Chapter 026. Confusion and Delirium (Part 7)

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Delirium: Treatment Management of delirium begins with treatment of the underlying inciting factor (e.g., patients with systemic infections should be given appropriate antibiotics and underlying electrolyte disturbances judiciously corrected). These treatments often lead to prompt resolution of delirium. Blindly targeting the symptoms of delirium pharmacologically only serves to prolong the time patients remain in the confused state and may mask important diagnostic information. Relatively simple methods of supportive care can be highly effective in treating patients with delirium. Reorientation by the nursing staff and family combined with visible clocks, calendars, and outside-facing windows can reduce confusion. Sensory isolation should be prevented...

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Chapter 026. Confusion and Delirium (Part 7) Delirium: Treatment Management of delirium begins with treatment of the underlying inciting factor (e.g., patients with systemic infections should be given appropriate antibiotics and underlying electrolyte disturbances judiciously corrected). These treatments often lead to prompt resolution of delirium. Blindly targeting the symptoms of delirium pharmacologically only serves to prolong the time patients remain in the confused state and may mask important diagnostic information. Relatively simple methods of supportive care can be highly effective in treating patients with delirium. Reorientation by the nursing staff and family combined with visible clocks, calendars, and outside-facing windows can reduce confusion. Sensory isolation should be prevented by providing glasses and hearing aids to those patients who need them. Sundowning can be addressed to a large extent through vigilance to appropriate sleep-wake cycles. During the day, a well-
lit room should be accompanied by activities or exercises to prevent napping. At night, a quiet, dark environment with limited interruptions by staff can assure proper rest. These sleep-wake cycle interventions are especially important in the ICU setting as the usual constant 24-h activity commonly provokes delirium. Attempting to mimic the home environment as much as possible has also been shown to help treat and even prevent delirium. Visits from friends and family throughout the day minimize the anxiety associated with the constant flow of new faces of staff and physicians. Allowing hospitalized patients to have access to home bedding, clothing, and nightstand objects makes the hospital environment less foreign and therefore less confusing. Simple standard nursing practices such as maintaining proper nutrition and volume status as well as managing incontinence and skin breakdown also help to alleviate discomfort and resulting confusion. In some instances, patients pose a threat to their own safety or to the safety of staff members, and acute management is required. Bed alarms and personal sitters are more effective and much less disorienting than physical restraints. Chemical restraints should be avoided, but, when necessary, very-low-dose typical or atypical antipsychotic medications administered on an as-needed basis are effective. The recent association of atypical antipsychotic use in the elderly with increased mortality underscores the importance of using these medications judiciously and only as a last resort. Benzodiazepines are not as effective as
antipsychotics and often worsen confusion via their sedative properties. Although many clinicians still use benzodiazepines to treat acute confusion, their use should be limited only to cases in which delirium is caused by alcohol or benzodiazepine withdrawal. Prevention Given the high morbidity associated with delirium and the tremendously increased health care costs that accompany it, development of an effective strategy to prevent delirium in hospitalized patients is extremely important. Successful identification of high-risk patients is the first step, followed by initiation of appropriate interventions. One trial randomized more than 850 elderly inpatients to simple standardized protocols used to manage risk factors for delirium, including cognitive impairment, immobility, visual impairment, hearing impairment, sleep deprivation, and dehydration. Significant reductions in the number and duration of episodes of delirium were observed in the treatment group, but unfortunately delirium recurrence rates were unchanged. All hospitals and health care systems should work toward developing standardized protocols to address common risk factors with the goal of decreasing the incidence of delirium. Acknowledgment In the previous edition, Allan H. Ropper contributed to a section on acute confusional states that was incorporated into this current chapter.
Further Readings Ely EW et al: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753, 2004 [PMID: 15082703] Inouye SK: Delirium in older persons. N Engl J Med 354:1157, 2006 [PMID: 16540616] ——— et al: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669, 1999 Kalisvaart KJ et al: Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: Implementation and validation of a medical risk factor model. J Am Geriatr Soc 54:817, 2006 [PMID: 16696749] Young J, Inouye SK: Delirium in older people. BMJ 334:842, 2007 [PMID: 17446616]