personality, behaviour, or sleep patterns that can be easily missed or mistaken for psychiatric illness or dementia exacerbation.

In prehospital care, identifying reversible causes is key. Immediate bedside tests such as blood glucose monitoring, pulse oximetry, and cardiac monitoring should be routinely performed. A quick but structured physical examination, focused history, and careful observation of the environment (e.g., presence of medications, toxins, or signs of infection) provide vital clues.

Recognising the Impact of Anticholinergic Medications

Paramedics must also consider the role of anticholinergic medications when assessing patients with delirium. Drugs such as oxybutynin, diphenhydramine, amitriptyline, and scopolamine possess significant anticholinergic effects that impair cognitive function, particularly in older adults. Research has demonstrated that a higher anticholinergic burden is strongly associated with both acute delirium and long-term cognitive decline (Campbell et al., 2020; Richardson et al., 2023). Multiple medications with anticholinergic properties can have a cumulative, synergistic impact — increasing the risk of delirium exponentially. Therefore, obtaining a thorough medication history, including over-the-counter substances, and recognising signs of anticholinergic toxicity (such as dry mouth, blurred vision, urinary retention, or confusion) are essential components of prehospital delirium assessment. Early identification of a high anticholinergic load allows paramedics to contribute critical information during handover, aiding in faster diagnosis and targeted treatment.

A Structured Prehospital Approach

Recognising delirium requires a mindset shift: instead of viewing agitation or confusion in isolation, paramedics should approach such symptoms as medical emergencies until proven otherwise. Haussner et al. (2025) propose a "worst-first" model, encouraging providers to presume a dangerous underlying cause until a benign explanation is found.

The assessment should focus on several domains:

  • Vital signs: hypoxia, fever, or hypotension may point toward infection or shock.

  • Neurological status: checking for focal deficits, seizure activity, or signs of stroke.

  • Infection risk: asking about urinary symptoms, cough, or skin infections.

  • Medication history: screening for new, missed, or excessive doses, especially sedatives, anticholinergics, or psychoactive drugs.

  • Environment and witnesses: noting any recent changes in routine, injuries, substance use, or exposure to toxins.

Communication techniques are crucial. Older adults with delirium may be disoriented and frightened. Using slow, clear, simple language; maintaining a calm, non-threatening posture; ensuring glasses and hearing aids are in place; and minimising background noise and lights can all reduce distress.

Additionally, creating a comfortable transport environment is important. Temperature control, limiting unnecessary monitoring alarms, and avoiding repeated physical examinations unless clinically indicated can help prevent exacerbation of delirium during transport.

The Broader Implications for Paramedic Practice

Delirium is not merely a transient inconvenience; it is a marker of serious underlying illness and a predictor of poor outcomes. Studies show that delirious patients are at greater risk of falls, prolonged hospital admissions, ICU transfer, and mortality. Moreover, the distress experienced by patients and families when delirium is unrecognised or mismanaged is profound.

Paramedics therefore play a critical role — not only in providing safe initial care, but also in influencing the patient’s trajectory once they enter the healthcare system. Accurate prehospital identification, clear documentation, and effective communication with emergency department teams can directly impact how quickly underlying causes are treated.

Moving Forward: The Need for Evidence-Based Protocols

Despite the high prevalence and seriousness of delirium, many EMS systems still lack specific protocols for its recognition and management. The work by Haussner et al. (2025) calls for the development of structured, geriatric-specific approaches that prioritise diagnosis and medical optimisation over simply managing symptoms.

There is a pressing need for more prehospital education around geriatric medicine, cognitive impairment, and polypharmacy. Standardised tools for delirium screening, such as the Delirium Triage Screen (DTS) or the Confusion Assessment Method (CAM), though validated in hospitals, could be adapted for EMS use. Importantly, paramedic services must foster a culture where early identification of delirium is seen as a vital clinical skill — not secondary to other "more obvious" medical emergencies.

Conclusion

Delirium is a medical emergency, not a psychiatric afterthought. Paramedics are often the first healthcare professionals to encounter delirium, and their actions can either set a patient on the road to recovery — or contribute to worsening outcomes if the syndrome is missed. A structured, evidence-based, patient-centred approach that includes recognition of anticholinergic burden, environmental risk factors, and reversible causes will elevate the quality of prehospital care.

In an ageing world, excellence in the management of delirium must become core business for all paramedics.

References

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