management
Last edited 07/2023 and last reviewed 07/2023
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:
management of disturbed behaviour in primary care
difficult and dangerous situations
delirium in patients with Parkinson's disease
agitation , terminal restlessness and confusion in palliative care