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Primary Care Companion for CNS Disorders

Rounds in the General Hospital October 6, 2026

Managing the Sequelae of Delirium Associated With Critical Illness

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Prim Care Companion CNS Disord.2026;28(5):26f04249

Lessons Learned at the Interface of Medicine and Psychiatry

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Prim Care Companion CNS Disord 2026;28(5):26f04249

Author affiliations are listed at the end of this article.

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Have you ever wondered what it is like to experience delirium? Have you been uncertain about whether your patients remember what happened to them in the intensive care unit (ICU)? Have you seen patients develop persistent mood or cognitive symptoms after undergoing painful procedures or enduring long, complex hospital stays? If you have, the following case vignette and discussion should prove useful.

CASE VIGNETTE

Ms B, a 76-year-old woman, was admitted to the cardiac care unit (CCU) for management of a large anterior wall myocardial infarction that was complicated by cardiogenic shock and delirium, during which she believed that the nurses were stealing things from her purse and selling her blood on the black market. When she attempted to elope from the CCU, she was placed in mechanical restraints and administered antipsychotics.

DISCUSSION

Which Affective, Behavioral, and Cognitive Disturbances Are Common in Critically Ill Individuals?

Delirium is common in ICUs, with an estimated prevalence above 30% overall and a prevalence of 50%–70% in mechanically ventilated patients.1,2 It is defined by disturbances in attention and other cognitive symptoms that develop over a short period.3 Common risk factors for delirium include premorbid cognitive impairment, older age, medical and psychiatric comorbidities, visual and hearing impairments, and polypharmacy.1 For critically ill patients, other contributors to delirium and associated symptoms include the critical illness itself, numerous medical interventions, and the general ICU environment that contains many personnel, machines, and noises.

In addition to the hallmark cognitive deficits, symptoms of delirium can manifest in myriad ways. Patients with hyperactive delirium commonly exhibit anxiety, agitation, and irritability, while patients with hypoactive delirium exhibit depressed mood, psychomotor slowing, and apathy. Sleep disturbances, hallucinations, delusions, and symptoms of acute stress disorder may accompany either of these states. Symptoms are often new, but they can also be preexisting and worsened by delirium.1 The etiology of sleep disturbances is often multifactorial with the physiological disruption of the sleep-wake cycle compounded by uncomfortable illness-related symptoms, environmental factors, and frequent awakenings for tests and monitoring. Many symptoms of delirium are temporary and abate as delirium resolves, but some symptoms may persist and lead to mood, anxiety, and posttraumatic stress disorder (PTSD) later in the hospital course or following discharge. Further complicating the development of psychiatric symptoms and disorders are the numerous physical, cognitive, and social disruptions that stem from critical illness. Collectively, these sequelae of critical illness are termed postintensive care syndrome (PICS), and their interplay can adversely impact the experience of patients and their families.4

How Often (and Why) Do Patients in ICUs Become Anxious, Afraid, or Paranoid, and How Does This Affect Their Recollections About Their ICU Stay?

Critical care settings provide the backdrop for stress, fear, and anxiety, often provoked by physical factors (eg, mechanical ventilation, invasive procedures, thirst, and pain). Psychological uncertainty about their medical condition and the fear of death are frequently reported by patients receiving ICU-level care.5,6 Communication barriers are also common for patients in ICUs, further compounding their distress. The physical environment is often unfamiliar to them, and it contains many potential stressors, eg, machine alarms, bright lights, and a lack of privacy.5,6 In addition, procedures and physical restraints, while often required for clinical care and safety, may be perceived as instruments of torture.7 Such experiences often contribute to anxiety, fear, and paranoia.

