Detecting and treating delirium—key interventions you may be missing

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Applied Evidence

Detecting and treating delirium—key interventions you may be missing

J Fam Pract. 2011 December;60(12):726-734

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References

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FAST TRACK

One study revealed that hospitalization on a geriatric unit was associated with a lower incidence of delirium compared with being on a general medical unit.

Several studies have evaluated the effectiveness of nonpharmacologic interventions in preventing or lowering the incidence of delirium. A large multicomponent delirium prevention study of patients >70 years on general medical units focused on managing risk factors. The interventions studied included (1) avoidance of sensory deprivation, (2) early mobilization, (3) treating dehydration, (4) implementing noise reduction strategies and sleep enhancement programs, and (5) avoiding the use of sleep medications. These interventions proved to be effective not only in lowering the incidence of delirium, but in shortening the duration of delirium in affected patients (NNT=20).²⁷

One study found that proactively using a geriatric consultation model (ie, implementing standardized protocols for the management of 6 risk factors) for elderly hospitalized patients led to a reduction in the incidence of delirium by more than a third.²⁶ Admission to a specialized geriatric unit is associated with a lower incidence of delirium compared with being hospitalized on a general medical unit.²⁹

Reducing the incidence of postoperative delirium. Bright light therapy (a light intensity of 5000 lux with a distance from the light source of 100 cm), implemented postoperatively, may play a role in reducing the incidence of delirium, research suggests.³⁰ Music may be helpful, as well. An RCT involving patients (>65 years) undergoing elective knee or hip surgery found that those who listened to classical music postoperatively had a lower incidence of delirium.³¹ Similarly, playing music in nursing homes has been shown to decrease aggressive behavior and agitation.³²

TABLE 4
Helpful interventions in the hospital or at home^26-28

Avoid sensory deprivation (provide hearing aids, eyeglasses, clock, calendar, adequate light)
Avoid patient transfers; consider using private rooms
Be especially vigilant in monitoring for postoperative complications/infection
Eliminate nonessential medications
Get patients out of bed as soon as possible
Ensure that nurses identify patients at risk and use delirium screening tools
Institute measures, as needed, to prevent fecal impaction and urinary retention
Institute more frequent checks to ensure adequate oxygen delivery
Involve family and caregivers in patient care
Prevent or provide early treatment of dehydration
Provide adequate nutrition
Provide adequate pain management (with scheduled pain management protocol)
Reduce noise
Seek early geriatric or geropsychiatric consult
Take steps to restore normal sleep/wake cycle (eg, avoid nighttime disturbances for medications or vital signs, whenever possible)

When medication is needed, proceed with caution

None of the medications currently used to treat delirium are approved by the US Food and Drug Administration for this indication, and many of them have substantial side effects. Nonetheless, palliative or symptomatic treatment requires some form of sedation for agitated patients with delirium. Thus, it is necessary to strike a balance in order to manage the symptoms of delirium and avoid potential side effects (primarily, sedation). Overly sedating patients can confuse the clinical picture of delirium and make it difficult to differentiate between ongoing delirium and medication side effects. Medication should be started at a low, but frequent, dose to achieve an effective therapeutic level, after which a lower maintenance dose can be used until the cause of delirium is resolved.

Antipsychotics are the cornerstone of drug treatment
Haloperidol has traditionally been used to treat delirium³³ and has proven effectiveness. However, it is associated with increased risk of extrapyramidal manifestations compared with atypical antipsychotics.

Atypical antipsychotics (olanzapine, risperidone, quetiapine) are increasingly being used to treat delirium because they have fewer extrapyramidal side effects.³⁴ With the exception of olanzapine (available in intramuscular and oral disintegrating form), atypical antipsychotics are available only in oral form, which may limit their usefulness as a treatment for agitated, delirious patients.

Risperidone (at a dose ranging from 0.25 to 1 mg/d) and olanzapine (1.25 to 2.5 mg/d) have shown similar efficacy to haloperidol (0.75 to 1.5 mg/d) in both the prevention and treatment of delirium, but with fewer extrapyramidal side effects.^35-39 Quetiapine, a second-generation antipsychotic, is widely used to treat inpatient delirium, although there are no large RCTs comparing it with placebo. One pilot study and another open-label trial found the drug to be beneficial for patients with delirium, with fewer extrapyramidal side effects than haloperidol.^40,41

Do a risk-benefit analysis. The use of antipsychotics in elderly patients with delirium has been associated with increased morbidity and mortality. The incidence of stroke and death were higher for community-dwelling patients (NNH=100) and patients in long-term care (N=67) who received typical or atypical antipsychotics for 6 months compared with that of patients who did not receive any antipsychotics.^42,43 Thus, a risk-benefit analysis should be done before prescribing antipsychotics for elderly patients. Both typical and atypical antipsychotics carry black box warnings of increased mortality rates in the elderly.