Section Three
Management of Delirium
Approx Time To Complete: 20 Mins
Identifying and Addressing Underlying Causes
Managing delirium involves a multi-faceted and multidisciplinary approach, addressing underlying causes, providing supportive care, utilising medications judiciously, and incorporating non-pharmacological treatments.
Identification of Underlying Causes
Delirium often results from a combination of factors, making it imperative to identify and manage the root causes. The initial step in the management of delirium is a thorough assessment to pinpoint potential triggers such as infections, medication side effects, or metabolic imbalances.
Effective Communication and Reorientation
Communication plays a pivotal role in managing delirium. Ensuring effective communication and reorientation is crucial in providing reassurance to individuals diagnosed with delirium. Involving family, friends, and carers can enhance the effectiveness of this process. Additionally, creating a suitable care environment contributes to the overall well-being of the individual.
Environment
The management of the environment holds paramount importance in delirium care, profoundly influencing the well-being and recovery of individuals experiencing this acute cognitive disturbance. Various environmental factors can significantly contribute to the disorientation and distress of patients with delirium. The range of sounds in a healthcare setting, emanating from patient call systems, intravenous monitors, or even the subtle noise of bed pan washers, can be disorientating and exacerbate the confusion already present.
Additionally, the impact of inappropriate lighting, whether it be the lack of a visible TV or disruptions to natural day-night cycles, can disrupt sleep-wake patterns, further complicating the recovery process. The unfamiliar view of clinical objects or other people, unintentional restraints like intravenous therapy or cardiac monitors, and the presence of unfamiliar staff, routines, uniforms, and signage can all contribute to heightened distress.
Even seemingly small details, such as the different positioning of a bed in relation to the bathroom, can disrupt the patient’s sense of familiarity and exacerbate their disorientation. Thus, a thoughtful and tailored approach to managing the environment becomes a crucial aspect of holistic delirium care, aiming to create a setting that promotes calmness, minimises stressors, and enhances the overall recovery experience for individuals facing this challenging condition.
Dr Pauline Boland Discusses Occupational Therapy
Watch Dr Pauline Boland talk a little about occupational therapy in relation to delirium.
Addressing Distress and Risk
Verbal and Non-Verbal De-escalation Techniques
When a person with delirium is distressed or poses a risk to themselves or others, employing verbal and non-verbal de-escalation techniques is the primary approach. This involves using communication strategies to calm the individual, considering that distress might not be immediately evident, especially in hypoactive delirium.
Pharmacological Intervention with Haloperidol
In cases where de-escalation techniques prove ineffective or inappropriate, short-term use of haloperidol is considered. Starting at the lowest clinically appropriate dose and titrating cautiously based on symptoms is recommended. However, caution should be exercised, particularly in older individuals with Parkinson's disease or dementia with Lewy bodies, considering the associated risks. These risks primarily revolve around potential side effects that may affect the heart and nervous system. People with Parkinson’s Disease or Lewy body dementia are particularly sensitive to these side effects, which can include problems with movement and cognition. Therefore, when considering haloperidol for someone with delirium and PD or Lewy bodies, healthcare providers need to be cautious and carefully assess the potential benefits against the risks. It's crucial for the medical team to monitor the individual closely for any adverse reactions and, if necessary, explore alternative approaches to manage delirium that may be better suited for individuals with these conditions.
Persistent Delirium
Re-evaluating for Underlying Causes
Persistent delirium refers to a prolonged state of cognitive disturbance characterised by confusion, altered awareness, and changes in attention that extend beyond the expected duration. In cases where delirium does not resolve within the anticipated timeframe, typically after the underlying causes have been addressed and treated, it is considered persistent. This extended duration of delirium poses challenges in patient management, as it may indicate ongoing underlying issues or complications. Persistent delirium requires a comprehensive re-evaluation to identify any new or lingering factors contributing to the prolonged cognitive impairment. Healthcare professionals may need to reassess the initial diagnosis, explore additional potential causes, and consider a more extended follow-up plan. Evaluating the persistence of delirium is essential not only for addressing the immediate symptoms but also for preventing potential long-term cognitive consequences and ensuring the overall well-being of the affected individual. When delirium persists, a systematic re-evaluation for underlying causes is essential. This involves revisiting the initial assessment and considering additional factors that may contribute to the prolonged delirium.
Assessing for Possible Dementia
For individuals in whom delirium does not resolve, assessing for possible dementia becomes crucial. This aligns with the broader perspective of cognitive health, necessitating a comprehensive evaluation following the guidelines provided in the NICE guideline on dementia.
Information and Support for Individuals and Their Caregivers
Providing information is a key aspect of delirium management. Individuals at risk or those diagnosed with delirium, along with their family and/or carers, should receive information that educates them about the common and usually temporary nature of delirium. Encouraging communication with the healthcare team and sharing experiences can facilitate better understanding and support.