Critically ill individuals have a bevy of physiological factors (especially respiratory disease, cardiac disease, and metabolic derangements) and exposure to polypharmacy that increase their risk of developing anxiety. Patients may also experience intense pain, both at rest and during procedures, and anxiety is often correlated with pain levels.8 Similarly, critically ill, mechanically ventilated patients often develop dyspnea, defined as the subjective experience of breathing discomfort, which is highly associated with anxiety.9,10 When respiratory acidosis arises, it can activate limbic areas (including the locus coeruleus, hypothalamus, and ventrolateral medulla), which are involved in respiratory control, panic, and fear circuitry.9 Accordingly, anxiety is highly prevalent in ICU settings, with 30%–80% of patients experiencing some anxiety, while many also report that anxiety is one of their more distressing symptoms.11–13 Risk factors for anxiety in the ICU include severe illness, delirium, premorbid anxiety, and substance use. Protective factors include older age, an optimistic outlook, and lower levels of pain.11–14

Anxiety is usually modulated by top-down regulation, from the prefrontal cortex to the limbic system; however, executive dysfunction due to delirium or other neurocognitive disorders may impair this regulatory process, making it more challenging for patients to attenuate anxious thoughts.15 Delirium-related confusion and difficulty making sense of an unfamiliar environment may also contribute to anxiety and fear. When delirium induces hallucinations and paranoia, it can turn an already difficult experience into one with bizarre and nightmarish qualities.16 Common recollections of their time in the ICU include memories of the environment, interactions with staff members, procedures, and visits from family members.17 However, patients with delirium often have impaired recall of hospital events,18 with 25%–75% of ICU patients reporting delirium-related memories of events that never happened.19 These “delusional memories” often consist of realistic elements (ie, ICU staff, physical sensations, and procedures) that are merged with delirium-related delusions, hallucinations, or other misperceptions. These memories are often paired with feelings of helplessness, fear, anxiety, and anger.19 Qualitative research has identified 3 common themes associated with the delirious state: concerns about fear and safety, problems differentiating between what is real and what is not, and delirium as a solitary experience.20 While these can be disorienting and frightening, many ICU survivors choose not to share these memories with health care professionals.19

How Long Do Affective, Behavioral, and Cognitive Changes Usually Persist After an Episode of Delirium?

As delirium’s underlying etiology has been treated, its symptoms tend to improve, although the time course for improvement varies and deficits can persist.21–23 Although delirium has historically been considered a transient and reversible state, current data suggest that, for many patients, it can mark the beginning of a chronic downward trajectory. Persistent affective, behavioral, and cognitive changes following an episode of acute delirium vary, with some impairments resolving within days, and others lasting months to years, frequently failing to return to premorbid baselines.21–23 Cognitive impairment is the most enduring and widely studied sequelae of delirium. Moreover delirium is a strong predictor of long-term cognitive impairment, with deficits that often mirror those of mild Alzheimer’s disease or traumatic brain injury.24 Approximately one-third (36%) of patients diagnosed with delirium continue to manifest symptoms of delirium at the time of hospital discharge, with up to 16% meeting diagnostic criteria for delirium 1 year after hospital discharge.25 Deficits in executive function, attention, and processing speed can persist for 1–5 years postdischarge. In a large cohort of survivors, these changes appeared to be permanent, particularly in older adults or those with severe illness during the acute phase of delirium.25 Our understanding of cognitive recovery is further complicated by the prevalence of sub-syndromal delirium, a state in which patients manifest core features of the syndrome without reaching the diagnostic threshold. Current findings suggest that subsyndromal delirium may linger and persist, creating long-term cognitive and functional impairment that is nearly equivalent to that of full-syndromal delirium.26–28

Psychological distress following delirium is a core component of PICS. Affective changes, primarily depression, anxiety, and PTSD, often persist with clinically significant depression affecting more than one-third of survivors within the first year.29 In addition, cognitive deficits (especially executive dysfunction at 3 months) are highly correlated with the severity of depression at 12 months, suggesting that cognitive and affective recovery are linked.29 In longitudinal studies, PTSD and anxiety symptoms (such as frightening hallucinations or delusions) related to delirium can persist for up to 5 years, and some delusions (or delusional memories) may not resolve following the treatment of delirium.28,30

Behavioral changes following delirium often involve a complex interplay between ongoing cognitive and affective symptoms and newly acquired physical disabilities and functional decline, which often leads to a sustained decline in activities of daily living and loss of independence.31 Sleep-wake cycle disruption is common in delirium, and it can become a chronic condition even after delirium resolves. Rather than clearing with treatment of the underlying medical illness, sleep architecture often remains fragmented for many delirium survivors.26 When sleep patterns fail to normalize, recovery from cognitive and affective symptoms may contribute to a vicious cycle of nonrecovery.

