How to get someone out of ICU delirium? A Comprehensive Guide

October 1, 2025 •

5 min read

Delirium affects an estimated 30–50% of patients in the intensive care unit (ICU), a state of acute confusion that can be terrifying for patients and their families. Effectively managing and reversing this condition is a complex, multi-faceted process that focuses on addressing underlying causes and implementing critical non-pharmacological interventions to aid a loved one experiencing ICU delirium.

Quick Summary

A comprehensive guide on managing ICU delirium through a combination of non-pharmacological strategies and, when necessary, targeted medication. It details the ABCDEF bundle, the importance of family engagement, environmental modifications, and provides practical communication tips for family members to aid a patient's recovery.

Key Points

Address Underlying Causes: The most effective way to treat delirium is to identify and resolve its root physiological cause, such as infection, pain, or medication side effects.
Implement the ABCDEF Bundle: Use the evidence-based, multicomponent ABCDEF approach (Pain, Sedation/Breathing, Medication Choice, Delirium Management, Early Mobility, Family Engagement) to manage and prevent delirium.
Prioritize Non-Pharmacological Care: Focus on environmental changes, sleep promotion, and reorientation. Avoid excessive reliance on medications, as some can worsen the condition.
Involve and Empower the Family: Family presence provides comfort and familiarity, which are powerful tools for reorienting and calming the patient. Train families on effective communication and reassurance techniques.
Correct Sensory Deficits: Ensure the patient has their glasses and hearing aids, as sensory impairment is a key driver of confusion and disorientation.
Encourage Early and Safe Mobility: Promote movement as early as possible, from simple exercises to assisted walking, to reduce delirium duration and prevent muscle weakness.
Use Medication Sparingly: Reserve antipsychotics for severe, dangerous agitation, not for routine treatment. Avoid benzodiazepines unless dealing with alcohol withdrawal.
Support Post-ICU Recovery: Continue reorientation and encourage cognitive and physical activity at home, and seek support groups to help process the experience.

Understanding ICU Delirium

Intensive Care Unit (ICU) delirium is an acute disturbance of consciousness and cognition that develops over a short period of time, often fluctuating throughout the day. It is not a sign of mental illness but rather a symptom of critical illness, infection, medication side effects, or other physiological imbalances. The experience can manifest in different ways:

Hyperactive delirium: The patient is agitated, restless, and can be aggressive or uncooperative. This is often the most recognizable form.
Hypoactive delirium: The patient appears withdrawn, quiet, and sleepy. This form is often missed but is associated with worse outcomes.
Mixed delirium: A combination of both hyperactive and hypoactive symptoms.

The goal of treatment is not to medicate the confusion away, but rather to identify and resolve the root cause while supporting the patient's cognitive function.

The Critical Importance of Non-Pharmacological Strategies

Modern intensive care guidelines emphasize that non-pharmacological interventions are the first and most effective line of defense against delirium. While medications may be used to manage dangerous agitation, they are not a cure and some, like benzodiazepines, can actually worsen the condition. The cornerstone of treatment is the ABCDEF bundle, a coordinated, evidence-based approach involving the entire care team.

The ABCDEF Bundle: A Structured Approach to Care

The Society of Critical Care Medicine (SCCM) developed the ICU Liberation Bundle (ABCDEF) to guide patient management and combat delirium. For families, understanding this framework can help them participate meaningfully in their loved one's care.

A: Assess, prevent, and manage pain: Untreated pain is a significant driver of delirium. The care team uses validated tools, even for non-communicative patients, to manage pain with appropriate analgesics.
B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs): Minimizing sedation is critical. SATs involve waking a patient daily to assess their neurological function, while SBTs test their ability to breathe on their own. This helps reduce dependence on sedatives and mechanical ventilation, both of which can increase delirium risk.
C: Choice of Analgesia and Sedation: The choice of medication is important. The bundle recommends avoiding benzodiazepines due to their deliriogenic potential, especially in older patients. Sedatives like dexmedetomidine may be preferred in some cases.
D: Delirium: Assess, prevent, and manage: The care team uses standardized tools like the Confusion Assessment Method for the ICU (CAM-ICU) to regularly screen for delirium. Early detection is key to prompt management.
E: Early Mobility and Exercise: Prolonged immobility is a major risk factor. Early and progressive physical activity, from in-bed exercises to walking, is safe and has been shown to reduce delirium duration.
F: Family Engagement and Empowerment: Involving family is crucial for reorientation and comfort. Families are encouraged to visit, bring familiar items, and participate in care under the guidance of the clinical team.

Empowering the Family: The 'F' in Action

Families are a powerful tool in helping a loved one emerge from ICU delirium. Your presence, voice, and familiar items can be vital anchors to reality.

Communicate Simply: Speak in a calm, clear, and soft voice. Use short, simple sentences and repeat things if needed. Give the patient time to process and respond.
Reorient Gently: Remind the patient of the day, date, time, and where they are. Talk about familiar family and friends. Avoid arguing with their misperceptions or hallucinations; instead, calmly reassure them.
Bring Familiar Items: Family photos, a favorite blanket, or a calendar can provide comforting reminders of home.
Offer Distractions: Engage them with calming activities like reading letters, listening to music they enjoy, or watching favorite TV shows.