- Please click here for a patient/family information leaflet from the Health Service Executive (HSE) in Republic of Ireland
- Please click here for a patient/family information leaflet from the Public Health Agency (PHA) in Northern Ireland
Recognising the diversity of individuals, it is imperative to ensure that the information provided meets cultural, cognitive, and language needs. Tailoring information enhances its accessibility and effectiveness in supporting both the affected individual and their caregivers.
Pharmacological Management of Delirium
Dr Heather Barry Discusses Medications and Delirium
The initial goal of delirium treatment revolves around a holistic approach aimed at identifying and addressing the underlying causes or triggers of the cognitive disturbance. One critical aspect in this comprehensive strategy is the careful examination of the individual’s medication regimen, often considering polypharmacy.
Polypharmacy, the concurrent use of multiple medications, can contribute to delirium, particularly in older adults. In addressing delirium, healthcare providers should assess the necessity of each prescribed medication, weighing potential benefits against risks, and making informed decisions regarding discontinuation or dosage adjustments.
Polypharmacy
Polypharmacy, or the use of multiple medications by an individual, can contribute to the development of delirium due to several interconnected factors. The complex nature of polypharmacy and its potential impact on cognitive function often manifests in older adults, who may be more vulnerable to medication-related side effects. Here are some key reasons why polypharmacy can cause delirium:
When multiple medications are prescribed concurrently, there is an increased risk of drug interactions. Some medications may enhance or inhibit the effects of others, leading to unpredictable outcomes.
These interactions can affect neurotransmitter levels in the brain, potentially contributing to cognitive impairment and delirium.
Many medications have anticholinergic properties, meaning they block the action of acetylcholine, a neurotransmitter involved in various cognitive functions. Accumulation of medications with anticholinergic effects, which is common in polypharmacy, can lead to cognitive deficits and increase the risk of delirium.
Medications with sedative or central nervous system depressant properties can accumulate in the system with polypharmacy. This can result in increased drowsiness, confusion, and impaired cognitive function, all of which are characteristic features of delirium.
Older adults may be more sensitive to the effects of medications due to age-related changes in metabolism and organ function. What might be a standard dose for a younger individual could be excessive for an older person, leading to an increased risk of adverse effects, including delirium.
Managing multiple medications can be challenging, especially for individuals with cognitive impairment or those who may have difficulty adhering to a complex medication schedule. Missed doses, incorrect timing, or unintentional medication duplications can occur, further increasing the risk of adverse effects.
Individuals prescribed multiple medications often have multiple health conditions. These underlying conditions, coupled with the medications used to manage them, can collectively contribute to a higher risk of delirium. Chronic diseases, such as diabetes, cardiovascular issues, or respiratory conditions, may necessitate several medications, compounding the risk.
Some medications have a significant impact on the central nervous system (CNS) and may penetrate the blood-brain barrier. When multiple medications with CNS effects are used together, the cumulative impact on brain function can increase the likelihood of delirium.
To mitigate the risk of polypharmacy-induced delirium, healthcare providers should conduct regular medication reviews, consider non-pharmacological alternatives when possible, and prioritise medication simplification. Close monitoring of older adults, particularly those with cognitive vulnerabilities, is crucial to identifying and addressing potential medication-related issues before they escalate into delirium.
Another crucial facet of delirium management is the consideration of analgesia, or pain management. Undiagnosed or undertreated pain can exacerbate delirium or contribute to its persistence. Therefore, healthcare professionals pay close attention to pain assessment and management, ensuring that individuals with delirium receive appropriate analgesic interventions to alleviate discomfort, which can, in turn, positively impact their cognitive state.
Pharmacy input plays a pivotal role in the overall management of delirium. Pharmacists collaborate with the healthcare team to review the individual’s medication history, provide expertise on potential drug interactions or side effects, and offer recommendations for optimising medication regimens. In the context of delirium, pharmacy input becomes especially valuable during the process of discontinuing certain medications that may be contributing to cognitive impairment. Pharmacists work alongside other healthcare professionals to ensure a smooth and safe transition, minimising the risk of withdrawal effects or complications related to medication adjustments.
Moreover, the holistic approach extends to treating infections, a common trigger for delirium. Infections, whether systemic or localised, can significantly impact cognitive function. Healthcare providers diligently identify and address infections promptly, employing appropriate antimicrobial therapies as needed. This infection management not only aids in resolving delirium but also prevents potential complications associated with untreated infections.
Non-Pharmacological Management of Delirium
Non-pharmacological interventions, focusing on holistic approaches that do not involve medications, are central to alleviating symptoms and enhancing the overall well-being of individuals experiencing delirium.
Dr Dympna Tuohy Discusses Non-Pharmacological Interventions
Watch a video on non-pharmacological interventions by Dr Dympna Tuohy.
Test Your Knowledge
You have completed this section
If you feel you have completed all of the learning from this section then you should progress on to the Prevention of Delirium.