October 12, 2023

ACEP Reaffirms Positions on Hyperactive Delirium

October 2023 Update

Today, the American College of Emergency Physicians (ACEP) reaffirmed several positions regarding the use of the terms “excited delirium" and "hyperactive delirium with severe agitation.”

The current ACEP position, outlined in a 2021 white paper and supported in an April 2023 statement, was further reinforced by an October 8 vote of the ACEP Council, ACEP’s representative policymaking body, and confirmed by its Board of Directors on October 12.

ACEP’s 2009 White Paper Report on Excited Delirium Syndrome is outdated and does not align with the College’s position based on the most recent science and better understanding of the issues surrounding hyperactive delirium. ACEP has withdrawn its approval of this paper. The term excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation. 

April, 2023

ACEP's Position on Hyperactive Delirium

The American College of Emergency Physicians (ACEP) recognizes the existence of hyperactive delirium syndrome with severe agitation, a potentially life threatening clinical condition characterized by a combination of vital sign abnormalities (e.g., elevated temperature and blood pressure), pronounced agitation, altered mental status, and metabolic derangements.1
Emergency physicians and appropriately trained and supervised paramedics most often encounter patients with life-threatening levels of severe agitation and are able to appropriately recognize and treat hyperactive delirium syndrome. These patients are at high risk of direct physical trauma, not only unintentional harm from trauma such as falls, but also the metabolic stress that may result from physical restraint that may be required to facilitate the safety of the patient, bystanders, and responding professionals and ensure appropriate patient evaluation by emergency personnel. ACEP believes there is value in strengthening the training and working relationship between emergency medical services, clinicians, and law enforcement professionals. The goal when treating patients with signs of hyperactive delirium syndrome is to focus on reducing stress, preventing physical harm and transporting them to an emergency department, where they can be treated by an emergency physician.

ACEP does not recognize the use of the term “excited delirium” and its use in clinical settings. In order to develop a more medically accurate understanding and description of this clinical syndrome, a 2021 ACEP task force synthesized the most current information available regarding the recognition, evaluation, and management of patients in the prehospital or emergency department setting presenting with hyperactive delirium accompanied by severe agitation. This report was approved by the ACEP Board of Directors and is available for download here

ACEP supports continued multi-disciplinary research, dialogue, and consensus to better recognize, manage, and advocate for patients who show signs of hyperactive delirium accompanied by severe agitation using evidence based, safe care. Any such multi-disciplinary work on this topic should include emergency medicine physicians as well as other stakeholders with diverse backgrounds and expertise in EMS, toxicology, neurology, emergency psychiatry, law enforcement and health equity. Improving the recognition and management of patients with hyperactive delirium syndrome with severe agitation can help prevent avoidable tragedies, enhance training, and encourage best practices and evidence-based medical care.


1. American College of Emergency Physicians Hyperactive Delirium Task Force. ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings. Approved by the ACEP Board of Directors, June 23, 2021. The report is available for download here.

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