Environmental Management for Better Outcomes

Creating a healing environment is fundamental to preventing and managing delirium.

Promote Natural Sleep Patterns: Maximize natural light during the day by opening curtains. At night, minimize noise and turn off lights to encourage restful sleep.
Reduce Noise: The continuous alarms and noise in an ICU disrupt sleep and can increase anxiety. Simple measures like providing earplugs or minimizing non-critical alarms can help.
Optimize Senses: Ensure the patient has their glasses, hearing aids, or dentures if they use them. Correcting sensory deficits helps them connect with their environment and reduces confusion.
Minimize Clutter and Restraints: A simple, orderly environment can be calming. Avoid physical restraints whenever possible, as they can increase agitation and worsen delirium.

The Cautious Use of Medication

While non-pharmacological interventions are the standard of care, medication may be necessary in specific situations. Pharmacological treatment is reserved for managing severe agitation or psychotic symptoms that pose a safety risk to the patient or staff. Antipsychotics like haloperidol and atypical antipsychotics are sometimes used, but their evidence for treating delirium itself is limited and guidelines recommend against routine use. Dexmedetomidine, a sedative, has shown some promise for ventilated patients with delirium. Medications known to cause or worsen delirium, especially benzodiazepines, should be avoided except in specific circumstances like alcohol withdrawal.

Non-Pharmacological vs. Pharmacological Management


Aspect	Non-Pharmacological Management	Pharmacological Management
Primary Goal	Treat underlying cause and provide supportive, reorienting care.	Control severe, dangerous agitation or psychosis; not a cure.
Effectiveness	Strong evidence supporting reduction in duration and incidence of delirium.	Limited evidence for effectiveness in reducing delirium duration or severity.
Safety	Low risk; focuses on minimizing risk factors like sleep deprivation and immobility.	Higher risk of side effects, including cardiac issues (QT prolongation) with antipsychotics and paradoxical agitation with benzodiazepines.
Patient Experience	Promotes cognitive stimulation, natural sleep, and connection to reality.	Can cause excessive sedation or worsen confusion if not used cautiously.
Family Involvement	Heavily emphasizes and relies on family for reassurance and reorientation.	Family involvement is still important but is not the primary mechanism of action.

Roadmap to Recovery: Beyond the ICU Stay

For many patients, recovery from ICU delirium continues long after discharge. Families can play a pivotal role in this journey:

Maintain Familiarity: Ensure the home environment is familiar and stable to prevent new confusion.
Encourage Activity: Support light physical activity and mental exercises to help rebuild cognitive function and strength.
Continue Reorientation: Keep reminding the patient of the date, time, and where they are. Display clocks and calendars prominently.
Discuss the Experience: As the patient recovers, they may have fragmented or distressing memories. Talking openly about the experience can help process the trauma.
Seek Out Support: Support groups for survivors of ICU delirium and their families can provide valuable perspective and coping strategies.

Conclusion: A Holistic Path to Healing

Getting someone out of ICU delirium requires a patient, holistic, and collaborative approach. Focusing on the underlying cause, implementing the evidence-based ABCDEF bundle, and actively involving family members provides the best chance for a smooth and swift recovery. While the process can be challenging, empowering both the care team and the family with the right tools and information can significantly improve outcomes and help patients return to their baseline cognitive function.

For more detailed information on critical care guidelines, visit the Society of Critical Care Medicine.

Frequently Asked Questions

ICU delirium is caused by a range of factors, including severe illness, infection, medication side effects, electrolyte imbalances, and sleep deprivation. The primary treatment focuses on identifying and managing the specific underlying cause.

As a family member, you can help by providing frequent reorientation, speaking in a calm and simple manner, bringing familiar items like family photos, ensuring they have their glasses and hearing aids, and encouraging a normal sleep-wake cycle.

There are no FDA-approved medications that specifically treat delirium itself. Medications like antipsychotics are sometimes used cautiously and at low doses to manage severe agitation but are not recommended for routine use and can have significant side effects.

No, you should not argue or contradict a patient experiencing hallucinations or delusions. Instead, calmly reassure them and redirect their attention. Arguing can increase their agitation and distress.

The ABCDEF bundle is a set of care strategies developed by the Society of Critical Care Medicine to manage and prevent delirium. It stands for Assess Pain, Spontaneous Awakening/Breathing Trials, Choice of Sedation, Delirium Management, Early Mobility, and Family Engagement.

The duration of ICU delirium and the recovery period can vary widely, lasting anywhere from days to months. Continued reorientation and support at home are crucial for a full recovery.

You can help by encouraging a natural sleep-wake cycle. This involves ensuring proper lighting during the day and minimizing noise and light at night, including providing earplugs or eye masks if the patient can tolerate them.