Chapter 026. Confusion and Delirium (Part 7)

Delirium: TreatmentManagement 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) Chapter 026. Confusion and Delirium (Part 7) Delirium: Treatment Management of delirium begins with treatment of the underlying incitingfactor (e.g., patients with systemic infections should be given appropriateantibiotics and underlying electrolyte disturbances judiciously corrected). Thesetreatments often lead to prompt resolution of delirium. Blindly targeting thesymptoms of delirium pharmacologically only serves to prolong the time patientsremain in the confused state and may mask important diagnostic information. Relatively simple methods of supportive care can be highly effective intreating patients with delirium. Reorientation by the nursing staff and familycombined with visible clocks, calendars, and outside-facing windows can reduceconfusion. Sensory isolation should be prevented by providing glasses and hearingaids to those patients who need them. Sundowning can be addressed to a largeextent through vigilance to appropriate sleep-wake cycles. During the day, a well-lit room should be accompanied by activities or exercises to prevent napping. Atnight, a quiet, dark environment with limited interruptions by staff can assureproper rest. These sleep-wake cycle interventions are especially important in theICU setting as the usual constant 24-h activity commonly provokes delirium.Attempting to mimic the home environment as much as possible has also beenshown to help treat and even prevent delirium. Visits from friends and familythroughout the day minimize the anxiety associated with the constant flow of newfaces of staff and physicians. Allowing hospitalized patients to have access tohome bedding, clothing, and nightstand objects makes the hospital environmentless foreign and therefore less confusing. Simple standard nursing practices suchas maintaining proper nutrition and volume status as well as managingincontinence and skin breakdown also help to alleviate discomfort and resultingconfusion. In some instances, patients pose a threat to their own safety or to the safetyof staff members, and acute management is required. Bed alarms and personalsitters are more effective and much less disorienting than physical restraints.Chemical restraints should be avoided, but, when necessary, very-low-dose typicalor atypical antipsychotic medications administered on an as-needed basis areeffective. The recent association of atypical antipsychotic use in the elderly withincreased mortality underscores the importance of using these medicationsjudiciously and only as a last resort. Benzodiazepines are not as effective asantipsychotics and often worsen confusion via their sedative properties. Althoughmany clinicians still use benzodiazepines to treat acute confusion, their use shouldbe limited only to cases in which delirium is caused by alcohol or benzodiazepinewithdrawal. Prevention Given the high morbidity associated with delirium and the tremendouslyincreased health care costs that accompany it, development of an effective strategyto prevent delirium in hospitalized patients is extremely important. Successfulidentification of high-risk patients is the first step, followed by initiation ofappropriate interventions. One trial randomized more than 850 elderly inpatientsto simple standardized protocols used to manage risk factors for delirium,including cognitive impairment, immobility, visual impairment, hearingimpairment, sleep deprivation, and dehydration. Significant reductions in thenumber and duration of episodes of delirium were observed in the treatmentgroup, but unfortunately delirium recurrence rates were unchanged. All hospitalsand health care systems should work toward developing standardized protocols toaddress 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 acuteconfusional states that was incorporated into this current chapter. Further Readings Ely EW et al: Delirium as a predictor of mortality in mechanicallyventilated 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 inhospitalized older patients. N Engl J Med 340:669, 1999 Kalisvaart KJ et al: Risk factors and prediction of postoperative delirium inelderly hip-surgery patients: Implementation and validation of a medical riskfactor model. J Am Geriatr Soc 54:817, 2006 [PMID: 16696749] Young J, Inouye SK: Delirium in older people. BMJ 334:842, 2007 [PMID:17446616]