Mental health problems are common features of older adults in hospital. Acute behavioural disturbance may be a presentation of delirium but it might also be misunderstood by clinical staff, and individuals with specific problems, such as dysphasia or agnosis, could be mislabelled as confused. Dr John Naylor, Mrs Samantha Boothroyd and Professor John Wattis outline a management approach and present the role of the liaison nurse to the psychogeriatric team.