Management

Initial management of the condition should address three simultaneous priorities:

• maintenance of the patient’s safety
  • protect airway and prevent aspiration
  • maintenance of hydration and nutrition
  • prevention of skin breakdown
  • provision of safe mobility while preventing falls
  • restraints and bed alarms should be avoided since they increase the risk and persistence of the condition
• identification of the cause or causes
  • in people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes
• non pharmacological prevention and treatment
  • once the causative factors are addressed, focus should shift to nonpharmacologic measures providing supportive care, and preventing complications
  • a tailored multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention
    • address cognitive impairment and/or disorientation by:
      • providing appropriate lighting and clear signage; a clock (consider providing a 24-hour clock in critical care) and a calendar should also be easily visible to the person at risk
      • talking to the person to reorientate them by explaining where they are, who they are, and what your role is
      • introducing cognitively stimulating activities (for example, reminiscence)
      • facilitating regular visits from family and friends
    • address dehydration and/or constipation by:
      • ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink - consider offering subcutaneous or intravenous fluids if necessary
      • taking advice if necessary when managing fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease)
    • assess for hypoxia and optimise oxygen saturation if necessary, as clinically appropriate
    • address infection by:
      • looking for and treating infection
      • avoiding unnecessary catheterisation
      • implementing infection control procedures
    • address immobility or limited mobility through the following actions:
      • encourage people to: mobilise soon after surgery walk (provide appropriate walking aids if needed - these should be accessible at all times)
      • encourage all people, including those unable to walk, to carry out active range-of-motion exercises
    • address pain by:
      • assessing for pain
      • looking for non-verbal signs of pain, particularly in those with communication difficulties (for example, people with learning difficulties or dementia, or people on a ventilator or who have a tracheostomy)
      • starting and reviewing appropriate pain management in any person in whom pain is identified or suspected
    • carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications
    • address poor nutrition
    • address sensory impairment by:
      • resolving any reversible cause of the impairment, such as impacted ear wax
      • ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order
    • promote good sleep patterns and sleep hygiene by:
      • avoiding nursing or medical procedures during sleeping hours, if possible
      • scheduling medication rounds to avoid disturbing sleep
      • reducing noise to a minimum during sleep periods (1,2)

Pharmacological treatment

• if a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.
• use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies (3)

Reference:

• (1) Kalish VB, Gillham JE, Unwin BK. Delirium in older persons: evaluation and management. Am Fam Physician. 2014;90(3):150-8.
• (2) Inouye SK, Westendorp RG, Saczynski JS. Delirium in  elderly people. Lancet. 2014;383(9920):911-22.
• (3) NICE (March 2019).Delirium: diagnosis, prevention and management