Management of Delirium in Long-Term Care Settings
Immediately implement a multicomponent nonpharmacologic intervention protocol while simultaneously conducting a focused medical evaluation to identify and treat the underlying cause of delirium. 1, 2
Immediate Assessment and Confirmation
Use the Confusion Assessment Method (CAM) to confirm delirium presence within the first 24 hours, which takes only 2-5 minutes and has the highest psychometric properties for detection. 1, 2
Look for the cardinal features: acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness. 1, 2
Identify and treat underlying medical causes including medications (especially anticholinergics, benzodiazepines, opioids), infections (particularly urinary tract infections and pneumonia), metabolic derangements (electrolyte abnormalities, hypoglycemia, renal/hepatic dysfunction), alcohol or drug withdrawal, and uncontrolled pain. 1, 2
Core Nonpharmacologic Interventions
The evidence shows that multicomponent interventions can prevent or reverse approximately one-third of delirium cases and reduce delirium incidence by about one-third, making this the cornerstone of management. 3, 1, 2
Environmental and Continuity Modifications
Maintain care team consistency by ensuring the same familiar healthcare professionals care for the resident whenever possible. 3, 2
Avoid room changes unless absolutely necessary, as frequent changes in surroundings contribute to disorientation and confusion. 3, 2
Provide appropriate lighting with adequate brightness during daytime hours and dim lighting at night to maintain normal circadian rhythms. 3, 2
Ensure visible clocks and calendars are easily accessible for regular reorientation (consider 24-hour clocks in some settings). 3, 2
Use clear signage to help residents navigate their environment. 3, 2
Cognitive and Sensory Optimization
Regularly reorient the resident by explaining where they are, who you are, and what your role is during each interaction. 2, 4
Introduce cognitively stimulating activities appropriate to the resident's baseline cognitive function. 2, 4
Facilitate regular visits from family and friends to provide familiar faces and emotional support. 2, 4
Ensure hearing aids and eyeglasses are available, used, and functioning properly at all times. 2
Resolve reversible sensory impairments such as impacted ear wax. 2
Physical Care Interventions
Promote early mobilization and rehabilitation with assistance as needed, avoiding prolonged bed rest. 2
Ensure adequate hydration and nutrition by monitoring intake and providing assistance with meals. 2
Address hypoxia and optimize oxygenation if respiratory compromise is present. 2
Treat infections promptly with appropriate antimicrobial therapy. 2
Manage pain effectively, preferably with nonopioid medications when possible, as both uncontrolled pain and opioids can precipitate delirium. 2
Sleep Hygiene
Avoid nursing or medical procedures during sleeping hours whenever possible. 2
Schedule medication rounds to avoid disturbing sleep, consolidating nighttime medications when clinically appropriate. 2
Reduce noise to a minimum during sleep periods to maintain normal day-night cycles. 2
Pharmacologic Management
Avoid antipsychotics and benzodiazepines for routine delirium treatment, particularly for hypoactive delirium, as evidence does not support their routine use and they carry significant risks. 1, 2, 5, 6
When to Consider Antipsychotics
Consider low-dose antipsychotics only in the following specific circumstances: 1, 2
- Severely agitated patients with distressing psychotic symptoms (hallucinations, delusions causing significant distress)
- Patients threatening substantial harm to themselves or others
- Symptoms refractory to nonpharmacologic interventions after adequate trial
If antipsychotics are used: 2
- Use the lowest effective dose
- Continue for the shortest possible duration
- Discontinue immediately following resolution of distressing symptoms
- Monitor for extrapyramidal symptoms and other adverse effects
Special Consideration: Alcohol Withdrawal Delirium
This is the one exception where benzodiazepines are indicated. 1, 4
Initiate benzodiazepines within the first 6-24 hours if alcohol withdrawal is suspected to prevent progression to delirium tremens. 1
Provide thiamine supplementation to all patients with alcohol use disorder. 1, 4
Common Pitfalls to Avoid
Do not use benzodiazepines as sleep enhancers, as they are associated with causing delirium rather than preventing it. 2
Avoid medications with high anticholinergic properties (e.g., diphenhydramine, first-generation antihistamines, tricyclic antidepressants). 2
Do not assume hypoactive delirium is "just sleeping" – this subtype is often missed but carries similar poor outcomes. 7
Failing to provide thiamine supplementation in residents with alcohol use disorder. 4
Monitoring and Family Support
Reassess mental status regularly using the CAM and adjust interventions based on symptom control and resident distress. 1, 2
Provide educational support and written information about delirium to families, explaining that it is a medical condition, not "just confusion," and discussing expected trajectory. 1, 2
Monitor for medication side effects, particularly extrapyramidal symptoms if antipsychotics are used. 2
Clinical Significance
The evidence demonstrates that delirium in LTC residents is associated with increased mortality, prolonged or new hospitalizations, and development of long-term cognitive impairment. 1, 2 The multicomponent nonpharmacologic approach is cost-effective and improves health outcomes compared with usual care. 3, 2 LTC residents are at particularly high risk due to clustering of risk factors, especially older age and dementia, making prevention and early intervention critical. 2, 8
A computerized medication review system that identifies medications contributing to delirium risk and triggers pharmacist-led medication review probably reduces delirium incidence in LTC settings, though this may not be practical in all facilities. 8