Evidence-Based Reviews

Delirium: Apply the ‘4 Ps’ for comprehensive treatment

Current Psychiatry. 2005 January;4(1):53-70

References

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Delirium occurred in 10% of the intervention group and in 15% of the usual-care group (matched odds ratio 0.6). Total days with delirium (105 vs. 161; P = 0.02) and total episodes (62 vs. 90; P = 0.03) were significantly lower in the intervention group. A potential source of bias in this study was a lack of randomization in assigning patients to intervention or usual care. Follow-up studies found that:

The intervention increased health care costs for patients at high risk for delirium but had no significant effect on overall costs for patients at intermediate risk.²⁷
Delirium risk decreased the most (89%) in older patients who were most adherent to the intervention protocols during hospitalization.²⁸
Among the 705 patients who survived at least 6 months after discharge, those who had been in the intervention and usual-care groups showed similar functional and cognitive status and rates of depression, delirium, nursing home placement, and rehospitalization.²⁹

CASE REPORT: A SUCCESSFUL INTERVENTION

Mr. A, age 66, who has moderate-to-severe chronic obstructive pulmonary disease, is hospitalized for surgery to remove a suspicious lung nodule. Two years ago, he experienced delirium following a transurethral prostatectomy. His hemoglobin is 9.1 g/dL (normal, 11.5 to 14 g/dL), defined as anemia related to chronic disease.

Because of his history of postoperative delirium, the hospital staff initiates preventive measures. Before surgery, he is given two units of blood for anemia. To assist with orientation, he and his family receive information about delirium, and his hearing aid—which has been malfunctioning—is readjusted to improve his auditory acuity. During surgery, his oxygen saturation and blood pressure are monitored scrupulously.

Afterward, no mental status changes are observed, and Mr. A recovers uneventfully. The surgery revealed a benign granuloma.

Discussion. Surgical patients such as Mr. A—particularly those with hemoglobin <10 g/dL—face a higher risk for delirium than medical patients do. The reason, although undetermined, may be related to unavoidable tissue injury and hemorrhage associated with surgery.³⁰

Nonpharmacologic intervention shows promise in preventing delirium, but more evidence is needed to develop simpler, less-costly strategies for at-risk hospitalized patients and to preserve their functional status after discharge.

Related resources

Cook IA. Guideline Watch. Practice guideline for the treatment of patients with delirium. American Psychiatric Association, August 2004. www.psych.org/psych_pract/treatg/pg/prac_guide.cfm (scroll down to “Delirium” under topic list). Accessed Dec. 14, 2004.

Drug brand names

Aripiprazole • Abilify
Cyclobenzapine • Flexeril
Haloperidol • Haldol
Olanzapine • Zyprexa
Phenylzine • Nardil
Physostigmine • Antilirium
Quetiapine • Seroquel
Risperidone • Risperdal
Warfarin • Coumadin
Ziprasidone • Geodon

Disclosures

Dr. O’Connor reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.