Delirium, or acute confusional state, which often results from hospital-related complications or inadequate hospital care for older patients, can serve as a marker of the quality of hospital care. By reviewing five pathways that can lead to a greater incidence of delirium--iatrogenesis, failure to recognize delirium in its early stages, attitudes toward the care of the elderly, the rapid pace and technological focus of health care, and the reduction in skilled nursing staff--we identify how future trends and cost-containment practices may exacerbate the problem. Examining delirium also provides an opportunity to improve the quality of hospital care for older persons. Interventions to reduce delirium would need to occur at the local and national levels. Local strategies would include routine cognitive assessment and the creation of systems to enhance geriatric care, such as incentives to change practice patterns, geriatric expertise, case management, and clinical pathways. National strategies might include providing education for physicians and nurses to improve the recognition of delirium and the awareness of its clinical implications, improving quality monitoring systems for delirium, and creating environments to facilitate the provision of high-quality geriatric care.