Delirium Management: Prevention and Treatment

The management of delirium consists of prevention (strategies aimed to reduce the likelihood of delirium before it occurs by means of brain optimization) and treatment (interventions to decrease delirium severity, duration, and poor outcomes in affected subjects). The NICE guidelines on the diagnosis, prevention, and management of delirium [16] recommend non-pharmacological interventions are used initially and pharmacological interventions are considered only when the latter is not sufficiently effective. In the light of paucity of research regarding management of delirium superimposed on dementia, these principles also apply, with nonpharmacological interventions being pursued first, and only if they fail, pharmacological interventions, with careful administration and monitoring of their side effects, are recommended.

Non-pharmacological Interventions

Non-pharmacological interventions used in both prevention and treatment of delirium are similar. These include behavioral interventions, monitoring devices, environmental adaptations, familiarizing and optimizing patients’ environment (e.g., bringing personal belongings, having a family member with them or a sitter), providing psychosocial support, orientation devices and avoidance of restraints, as well as revision of medication (avoiding psychoactive substances, including complementary and alternative medicine) [149].

In addition, educational programs about delirium, targeting the full spectrum of healthcare and other affiliated professionals involved in various stages of the medical care provided to patients with delirium, have been recommended to improve clinical detection of delirium in the clinical setting [149, 150]. These educational programs should focus on delirium recognition, embedding screening tools in practice, detection of risk factors, and non-pharmacological and pharmacological interventions for prevention and management. They should also involve enabling and reinforcing factors to help sustain learning [151]. Numerous reviews have shown the benefits of education as an effective approach to manage delirium [151-153].

Multicomponent intervention programs (MCIPs) have been recently recommended for delirium prevention [149]. These programs should be delivered by an interdisciplinary team that involves physicians, nurses, and other healthcare professionals. In turn, this will facilitate a focused multicomponent intervention following detailed assessment to identify, modify, and treat risk factors of delirium. Examples include early mobilization (physical therapy), cognitive stimulation and reorienta?tion, nutritional and fluid supplementation, optimizing sensorial function (e.g., optimizing hearing and visual impairment, reduction of noise levels, and excessive light or darkness), pain management, avoidance of inappropriate medication, adequate oxygenation, and prevention of constipation [154]. In the intensive care setting, the reduction of sedative exposure and duration of mechanical ventilation [155-157] and noise levels [158] has been reported to contribute to a lower prevalence and duration of delirium, better cognitive outcomes and survival rates.

Using the MCIP approach, the incidence of delirium can be reduced by up to 30 % regardless of clinical setting and cognitive decline in delirium subjects [154]. When implemented in older people, the MCIP model contributes to a shorter duration of delirium and reduced hospital stay [159], though its effect on clinical outcomes remains unclear. Although evidence supports effectiveness of the MCIP model, the challenge however is its implementation and crossing the knowingdoing gap [160].

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