What is the initial approach to evaluating and managing delirium in a long-term care (LTC) setting?

Initial Approach to Evaluating and Managing Delirium in Long-Term Care Settings

A multicomponent intervention approach delivered by a multidisciplinary team should be the foundation of delirium evaluation and management in long-term care settings, as it can prevent approximately one-third of delirium cases and is cost-effective. 1, 2

Initial Assessment (Within 24 Hours)

• Perform a comprehensive evaluation to identify clinical factors contributing to delirium within 24 hours of suspected delirium 1, 2
• Use standardized screening tools like the Confusion Assessment Method (CAM) to detect and monitor delirium 2, 3
• Target assessment toward high-risk residents, including those aged 65 years or older, those with cognitive impairment/dementia, and those with severe illness 1, 2
• Evaluate for common precipitating factors including infections, metabolic disturbances, medication effects, pain, dehydration, and constipation 2, 4

Multicomponent Intervention Package

Environment and Continuity of Care

• Ensure residents are cared for by a consistent team of healthcare professionals who are familiar with them 1
• Avoid moving residents between rooms unless absolutely necessary, as changes in surroundings contribute to disorientation 1, 2
• Provide appropriate lighting and clear signage in the resident's environment 1, 5

Cognitive Support

• Ensure clocks and calendars are easily visible to the resident 1, 2
• Regularly reorient the resident by explaining where they are, who they are, and what your role is 1, 5
• Introduce cognitively stimulating activities such as reminiscence therapy 1, 5
• Facilitate regular visits from family and friends to help with reorientation 1, 2

Physical Health Management

• Address dehydration by ensuring adequate fluid intake 1, 2
• Manage constipation through appropriate dietary and medication interventions 1
• Ensure proper nutrition through regular meals and supplements if needed 2
• Provide early mobilization and rehabilitation to prevent functional decline 2, 4
• Ensure proper use of hearing aids and eyeglasses to optimize sensory input 2
• Manage pain effectively, preferably with non-opioid medications when possible 2, 4
• Promptly treat infections and other acute medical conditions 2, 4

Sleep Promotion

• Implement sleep hygiene measures by reducing noise and interruptions during sleep hours 2
• Maintain normal day-night cycles with appropriate lighting 2

Medication Management

• Review medications and discontinue those that may contribute to delirium 4
• Avoid medications with high risk for precipitating delirium, particularly benzodiazepines 1, 2

Pharmacological Management (Only When Necessary)

• Avoid routine use of antipsychotics for delirium management 2, 4
• For severely agitated or distressed residents, or those threatening substantial harm to self/others, consider antipsychotics at the lowest effective dose for the shortest possible duration 2, 4
• Monitor closely for medication side effects, particularly extrapyramidal symptoms with antipsychotics 2

Implementation Considerations

• Ensure high fidelity in implementing all components of the intervention package 1, 4
• Provide education and training for staff on delirium prevention and management 4
• Deliver interventions through a multidisciplinary team approach 1, 2

Common Pitfalls to Avoid

• Failing to distinguish between delirium and dementia, especially in long-term care settings where both conditions frequently coexist 6
• Using antipsychotics as first-line treatment instead of non-pharmacological approaches 2, 4
• Overlooking potentially reversible causes of delirium 4, 7
• Discharging residents with unresolved delirium symptoms without appropriate follow-up 7
• Inconsistent implementation of multicomponent interventions, which reduces their effectiveness 1