Delirium is missed in most older inpatients when detection relies on clinical impression, particularly the hypoactive form, where the patient is quiet and withdrawn rather than agitated. A brief structured tool such as the 4AT takes about two minutes and needs no special training: it checks alertness, orientation, attention (months of the year backwards) and acute change or fluctuation.
Screen at admission and whenever a patient seems different. A positive screen means looking for the cause — infection, drugs, retention, constipation, pain, dehydration — not reaching for a sedative.
- Use a structured screen such as the 4AT at admission in older patients.
- Test attention with months of the year backwards.
- Look actively for hypoactive delirium in quiet, withdrawn patients.
- Search for the cause before considering any sedative.
Why it matters
Hypoactive delirium is the form most often missed and carries the worst outcomes.
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