Delirium, what to do?

DeliriumDelirium is a medical emergency. Thus, the management must focus initially on the identification and treatment of the causes. This could seem obvious but the diagnosis of delirium could be difficult initially and probably the majority of patients admitted to the hospital do not go through important diagnostic procedures. On the other side patients with dementia are often falsely diagnosed with delirium. However patients with dementia are at greater risk of delirium because of their neurological frailty.
Non-pharmacological interventions (vital sign monitoring, ensuring nutrition, correction and prevention of dehydration, encouragement of mobility, and ensuring a good sleep pattern) are undoubtedly the most important measures of delirium management. It should not be forgotten that patients with delirium can aspirate food and have pneumonia. Confinement to bed increases infections and physical deconditioning.
The use of physical restraint should be limited to the few cases of patients who could harm themselves or remove medical devices (as iv lines) or falling. In this context, the involvement of the family should be the most helpful intervention. Family members can calm, assist, protect, reassure and provide orientation. It is very important to maintain eye-contact with the patient. Doctors, nurses, family members, caregivers should share every possible information on the patient’s situation. Family members should know the significance of frightening symptoms such as disinhibition, aggressiveness, hallucinations, delusions.  They should know that behavioral fluctuations might intervene from hour to hour or from day to day. The environment should be adapted and nurses should provide a clock, a calendar, give frequent reminders about the time, day and place and scheduled medical examinations or investigations. Sensory deprivation should be avoided just sampling raising up the bed of the patient (which is often forgotten) or moving the patient from the bed to a chair. Windowless and dark rooms should be avoided. The environment should be very calm and soft relaxing music could be helpful. The patient should have with him his glasses, hearing aids and dentures. Family pictures (which includes the patient) should be provided. Physiotherapists should be involved to let the patient to move.
Not everyone knows that pharmacological interventions in delirium are not curative at all. The only cure is treating the underlying diseases that are at the origin of the delirium. Drugs have the same intent of physical restraints as they are useful in case of severe agitation and when the patient is at risk to harm himself or interfere with medical interventions. Drugs should be also considered when all the other non-drug measures failed. Haloperidol or olanzapine could be useful for a very short time (few days or a week) and should be introduced and removed gradually. Haloperidol iv or im should be used when the patient’s heart rate and blood pressure are continuously monitored. Neuroleptics can cause akathisia (motor restlessness), parkinsonism, cardiac arrhythmias, sudden death, vascular complications and can contribute to isolate the patient from reality. They should be avoided in patients who are known for extrapyramidal disorders (or considerate low doses of atypical neuroleptics). For example neuroleptic can be even fatal to patients with Lewy-Body disease. Benzodiazepines are most useful in alcohol or drug withdrawal syndromes or in case patients are known for psychiatric diseases. Psychotropic drugs enhance falls.
Cholinesterase inhibitors could be useful to treat delirium in patients known for dementia but there are is not sufficient clinical evidence. Remove antihistamines, sleeping pills, and drugs for nausea and ulcers at least they are necessary. Considerate to reduce the dose or stop antidepressants if there is a risk of serotoninergic syndrome. Always simplify pharmacological treatments when this is possible. The plan of discharge from the hospital is always very complex and should involve many actors and take in account the patients’ style of life and habits.

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