What is the best approach to manage delirium in a care home setting?

Managing Delirium in Care Homes

Immediately implement a multicomponent nonpharmacologic intervention protocol while simultaneously conducting a focused medical evaluation to identify and treat the underlying cause of delirium. 1

Immediate Assessment and Confirmation

• Use the Confusion Assessment Method (CAM) to confirm delirium presence, which takes only 2-5 minutes and has the highest psychometric properties for detection 1
• Look for the cardinal features: acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness 1
• Identify and treat underlying medical causes including medications, infections, metabolic derangements, alcohol or drug withdrawal, and pain 1

Core Nonpharmacologic Interventions (The Foundation of Management)

These multicomponent interventions can prevent or reverse approximately one-third of delirium cases and should be implemented immediately. 1, 2

Environmental and Cognitive Modifications

• Provide regular reorientation using visible clocks and calendars 2
• Ensure adequate lighting and clear signage 2
• Minimize room changes and maintain care team consistency 2
• Reduce noise and interruptions during sleep hours to maintain normal day-night cycles 3, 2

Sensory Optimization

• Ensure hearing aids and eyeglasses are available, used, and in good working order 3, 2
• Resolve reversible sensory impairments such as impacted ear wax 3

Physical Care Interventions

• Promote early mobilization and rehabilitation 2, 4
• Ensure adequate hydration and nutrition 2, 4
• Address hypoxia and optimize oxygenation 2
• Treat infections promptly 2
• Manage pain effectively, preferably with nonopioid medications 2, 4

Sleep Hygiene

• Avoid nursing or medical procedures during sleeping hours when possible 3
• Schedule medication rounds to avoid disturbing sleep 3
• Reduce noise to a minimum during sleep periods 3

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

Tolerate, Anticipate, and Don't Agitate is the core principle that goes beyond traditional reorientation strategies. 5 This approach emphasizes:

• Tolerating behaviors that are not harmful rather than attempting to suppress them 5
• Anticipating needs before agitation occurs 5
• Avoiding interventions that increase agitation 5

Pharmacologic Management (Use Sparingly)

Avoid antipsychotics and benzodiazepines for routine delirium treatment, particularly for hypoactive delirium. 1, 2

When to Consider Medications

Consider low-dose antipsychotics ONLY for: 1, 4

• Severely agitated patients with distressing psychotic symptoms
• Patients threatening substantial harm to themselves or others
• Symptoms refractory to nonpharmacologic interventions

Use the lowest effective dose for the shortest possible duration and discontinue immediately following resolution of distressing symptoms. 4

Critical Exception: Alcohol Withdrawal

• If alcohol withdrawal is suspected, initiate benzodiazepines within the first 6-24 hours to prevent progression to delirium tremens 1
• Provide thiamine supplementation to patients with alcohol use disorder 1

Common Pitfalls to Avoid

• Do not use benzodiazepines as sleep enhancers as they may be associated with causing delirium 3
• Avoid physical restraints as a restraint-free environment can be achieved and may improve outcomes 5
• Do not assume confusion is normal in older adults - delirium indicates a serious underlying medical condition requiring immediate evaluation 6
• Avoid medications with high risk for precipitating delirium 2

Monitoring and Family Support

• Reassess mental status regularly using the CAM and adjust interventions based on symptom control and patient distress 1, 2
• Provide educational support and written information about delirium to families 1, 2
• Monitor for medication side effects, particularly extrapyramidal symptoms if antipsychotics are used 2

Clinical Significance

Recognize that delirium is associated with increased mortality, prolonged hospitalization, and development of long-term cognitive impairment. 1 The multicomponent nonpharmacologic approach is cost-effective and improves health outcomes compared with usual care. 2 Care homes have particularly high risk for delirium due to clustering of risk factors, especially older age and dementia, making prevention and early intervention critical. 3