What are the non-pharmacological methods to manage delirium in a hospital setting?

Non-Pharmacological Management of Delirium in Hospital Settings

Multicomponent non-pharmacological interventions implemented by an interdisciplinary team should be the first-line approach for managing delirium in hospitalized patients, as these strategies can reduce delirium incidence by approximately 43% compared to usual care. 1

Core Components of Effective Delirium Management

Orientation and Cognitive Support

• Provide frequent reorientation to time, place, and person
• Use orientation boards with day, date, and location information
• Place visible clocks and calendars in patient rooms
• Ensure cognitive stimulation through appropriate activities and conversations 2
• Use familiar objects from home to create a recognizable environment 1

Sleep Enhancement

• Implement a non-pharmacological sleep protocol:
  • Reduce noise and light during nighttime hours
  • Schedule care activities to avoid sleep disruption
  • Discourage daytime napping
  • Increase daylight exposure during waking hours 2, 3
• Use sleep hygiene measures (warm drinks, relaxation techniques) 1

Early Mobilization and Physical Activity

• Implement early and progressive mobilization protocols
• Assist with ambulation at least three times daily when possible
• Provide physical therapy consultation for individualized mobility plans
• Avoid unnecessary bed rest and physical restraints 2

Sensory Optimization

• Ensure patients have access to their eyeglasses and hearing aids
• Check for impacted ear wax that may contribute to sensory deprivation
• Provide adequate lighting during daytime hours
• Consider amplification devices for patients with hearing impairment 2, 3

Environmental Modifications

• Minimize unnecessary patient transfers between units
• Maintain a consistent care team when possible
• Create a restraint-free environment that promotes safety 2, 4
• Keep noise levels low and reduce unnecessary stimulation 2

The "T-A-DA" Method for Delirium Management

The "Tolerate, Anticipate, Don't Agitate" approach has shown effectiveness in managing patients with delirium:

1. Tolerate: Accept behaviors that aren't harmful rather than trying to control all unusual behaviors
2. Anticipate: Predict needs before they arise (hunger, thirst, toileting)
3. Don't Agitate: Avoid confrontation, arguments, or restraints that can worsen agitation 4

Hydration and Nutrition Management

• Encourage oral hydration with assistance as needed
• Monitor food and fluid intake
• Assist with meals in an upright position
• Address swallowing difficulties promptly 3, 1

Pain Management

• Regularly assess and treat pain using appropriate scales
• Use non-pharmacological pain management strategies when possible
• Schedule pain medications to prevent pain crises 2

Family Engagement

• Encourage family presence and participation in care
• Educate family members about delirium, its fluctuating nature, and how they can help
• Incorporate familiar faces and voices in reorientation strategies 2, 3

Implementation Considerations

High-Risk Patient Identification

Focus intensive prevention efforts on patients with:

• Age ≥65 years
• Pre-existing cognitive impairment or dementia
• Severe illness
• Current hip fracture 2

Interdisciplinary Team Approach

• Implement formal educational programs for all healthcare staff about delirium recognition and management
• Use interactive education that engages leadership and employs unit champions
• Establish daily interdisciplinary rounds for delirium assessment and management 2

Monitoring and Assessment

• Use validated delirium screening tools (CAM, CAM-ICU) at least once per shift
• Monitor for both hyperactive and hypoactive forms of delirium
• Document delirium presence, duration, and severity 2, 3

Common Pitfalls to Avoid

• Failing to recognize hypoactive delirium (quiet confusion often missed)
• Misdiagnosing delirium as dementia
• Overlooking delirium superimposed on dementia
• Excessive focus on pharmacological interventions before optimizing non-pharmacological approaches
• Inconsistent implementation of multicomponent interventions 3

When to Consider Pharmacological Management

While this question focuses on non-pharmacological approaches, it's important to note that pharmacological interventions should only be considered when:

• Patient experiences significant distress from symptoms like hallucinations or delusions
• Agitation poses a safety risk to the patient or others
• Non-pharmacological approaches have been maximized 2, 3

The evidence clearly demonstrates that multicomponent non-pharmacological interventions are the most effective approach for managing delirium in hospitalized patients, with the potential to significantly reduce delirium incidence, duration, and hospital length of stay.