What are the strategies to resolve hospital-acquired delirium?

From the Guidelines

Hospital-acquired delirium can be effectively resolved through a multicomponent nonpharmacologic strategy that includes reducing modifiable risk factors, improving cognition, and optimizing sleep, mobility, hearing, and vision, as recommended by the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU 1.

Key Strategies

• Identify and treat underlying causes of delirium, such as infection, medication side effects, or metabolic disturbances
• Create a supportive environment by ensuring adequate lighting, minimizing noise, and providing orientation cues like clocks and calendars
• Maintain the patient's normal sleep-wake cycle, ensure proper hydration and nutrition, and promote early mobility when possible
• Implement a multicomponent intervention package that includes strategies to reduce or shorten delirium, improve sleep, improve wakefulness, reduce immobility, and reduce hearing and/or visual impairment

Nonpharmacologic Interventions

• Use of clocks and calendars to help orient patients
• Reorientation and cognitive stimulation
• Minimizing light and noise to improve sleep
• Early rehabilitation and mobilization to reduce immobility
• Enabling use of devices such as hearing aids or eye glasses to reduce hearing and/or visual impairment

Pharmacologic Management

• Low-dose antipsychotics, such as haloperidol or quetiapine, may be used cautiously
• Benzodiazepines should generally be avoided except in alcohol withdrawal cases
• Dexmedetomidine infusion may be considered in ICU settings

Prevention

• Identify high-risk patients, such as the elderly, those with cognitive impairment, severe illness, or sensory deficits
• Minimize high-risk medications and implement early mobility protocols
• Provide a tailored intervention to meet each patient's needs, using a multidisciplinary team trained and competent in delirium prevention 1

From the Research

Strategies to Resolve Hospital-Acquired Delirium

• Non-pharmacological interventions are thought to be important in delirium prevention, with multicomponent interventions probably reducing the incidence of delirium compared to usual care 2
• Re-orientation, cognitive stimulation, and sleep hygiene are associated with reduced risk of incident delirium 2
• Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care are probably associated with a reduction in incident delirium 2
• Light therapy can improve the patient's circadian rhythm and thus contribute to reducing the incidence of delirium 3
• Non-pharmacological nursing interventions, such as reorientation, promotion of mental activities, adequate communication, early physiotherapy, and avoidance of polypharmacy and sleep deprivation, have a high impact on the prevention and therapy of delirium 4
• Cognitive stimulation, including traditional and novel digital technology-based techniques, may be effective in preventing and managing delirium in acute hospital settings 5
• Multicomponent interventions, including delirium prevention interventions against usual care, have been shown to reduce the incidence of delirium compared to usual care 6

Non-Pharmacological Interventions

• Multicomponent interventions, such as those including re-orientation, cognitive stimulation, and sleep hygiene, are the most promising methods in preventing delirium 2, 3
• Non-pharmacological nursing interventions, such as promotion of mental activities and early physiotherapy, are important in the prevention and therapy of delirium 4
• Cognitive stimulation, including traditional and novel digital technology-based techniques, may be effective in preventing and managing delirium in acute hospital settings 5

Pharmacological Interventions

• There is no clear evidence that cholinesterase inhibitors, antipsychotic medication, or melatonin reduce the incidence of delirium 6
• Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement 6
• The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain 6