In a recent systematic review, Strömmer, et al.²² systematically identified arguably all 168 cases of either excited delirium or agitated delirium described in the literature. Sixty-two percent of these were fatal, and the authors found that a diagnosis of excited delirium was nearly 10 times as likely to be applied in cases that were fatalities and nearly five times as likely in those that involved aggressive restraint such as hobbling and physical force. Aggressive restraint was itself also strongly associated with fatality (OR 7.4). Given that this review included most, if not all, of the evidence used previously to justify excited delirium as a fatal clinical entity, the authors conclude that “there is no evidence to support [excited delirium] as a cause of death in the absence of restraint.” With restraints employed in 90 percent of deaths where these diagnoses were applied,”when death has occurred in an aggressively restrained individual who fits the profile … restraint-related asphyxia must be considered as a cause of the death.”

The 2023 ACEP statement reiterates that there are valid concerns related to hyperactivity and delirium in the setting of emergency assessment and treatment. It also recognizes that these concerns affect not just emergency physicians but many important partners in these settings, including first responders and law enforcement. The complex history of the terminology used to identify and respond to these agitated patients illustrates the power of ACEP to shape national dialogue. This organizational shift represents an opportunity to reflect on the real-world consequences of that influence, and on the responsibility that comes with it.

Dr. Lee is a second-year resident in emergency medicine at Highland Hospital in her hometown of Oakland, California. Her primary interests are in ultrasound, machine learning, and health justice.

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