Delirium Treatment and Prevention Guidelines: Discussion With Mark Oldham, MD, and John J Miller, MD

In this discussion, John J. Miller, MD, talks with Mark Oldham, MD, on the newly updated APA Practice Guideline for the Prevention and Treatment of Delirium—the first revision in 26 years—and about Oldham’s recent paper discussing a structured framework for understanding the neuropsychiatric disturbances of delirium.^1,2 Oldham emphasized that psychiatry’s role in delirium has long been complicated by historical shifts between psychiatric and medical ownership.³ Clinically, consultants are asked not to “treat delirium,” but to manage agitation and related behavioral phenomena, which Oldham suggested should be conceptualized as distinct neuropsychiatric disturbances rather than as delirium itself.

Oldham outlined proposed subtypes, including excessive psychomotor activity, akathisia, inadequate psychomotor activity (from reduced arousal or avolition), psychotic symptoms, emotional disturbances, catatonia, and sleep–wake/circadian disruption. Oldham noted that these categories are provisional and intended to spur research and clinical dialogue. He highlighted the importance of avoiding reflexive antipsychotic use; the evidence for dopamine-driven psychosis in delirium is limited, and alternative mechanisms (eg, serotonergic or sleep-wake dysregulation) may predominate. Stimulants such as low-dose methylphenidate or modafinil may benefit hypoactive or avolitional states, while emotional symptoms and catatonia require tailored evaluation and treatment. He also underscored the growing role of dexmedetomidine and related α2-agonists (eg, clonidine, guanfacine) for hyperactive presentations and sleep promotion without disrupting sleep architecture.

Oldham concluded by urging the field to distinguish core delirium features from its associated disturbances, validate proposed subtypes, test targeted interventions, and ultimately improve patient outcomes through a more nuanced, mechanism-informed approach.

Dr Oldham is a practicing psychiatrist based in Rochester, New York, and an associate professor of psychiatry at the University of Rochester Medical Center.

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Volunteer Consulting Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

References

1. American Psychiatric Association publishes updated comprehensive guideline for the prevention and treatment of delirium. Press release. September 2, 2025. Accessed December 9, 2025. https://www.psychiatry.org/news-room/news-releases/apa-published-updated-guideline-for-delirium

2. Crone C, Fochtmann LJ, Ahmed I, et al. The American Psychiatric Association practice guideline for the prevention and treatment of delirium. Am J Psychiatry. 2025;182(9):880-884.

3. Oldham MA, Slooter AJC, Ely EW, et al. An interdisciplinary reappraisal of delirium and proposed subtypes. J Acad Consult Liaison Psychiatry. 2023;64(3):248-261.