Current literature refutes the notion that delirium is a short-term and fully reversible condition. Significant recovery can occur in initial days, but much of the recovery occurs 3–6 months after it has been diagnosed, with an apparent plateau in recovery that often leaves patients with residual deficits, often in multiple domains. Cognitive and behavioral changes can persist for more than 12 months, while sleep disturbance and affective symptoms can last for years after an episode of delirium.

How Can Clinicians Educate Patients and Families About What to Expect During and After an Episode of Delirium?

Unfortunately, patients and family members often know little about the etiology and course of delirium. However, once they have been exposed to delirium, they often want to understand it better.32,33 Education by clinicians empowers caregivers to serve as vital members of the care team, as they can help identify disturbances of affect, behavior, and cognition, often having the best perspective of whether their loved one is functioning differently from their baseline. Family members can also aid in delirium recovery by providing frequent reorientation and reassurance (that may be better received when spoken by someone familiar to the patient).34 Family members are also invaluable when providing calm mental stimulation during the daytime and familiar objects or conversation related to their life outside of the hospital.

When educating patients and families, delirium should be distinguished from dementia, emphasizing that delirium is defined by its acute onset and fluctuating course, whereas dementia is typically characterized by a chronic and progressive cognitive decline.34 Moreover, the treatment for delirium targets the identification and correction of its underlying medical cause. Nevertheless, symptoms of these neurocognitive disorders often appear similar. Clinicians can frame the cognitive deficits of delirium in terms that families can recognize. Attention, the core cognitive domain that is affected during delirium, may appear as distractibility or an inability to stay on task. Deficits in other domains (eg, memory, language, executive function, and social cognition) may stem from attentional deficits and present as disorientation, forgetfulness, and trouble engaging in conversations.20 Other common symptoms include changes in mood (eg, depression, irritability), altered perceptions (eg, paranoia, hallucinations), and behavioral changes (eg, psychomotor agitation or slowing).35 When psychotic symptoms arise, clinicians can coach family members on how to respond. For example, family members can be instructed not to argue with or to validate these beliefs, but instead to provide general reassurance, eg, “I’m here to support you, and your treatment team is helping you get better.” Other helpful responses may acknowledge the patient’s emotional response, eg, “I can see you’re very scared.” Patients and families should also be encouraged to share descriptions of these symptoms with the medical team to ensure that care is tailored to the patient’s symptoms.

As patients transition toward the recovery phase of their illness, clinicians should help patients and families appreciate that the symptoms of delirium do not necessarily resolve immediately after treatment of the underlying cause. Symptoms may persist for days, weeks, or even months after hospital discharge.1,23,34,35 While delirium is primarily a disorder of cognition, clinicians can educate families about other functional sequelae, eg, that delirium is an independent predictor of long-term disability and ambulatory instability associated with agitation or lethargy and a higher risk of falls.1 Clinicians can then help families form realistic expectations for recovery and understand that a longitudinal, multidisciplinary approach will lead to the best chance for recovery.

The efficacy of structured educational tools that improve patient and caregiver health literacy surrounding delirium has also been studied. One study incorporated educational videos in the ICU setting, which improved caregiver knowledge about delirium.32 Quality improvement projects that utilize educational booklets have led to improvements in the ability of older adults to recognize risk factors, signs, and complications of delirium.33 Clinicians and health care systems can benefit from using multimodal interventions (eg, the internet, brochures, in-person education) to accommodate different learning preferences and ensure broad access to educational materials.

Which Pharmacologic Considerations Can Help Delirium Resolve?

