New Delirium Guidelines Discussed at APA Annual Meeting

CONFERENCE REPORTER

“About 40% of delirium cases are preventable,” Mark A Oldham, MD, told John J. Miller, MD, at the 2025 American Psychiatric Association Annual Meeting in Los Angeles, California. Oldham joined a panel at the conference discussing the recently updated APA Clinical Practice Guidelines for Delirium.^1,2

Prevention is a key differentiator from the last guidelines, which were published in 1999, Oldham said in the interview discussion. Most guidelines are considered out of date after 5 years, he said. The lack of newer treatments may have delayed the revisions, Oldham added.

Miller and Oldham discussed a few issues regarding the treatment of delirium. Miller, editor in chief of Psychiatric Times, asked about the practice of prescribing haloperidol and antipsychotics for delirium, something he hoped was no longer advocated. “The short answer is haloperidol is not first line or second line or third line for managing delirium itself,” said Oldham, associate professor of psychiatry at the University of Rochester Medical Center (URMC) and member of the workgroup that developed the updated guidelines. “We have a statement where we say haloperidol, and I should say antipsychotics in general, are not recommended for the treatment or prevention of delirium.

The use of benzodiazepines is another contested area that Miller inquired about, and Oldham shared clarifications and cautions regarding its use.

“Benzodiazepines: There's an interesting conversation: We say we never use benzos in delirium… But unfortunately, I don't think that's quite right,” Oldham told Miller. “If you're withdrawing from benzodiazepines, if you're withdrawing from alcohol and you have delirium tremens or something of that nature, benzodiazepines are entirely appropriate as first-line management to kind of reinstate the kind of the inhibitory tone that's been lost in the delirium tremens condition.”

“There might be other conditions where benzodiazepines might be, let's say an indication, even in the context of delirium,” Oldham explained. “There's a growing body of literature looking at delirium with catatonic features or delirium with catatonia, so a low dose lorazepam challenge in that context might be appropriate, might prove liberating for the catatonic symptoms that are superimposed on or kind of co-occurring with delirium.”

There are times when removing a benzodiazepine could cause more harm than good, Oldham added. Doing so for individuals with panic disorders is a good example of such, he said.

“We actually do in the guidelines have a table that identifies a variety of different clinical opportunities where benzos might be considered,” Oldham told Miller, adding that it is important to be mindful of the dose.

References

1. Oldham MA, Crone C, Fochtmann L. Applying recommendations to the real world: A clinically focused review of the updated APA clinical practice guidelines for delirium. Presented at the 2025 American Psychiatric Association Annual Meeting; May 17-21, 2025; Los Angeles, California.

2. New 2025 APA Guidelines for Prevention and Treatment of Delirium Now Available. February 28, 2025. Accessed May 19, 2025. https://www.guidelinecentral.com/insights/draft-apa-delirium-cpg/