What's the best strategy to prevent hospital-induced delirium in the geriatric population?

Best Strategies to Prevent Hospital-Induced Delirium in Geriatric Population

Multicomponent nonpharmacologic interventions implemented by an interdisciplinary team are the most effective strategy for preventing hospital-induced delirium in the geriatric population. 1, 2

Primary Prevention Strategies

Multicomponent Interventions

The American Geriatrics Society strongly recommends implementing multicomponent nonpharmacologic interventions delivered by an interdisciplinary team for the entire hospitalization in at-risk older adults to prevent delirium 2. These interventions have been shown to reduce delirium incidence by up to 40% 1.

Key components include:

1. Orientation Strategies

   • Frequent reorientation to time, place, and person
   • Clear communication
   • Visible clocks and calendars
   • Familiar objects from home 1

2. Sensory Optimization

   • Return cognitive aids (glasses, hearing aids) immediately after procedures
   • Ensure adequate lighting during the day
   • Reduce noise
   • Adapt for visual and hearing impairment 2, 1

3. Sleep Enhancement

   • Implement nonpharmacologic sleep protocols
   • Provide dark, quiet rooms at night
   • Schedule care activities to minimize sleep disruption 2, 1

4. Early Mobility

   • Encourage early and frequent mobilization
   • Implement physical rehabilitation when appropriate 2

5. Hydration and Nutrition

   • Ensure adequate fluid intake
   • Provide assistance with meals if needed
   • Consider nutritional supplements for malnourished patients 1

6. Pain Management

   • Optimize pain control using minimally sedating multimodal approaches
   • Titrate opioids to minimal effective dose
   • Consider non-opioid alternatives when possible 1

7. Medication Review

   • Avoid high-risk medications
   • Minimize unnecessary medications 2

Interdisciplinary Team Approach

Implementation requires:

• Daily rounds by the managing team providing both general and specific recommendations 2
• Communication of the management plan to all healthcare professionals 1
• Involvement of nursing, physicians, physical therapy, and nutrition services 1
• Training staff on delirium prevention, recognition, and management 1
• Using checklists to promote adherence to interventions 1

Screening and Risk Assessment

Early identification of at-risk patients is crucial:

• Use validated screening tools such as the 4 'A's Test (4AT) or Confusion Assessment Method (CAM) 1
• Continue screening twice daily until day 5 or discharge 1
• Pay special attention to patients with known risk factors:
  • Visual impairment
  • Previous cognitive impairment
  • Severe illness
  • Elevated blood urea nitrogen/serum creatinine ratio 3

Pharmacological Considerations

• Avoid routine use of medications for delirium prevention 1
• Antipsychotics should not be used prophylactically but reserved only for patients who are severely agitated and threatening substantial harm to themselves or others 1
• Benzodiazepines should not be used as first-line treatment except in cases of alcohol or benzodiazepine withdrawal 1

Implementation Considerations

The Hospital Elder Life Program (HELP) is a well-established protocol that has been successfully implemented in more than 200 hospitals worldwide 4. It focuses on:

• Identifying a patient's delirium risk profile
• Assigning individually tailored intervention protocols
• Providing cognitive activation, simple mobilization, meal companionship, and nonpharmacological sleep promotion 4

Common Pitfalls and Caveats

1. Underrecognition of hypoactive delirium: Hypoactive delirium is often missed but is as serious as hyperactive forms 5

2. Overreliance on pharmacological interventions: Despite common use, evidence does not support routine use of antipsychotics for delirium prevention 5

3. Inadequate staff education: Educational programs are essential for successful implementation of delirium prevention strategies 2

4. Failure to involve family members: Encouraging the presence of family and friends and educating them to assist with reorientation can help support patients 1

5. Unnecessary transfers between hospital units: Reducing transfers can help prevent delirium 1

6. Continuing medications after resolution: Avoid continuing medications initiated for delirium management after resolution 1

Cost-Effectiveness

While implementing multicomponent interventions requires resources, the cost-effectiveness of these strategies has been demonstrated in various settings, offsetting the considerable costs of delirium 2.