Not surprisingly, there is no specific pharmacologic treatment for delirium. However, medications, especially antipsychotics, valproic acid, α-2 agonists (eg, dexmedetomidine, clonidine, guanfacine), melatonin, melatonin receptor agonists, and trazodone, are often used to manage distressing symptoms associated with delirium (eg, agitation, paranoia, hallucinations, and insomnia).36–40 Benzodiazepines (BZs) are also used, particularly when withdrawal from alcohol or BZs may have contributed to delirium.41 Typically, as cognition improves, medications that were necessary to maintain safety and minimize distress are no longer necessary, thereby eliminating a source of excess sedation, which can contribute to delayed recovery and lack of engagement with physical rehabilitation. With respect to the use of antipsychotics, their long-term use increases the risk of falls, metabolic dysfunction, and extrapyramidal symptoms.42 A population-based cohort study found that discontinuation of antipsychotics that were prescribed for older adults without a psychiatric illness after a medical hospitalization reduced the risk of all-cause rehospitalization and mortality.42 Nevertheless, antipsychotics that were started in ICUs tend to be continued after hospital discharge in one-fourth to one-half of patients.43,44

Each medication used to manage delirium and its manifestations should be reviewed carefully for its indications, risks, and benefits before it is continued.45 Typically, a stepwise approach to deprescribing can begin in inpatient settings, although it must often be continued after hospital discharge.39,46,47 Since many medications used to manage delirium are initiated by practitioners from multiple specialties, a collaborative approach among the members of a patient’s care team is warranted when considering the risks and benefits of deprescribing.4

What Are Important Considerations for Outpatient Follow-Up Care After an Episode of Delirium?

Delirium that arises during critical illness often causes more than transient disturbances; it can lead to PICS, with multidimensional manifestations that persist well beyond hospital discharge.4,31 Delirium is also associated with long-term cognitive impairment, psychiatric morbidity, functional decline, and reduced quality of life.4,48 Delirium with a longer duration has been noted to worsen long-term cognitive performance, after adjustment for age, education, preexisting cognitive function, illness severity, and exposure to sedatives.49 Taken together, these findings suggest the need for outpatient follow-up and coordinated longitudinal care following delirium, with specific focus on medication review, reconciliation, and reassessment of indications; repeat cognitive assessments to assess for continued delirium or residual deficits; assessment for consequences of delirium (eg, posttraumatic symptoms); and psychoeducation about delirium for patients and care partners.45 Many recommended areas of focus for outpatient care echo those for in-hospital transitions of care, illustrating that serial reassessments are a core feature of postdelirium care.

Primary care providers (PCPs) provide essential follow-up care after their patients have been delirious, given that postintensive care clinics are rarely found outside of large academic medical centers. The 2020 Society of Critical Care Medicine’s (SCCM) International Consensus Conference on Prediction and Identification of Long-term Impairments after Critical Illness recommended serial assessments beginning within 4 weeks of hospital discharge for those at an elevated risk of PICS (eg, those with preexisting frailty, cognitive impairment, psychiatric disorders, sepsis, shock, acute respiratory distress syndrome, and delirium).50 Systematic screening (eg, with the Montreal Cognitive Assessment, the Hospital Anxiety and Depression Scale, the Impact of Event Scale–Revised, the 6-minute walk test, and the EuroQol 5-dimension 5-level) helps to identify persistent, clinically meaningful symptoms and deficits that might otherwise be dismissed as part of a prolonged but “expected” recovery.50

PCPs also play a critical role in medication reconciliation and deprescribing of sedatives that were initiated during episodes of delirium and that were continued following hospital discharge. In one study, roughly one-fifth (20.6%) of patients were discharged on an antipsychotic without a clear indication for its continued use.39 The 2018 SCCM Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guidelines recommend against the routine use of first-generation antipsychotic, haloperidol, or second-generation antipsychotics for delirium management. Nevertheless, patients started on these agents in ICUs often remain on these agents, which may expose them to adverse effects.51 Therefore, use of these agents and other sedative-hypnotics should be reviewed routinely, and the medications tapered off if there is no ongoing need for them. If the results of screening tests and functional assessments indicate impairment, PCPs can triage patients to specialists (in psychiatry, neurology, and rehabilitation services, among others).

What Happened to Ms B?

As Ms B’s hemodynamic instability resolved, her need for antipsychotic medications abated before her hospital discharge; her anxiety, paranoia, and insomnia each improved. She felt comforted by visits from her niece while she was in the ICU, and she looked forward to returning to her home, with added supports that would be provided by her niece, visiting nurses, and her PCP (who had known her for the past several decades).

