Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.
The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.
A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.
No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.
The recommendations include:
- Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.
"Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.
"Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).
- Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
- Reorient patients by explaining where they are and what your role is.
- Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
- Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
- Assess for hypoxia and optimize oxygen saturation.
- Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.
The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.
- Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
- Assess for pain, attending to nonverbal signs of pain, and manage it.
Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.
- Review both the type and the number of medications.
- Address poor nutrition, and make sure that dentures fit properly in patients who have them.
- Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
- Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.
"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.
"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.
"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.
The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.
The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.