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Discharging Delirium Is Dangerous

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Written by Jason Lesnick

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Older adults discharged from the ED with delirium had almost 3 times the risk of 30-day mortality compared to those discharged without delirium.

Delirium dispo double-take
This retrospective cohort study asked whether older adults discharged from the ED with delirium experience higher 30-day mortality and ED return rates. 

This study included 22,940 visits of adults ≥ 75 years old from a large academic ED in Minnesota from 2021-2023. Patients were screened for delirium by nurses using the Delirium Triage Screen (DTS) and brief Confusion Assessment Method (bCAM) and were grouped into four categories: delirium positive—discharged, delirium positive—admitted, delirium negative—discharged, and delirium negative—admitted.

The authors found after multivariable adjustments, delirium positive—discharged patients had significantly increased 30-day mortality (8.4%; aRR 2.86, 95%CI 2.04–4.00) and higher ED return rates (32.2%; aRR 1.52, 95%CI 1.43–1.61) compared with delirium negative discharges. 

Interestingly, 30-day mortality was highest in the delirium positive—admitted group (13.4%), followed by delirium positive—discharged group (8.4%), then delirium negative—admitted (6.0%), and delirium negative—discharged (1.5%) groups. 

They also found that delirium positive—discharged patients had a significantly higher risk of ED return within 30 days compared to delirium positive patients admitted to the hospital (aRR 1.64, 95% CI 1.40 to 1.92).

How will this change my practice?
I generally only discharge patients with delirium in palliative care or very specific, complex social situations. My take on this paper is that disposition planning for every patient with delirium needs to involve multiple other people to ensure that we are doing what is best for the patient, and that we better have a great reason for discharging someone with delirium.

Source
Outcomes of Older Adults With Delirium Discharged From the Emergency Department. Ann Emerg Med. 2025 Nov;86(5):484-495. doi: 10.1016/j.annemergmed.2025.02.003. Epub 2025 Mar 12. PMID: 40072382; PMCID: PMC12353625.

View Critical Appraisal

Critical Appraisal

Title: Outcomes of Older Adults With Delirium Discharged From the Emergency Department.
Background: Delirium is a common and serious condition in older adults that can lead to increased mortality and healthcare utilization. Understanding the outcomes of delirious patients discharged from the ED is crucial for improving care.
Study Question: What are the 30-day mortality and return ED visit rates among older adults with delirium discharged from the ED compared to those without delirium and those admitted to the hospital?
Study Design: Retrospective cohort study
Population: Adults ≥75 years assessed for delirium in the ED
Intervention: Discharge from the ED with delirium
Comparison: Discharge without delirium and hospital admission with/without delirium
Primary Outcome: 30-day mortality
Secondary Outcomes: Return ED visits within 30 days
Key Statistics: Adjusted relative risk (aRR) with 95% confidence intervals (CIs)
Results: Discharged delirium-positive patients had higher 30-day mortality (aRR 2.86, CI 2.04-4.00) and ED return rates (aRR 1.52, CI 1.43-1.61) compared to those without delirium.
Risk of Bias – Newcastle-Ottawa Scale:
  • Selection (3/4 stars) — Some concerns: Good representativeness but potential selection bias due to retrospective design.
  • Comparability (1/2 stars) — Some concerns: Limited adjustment for confounders such as comorbidities and social factors.
  • Outcome (2/3 stars) — Some concerns: Outcome assessment relies on accurate record-keeping; follow-up completeness is unclear.
Take Home: Older adults discharged with delirium face increased risks, necessitating better discharge protocols and follow-up care.
This critical appraisal is generated using a structured framework applied to the full text of the original article and is presented separately from the physician’s commentary.

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