CONCLUSION

PCPs and psychiatrists are increasingly likely to evaluate and treat patients who are recovering from critical illness that has been complicated by delirium. The clinical evaluation should involve a review of the patient’s ICU course, manifestations of delirium, and use of medications, while also considering the amount and impact of cognitive, physical, and social impairments. Reviewing the patient’s recollection of their delirium, including frightening or distorted experiences, can provide meaningful insights and may uncover the source of intrusive thoughts, frightening nightmares, and other symptoms of anxiety or fear.4 Treatment planning should prioritize the use of medications that are less likely to impair cognition, thereby using serious caution when considering sedative-hypnotics and medications with strong anticholinergic properties. That said, nonpharmacologic interventions remain as key components of recovery following episodes of delirium, and these should be presented to patients and families as a central part of recovery after delirium, not simply as an adjunct to medication.4

Many individuals describe fragmented, frightening, or delusional memories that linger well beyond their ICU stay. Supportive or trauma-focused psychotherapy, including cognitive-behavioral therapy (CBT) and exposure-based approaches, can help patients make sense of these experiences and reduce the risk of persistent posttraumatic stress symptoms. Sleep-focused interventions (like CBT for insomnia, stimulus control, and circadian rhythm normalization strategies) are especially important given the close relationship among sleep disruption, mood symptoms, and cognitive recovery.51 Multicomponent nonpharmacologic interventions that include reorientation, cognitive stimulation, early mobilization, family participation, and environmental optimization have demonstrated effectiveness in reducing the incidence and duration of delirium.51 Of note, these interventions can be implemented both while a patient is still in the hospital and after their return to the community. Referral for cognitive rehabilitation may benefit patients with ongoing attention, executive function, or memory difficulties. These programs, often delivered by neuropsychologists, occupational therapists, or speech-language pathologists, combine compensatory strategy training (eg, use of external memory aids, task chunking, environmental structuring) with targeted cognitive exercises and have become a recommended component of postcritical illness care frameworks.52 Ongoing communication among clinicians with coordinated, patient-centered management helps to address the complex and often persistent consequences of critical illness.

Article Information

Published Online: October 6, 2026. https://doi.org/10.4088/PCC.26f04249
© 2026 Physicians Postgraduate Press, Inc.
Submitted: April 9, 2026; accepted June 15, 2026.
To Cite: Dragonetti JD, Cassady MK, Torncello ER, et al. Managing the sequelae of delirium associated with critical illness. Prim Care Companion CNS Disord.2026;28(5):26f04249.
Author Affiliations: Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina (Dragonetti); Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts (Cassady); Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (Torncello); Virginia Commonwealth University School of Medicine, Richmond, Virginia (Williams); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina (Shelton); Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Illinois (Bean); Department of Psychiatry, Memorial Healthcare System, Hollywood, Florida (Rodulfo); Department of Behavioral Health, Atrium Health, Charlotte, North Carolina (Soliman); Wake Forest University School of Medicine, Charlotte, North Carolina (Soliman); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts (Stern).
Corresponding Author: Joseph D. Dragonetti, MD, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina ([email protected]).
Dragonetti, Cassady, Torncello, Williams, Shelton, Bean, Rodulfo, and Soliman are co-first authors; Stern is the senior author.
Financial Disclosure: Dr Stern has received royalties from Elsevier for publishing textbooks on Psychiatry. The other authors have no conflicts to disclose.
Funding/Support: None.

Clinical Points

  • Affective, behavioral, and cognitive disturbances (including confusion, anxiety, agitation, depression, delusions, and insomnia) are common in patients with delirium that is associated with critical illness.
  • While symptoms of delirium have traditionally been considered transient and fully reversible, many patients have symptoms for months to years, while some fail to return to their baseline.
  • Serial assessments of cognition, mood, anxiety, and other symptoms associated with delirium are a core part of postdelirium care, which should continue after discharge through outpatient care.
  • Deprescribing antipsychotics, use of nonpharmacologic interventions, and facilitation of patient/family education are core components of inpatient and outpatient care for individuals following an episode of delirium.
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Vol 28 • 2026 • Number 4

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