From the Guidelines
For a frail elderly patient with a history of severe delirium and hearing difficulties, a multicomponent non-pharmacological intervention approach, including the provision of hearing aids, should be recommended as the first-line prevention strategy. This approach is supported by the most recent and highest quality study, which suggests that a multicomponent, nonpharmacologic strategy can reduce delirium in critically ill adults 1. The key components of this approach include ensuring proper use of hearing aids or assistive listening devices during hospitalization, maintaining a consistent daily routine, promoting normal sleep-wake cycles by reducing nighttime disruptions and noise, ensuring adequate hydration and nutrition, early mobilization as tolerated, and frequent orientation by staff and family members.
Some of the key elements of this approach include:
- Ensuring proper use of hearing aids or assistive listening devices during hospitalization to reduce sensory impairment
- Maintaining a consistent daily routine to promote orientation and reduce confusion
- Promoting normal sleep-wake cycles by reducing nighttime disruptions and noise to improve sleep quality
- Ensuring adequate hydration and nutrition to prevent dehydration and malnutrition
- Early mobilization as tolerated to reduce immobility and promote physical function
- Frequent orientation by staff and family members to promote cognitive function and reduce confusion
The environment should be optimized with adequate lighting during the day, minimal room changes, and familiar objects from home when possible. Family presence should be encouraged as much as feasible. Medications that can trigger delirium (such as anticholinergics, benzodiazepines, and certain antihistamines) should be avoided or minimized. If pharmacological intervention becomes necessary, low-dose antipsychotics like haloperidol 0.25-0.5mg orally or quetiapine 12.5-25mg might be considered for short-term use, but only after non-pharmacological approaches have been maximized, as suggested by previous studies 1.
In this case, provision of hearing aids (option C) is the most appropriate recommendation, as it directly addresses the patient's hearing difficulties and is a key component of the multicomponent non-pharmacological intervention approach.
From the Research
Intervention to Prevent Delirium
To prevent delirium in a frail elderly patient with a history of severe delirium and hearing difficulties, the following interventions should be considered:
- Provision of hearing aids: This is supported by studies that show the importance of addressing sensory deficits, such as hearing impairment, in preventing delirium 2, 3, 4.
- Multifaceted approach: A multifaceted approach to prevention of delirium, including environmental changes, sleep-wake cycle correction, orientation, and use of vision and hearing aids, has been shown to be effective in reducing rates of delirium 5, 3, 6.
- Regular assessment and management: Regular assessment and management of delirium risk factors, including cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration, can help prevent delirium 3, 6.
Rationale
The patient's history of severe delirium and hearing difficulties makes them a high-risk candidate for delirium. Providing hearing aids and addressing other sensory deficits can help reduce this risk. A multifaceted approach to prevention, including regular assessment and management of delirium risk factors, can also help prevent delirium.
Relevant Findings
Studies have shown that:
- Vision and hearing impairments are modifiable risk factors for delirium 2, 3, 4.
- A multifaceted approach to prevention of delirium can deliver sustained reductions in rates of delirium 5.
- Early recognition and multifaceted interventions can prevent postoperative delirium in the elderly 6.
- Bi-sensory impairment (visual and hearing impairment) is associated with delirium in hospitalized patients 4.