Scope of this summary
Adults aged 65 years or older receiving perioperative care and adults admitted to an ICU with an acute or fluctuating disturbance in attention, awareness or cognition. The AGS source is postoperative and the SCCM source is ICU-specific. Emergency-department, general medical-ward, long-term-care and community management is outside this summary and must follow a setting-specific protocol.
The Bottom Line
- In older perioperative patients, establish an acute change from a reliable baseline and use a validated assessment; hypoactive withdrawal, reduced movement or quiet inattention can be missed or mistaken for dementia or fatigue.
- Within the postoperative and ICU populations covered here, investigate medical, medication, substance and environmental contributors rather than treating agitation as the diagnosis.
- AGS recommends multicomponent nonpharmacologic prevention and management for at-risk older surgical patients, including orientation, sensory support, hydration, nutrition, pain management, sleep hygiene and mobility.
- The 2025 SCCM focused update could not recommend for or against antipsychotics over usual care for ICU delirium. AGS allows the lowest effective dose for the shortest duration only for severely agitated or distressed postoperative older adults who threaten substantial harm after behavioral measures fail.
- AGS advises against benzodiazepines as first-line postoperative delirium treatment except when specifically indicated, such as withdrawal; the SCCM focused update separately found insufficient evidence to recommend benzodiazepines for anxiety in adult ICU patients.
Practical clinical workflow
1
For a postoperative older adult or ICU patient, ask family or caregivers about cognition, function and exact onset; review fluctuation and use the validated delirium tool adopted by that service.
2
Stabilize immediate physiology, perform a focused neurologic and systemic examination and select tests from the presentation and perioperative or ICU protocol rather than an indiscriminate panel.
3
Reconcile prescribed, nonprescription and substance exposure, emphasizing newly started, increased or stopped sedatives, anticholinergic medicines, opioids and alcohol or benzodiazepines.
4
Create a visible contributor-and-care plan with daily review of hydration, pain, bowel and bladder function, mobility, sleep, sensory support and the ongoing need for devices or restraints.
5
Reassess cognition and function as contributors are treated, document any short-term drug indication and stop plan, and communicate the delirium episode and unresolved impairment at transition.
Safety boundaries and escalation
- Focal neurologic deficit, head injury, meningism, seizure, severe hypoxia, hypoglycemia, sepsis or toxic exposure requires the corresponding emergency pathway while delirium care proceeds.
- Physical restraint, urinary catheterization and sedating medication can worsen delirium and injury; use only when a specific immediate safety need outweighs harm and review continuously.
- Antipsychotics add QT, movement, aspiration, stroke and mortality risks, particularly in dementia; document indication and stop date rather than allowing discharge continuation by default.
- Capacity is decision-specific and can fluctuate; involve the patient whenever possible and use the legally appropriate surrogate without assuming permanent incapacity.
Localization
This US summary intentionally stops at the populations studied by AGS and SCCM. It must not be rendered as a universal community or emergency-department algorithm; local perioperative or ICU tools, medication policy and pharmacy review control implementation.
Source documents
Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.
- American Geriatrics Society Expert Panel on Postoperative Delirium in Older AdultsAmerican Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older AdultsDOI 10.1111/jgs.13281 路 published 2015-01-01 路 accessed 2026-08-20view source
- Society of Critical Care MedicineA Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICUDOI 10.1097/CCM.0000000000006574 路 focused update 路 published 2025-03-01 路 accessed 2026-08-20view source
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