Hrev_master Dear Editor, We feel it is appropriate to highlight the need for accurate diag- nosis and sustained monitoring of delirium in the Emergency Department (ED) context. Despite the high-risk setting, there is a notable lack of research quantifying the incidence of delirium specifically within the ED, which remains a significant gap in the current literature. Over the past four decades, the published preva- lence and incidence of delirium in adult acute medical inpatients has remained broadly stable at 23%1 (approximately one in four older hospitalized adults). A recent limited data collection in two emergency departments in northern Italy showed that the percent- age of patients aged >65 years with delirium was 16.1% and 34.6%, respectively.2 Still now it remains poorly detected, being missed in up to 76% of cases attending the ED.3 There are several reasons to look for delirium: it can be a symptom of life-threatening conditions such as infection, metabol- ic disorders or drug intoxication. Early recognition allows for time- ly intervention. Identifying delirium leads to a structured search for underlying causes, improving diagnosis and treatment. A formal diagnosis of delirium helps patients and families understand the condition, reducing anxiety and improving support. Undiagnosed delirium has profound clinical and economic consequences. Research shows a 39% increased risk of death and a threefold increase in the likelihood of developing dementia in affected patients.4 Delayed or missed diagnoses of delirium con- tribute to longer hospital stays, increased institutionalization rates and poor cognitive outcomes. In addition, mismanagement - including inappropriate pharmacological interventions - can exac- erbate patient morbidity, highlighting the need for timely and accu- rate recognition. The 4AT is an accurate method of screening for delirium in ED. Its brevity and simplicity make it easy to use in routine clinical practice.5 The high prevalence and serious consequences of unde- tected delirium require the implementation of standardized diag- nostic protocols, routine staff training and comprehensive care models. By promoting early detection and intervention, healthcare providers can reduce mortality, minimize cognitive decline and improve quality of care for this vulnerable population. Because of its ubiquity and heterogeneous clinical presenta- tion, the responsibility for the diagnosis and management of delir- ium extends to all clinicians. The prevalence of delirium is not lim- ited to a single specialty, but spans both hospital and community settings. Emergency physicians are the first point of contact, mak- ing their vigilance and expertise essential in managing this critical condition. References 1. Gibb K, Seeley A, Quinn T, et al. The consistent burden in pub- lished estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Age Ageing 2020;49:352-60. 2. Zucchelli A, Apuzzo R, Paolillo C. et al. Development and val- idation of a delirium risk assessment tool in older patients admitted to the Emergency Department Observation Unit. Aging Clin Exp Res 2021;33:2753-8. 3. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009;16:193-200. 4. Gordon EH, Ward DD, Xiong H. Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study. BMJ 2024;384:e077634. 5. Bellelli G, Morandi A, Davis DHJ. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalized older people. Age and Ageing 201443: 496–502. Emergency Care Journal 2025; volume 21:13861 [Emergency Care Journal 2025; 21:13861] [page 23] Why it is important to recognize delirium in our emergency department Ciro Paolillo,1 Ivo Casagranda2 1Emergency Department, University Hospital of Verona, Verona; 2Academy of Emergency Medicine and Care, Pavia, Italy Correspondence: Ciro Paolillo, Emergency Department, University Hospital of Verona, Verona, Italy. E-mail: ciropaolillo@gmail.com Key words: delirium, emergency medicine education, older adults. Conflict of interest: the authors declare no potential conflict of inter- est, and all authors confirm accuracy. Received: 1 April 2025 Accepted: 28 April 2025 Early view: 13 June 2025 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13861 doi:10.4081/ecj.2025.13861 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.