Are non-pharmacological approaches the primary intervention for a geriatric patient with mild delirium?

Non-Pharmacological Approaches Are the Primary Intervention for Mild Delirium in Geriatric Patients

Yes, non-pharmacological multicomponent interventions delivered by an interdisciplinary team are the primary and first-line approach for managing mild delirium in geriatric patients, with strong evidence supporting their effectiveness and safety. 1

Strength of Recommendation

The American Geriatrics Society provides a strong recommendation for multicomponent non-pharmacological interventions in the management of delirium, though the quality of evidence is rated as low for treatment (compared to moderate for prevention). 1 Importantly, no harmful effects of non-pharmacological approaches have been reported, other than program resource costs, which are offset by the substantial costs associated with untreated delirium. 1

Why Non-Pharmacological Approaches Come First

Safety Profile

• Non-pharmacological interventions carry essentially no risk of harm, making them ideal for mild delirium where the risk-benefit ratio of medications is unfavorable. 1
• Antipsychotics and benzodiazepines should be avoided for hypoactive delirium and reserved only for severe agitation threatening substantial harm. 1

Evidence Base

• Seven out of 13 studies evaluating multicomponent interventions for delirium treatment showed benefits in at least one outcome: delirium rate, duration, cognitive decline, functional decline, length of stay, or costs. 1
• The interventions demonstrate cost-effectiveness across multiple healthcare settings. 1

Core Components of Non-Pharmacological Management

The following elements should be implemented simultaneously by an interdisciplinary team: 1

Cognitive and Sensory Interventions

• Cognitive reorientation: Regular orientation to person, place, time, and situation using simple, clear instructions with visual cues. 1, 2
• Visual and hearing adaptations: Ensure patients use their glasses and hearing aids, as sensory impairments significantly contribute to delirium. 2

Sleep and Activity Management

• Sleep enhancement: Implement non-pharmacological sleep protocols and sleep hygiene measures (not sedatives). 1
• Early mobility: Physical rehabilitation and exercise distributed throughout the day in short sessions to prevent fatigue. 1

Environmental Modifications

• Maintain consistent daily routines to reduce confusion and agitation. 3
• Improve lighting, especially in pathways to bathrooms. 3
• Remove clutter and tripping hazards to prevent falls that could worsen delirium. 3

Medical Optimization

• Nutrition and hydration: Ensure adequate fluid intake (1.6L daily for women, 2.0L for men) and address nutritional deficiencies, particularly vitamin D, B12, and folate. 3
• Pain management: Optimize pain control preferably with non-opioid medications. 1
• Medication review: Discontinue or minimize medications that precipitate delirium, including anticholinergics and benzodiazepines. 2
• Adequate oxygenation and prevention of constipation. 1

Critical First Step: Identify and Treat Underlying Causes

Before focusing solely on symptom management, perform a comprehensive medical evaluation to identify and treat the underlying contributors to delirium. 1, 2 This is a strong recommendation from the American Geriatrics Society. 1

Key Etiologies to Address

• Infections: Urinary tract infections and pneumonia are the most common infectious causes, with over 80% of bacteremia patients showing neurological symptoms. 2
• Metabolic derangements: Check for dehydration (may not be apparent on initial labs), hypercalcemia (reversible in 40% of cases), and hyponatremia due to SIADH. 2
• Medications: Discontinue anticholinergics (including antihistamines like cyclizine), benzodiazepines (unless treating withdrawal), and review opioids especially in renal impairment. 2
• Often-overlooked factors: Pain, constipation, urinary retention, and pressure ulcers. 2

Delays in treating underlying causes prolong delirium and increase morbidity and mortality. 1, 2

Implementation Strategy

Team Composition

The interdisciplinary team should include physicians, nurses, and potentially physical therapists, occupational therapists, and social workers. 1 Daily rounds should provide both general and specific recommendations with attention to adherence. 1

Education Component

Healthcare systems should implement formal educational programs with ongoing refresher sessions for all staff on delirium recognition, screening tools, risk factors, and both non-pharmacological and pharmacological approaches. 1 Education is most effective when interactive, engages leadership, and uses peer support or unit champions. 1

When Pharmacological Intervention May Be Considered

Antipsychotics at the lowest effective dose for the shortest duration may be considered only when: 1

• The patient is severely agitated or distressed
• The patient is threatening substantial harm to self or others
• Non-pharmacological approaches have been attempted

This is a weak recommendation, and medications should never be considered first-line treatment for mild delirium. 1

Common Pitfalls to Avoid

• Do not use physical restraints to manage behavioral symptoms, as this can worsen delirium. 2
• Do not prescribe benzodiazepines as first-line treatment for agitation associated with delirium (unless treating alcohol or benzodiazepine withdrawal). 1, 2
• Do not newly prescribe cholinesterase inhibitors to prevent or treat postoperative delirium (strong recommendation against). 1
• Do not fail to address underlying causes such as orthostatic hypotension or medication side effects. 3
• Do not underestimate hypoactive delirium, which is often missed but requires the same non-pharmacological approach. 4, 5

Monitoring and Reassessment

• Regularly reassess delirium severity using validated tools like the Delirium Triage Screen followed by the Brief Confusion Assessment Method. 2
• Repeat screening regularly as mental status fluctuates throughout the day. 2
• Monitor for resolution before considering any elective procedures, as delirium significantly increases postoperative complications. 6