Delirium

Care & Treatment

The best way to treat delirium is to first prevent it.

People who are scheduled to have surgery should have a preoperative assessment of mental status, so that postoperative assessments have a baseline for comparison.  If there are risk factors that make it more likely that a patient will experience delirium, healthcare providers should pay close attention to the condition.

Research has shown that paying attention to six particular factors is most helpful in preventing delirium in hospitalized older adults:  

  1. Help orient cognitively impaired patients in time and place (using clocks, calendars, windows, blackboards with healthcare providers’ names).

  2. Get patients up and about as soon as possible.
  3. Minimize the use of psychoactive (mood) medications by using non-drug therapies whenever possible.
  4. Implement a healthy sleep-wake cycle, using windows, bright morning light, reduction in night noises, etc.
  5. Improve sensory input and communication using appropriate aids, especially good eyeglasses, hearing aids (check the batteries!), and dentures if needed.
  6. Give plenty of fluids, and make sure patients don’t get dehydrated. 

Prevention and Treatment Starts Here

Delirium is a true medical emergency which requires immediate professional attention and treatment. The main goal of treatment is to identify and correct the underlying causes of the syndrome using tests described in the Diagnosis and Tests section. The healthcare provider will:

  • identify the condition and the specific cause as quickly as possible
  • manage agitation or disruptive behavior
  • provide general supportive care 

The provider will also review every medication looking to stop or reduce the dose of those which may be contributing to the delirium. However, preventing and treating delirium use similar strategies.

Supportive care

Care for older people with delirium involves special hospital care with careful attention to medical, environmental, and social situations. People with delirium are particularly vulnerable to medical complications such as falls, dehydration or malnutrition, pressure ulcers, joint stiffness, constipation, or wetting the bed. This is because they aren’t able to move around much or because of reduced consciousness. These complications often result in poor outcomes.

Non-pharmacologic management and therapies for delirium

To reduce the risk of delirium, or to help someone who develops symptoms of delirium, the environment must be managed so that the the person feels oriented. Avoid moving them from one room or space to another unnecessarily and try to keep staff changes to a minimum if possible. Encourage regular schedules for meals, tests, exercise, and monitoring. Family members, close friends, or even paid assistants should try to stay with the person in order to reduce the fear and anxiety often seen in delirium.    

If possible, attempt to treat sleep problems without medications. Try warm milk or herbal tea, music, and massage in the evening, and keep nighttime noise to a minimum – research has shown that these steps are more effective than medications and lead to better sleep quality. Dim lights left on at night can help decrease delusions or hallucinations.

Encourage the person to move and take walks three times every day, to practice range of motion exercises, and minimize the use of equipment that would keep them immobilized.

If an infection, pain, or other medical condition has been identified as a precipitating factor, ensure that it has been treated adequately.

Physical restraints are only used as a last resort to keep the older person safe and prevent them from pulling out tubes and catheters. There’s no evidence that physical restraints reduce falls or other accidents. Worse, they keep the person immobilized, which increases the risk of developing pneumonia or pressure ulcers. Accidental strangling is even a possibility. Also, restraints and very strong medications are considered a form of involuntary treatment and may violate the rights of an agitated person. Physical restraints are supervised and monitored often. They should be applied for the shortest time possible.

Professionals in social work and nursing are often quite skilled at helping people with delirium. Remember that a person suffering from delirium in the hospital may improve considerably once they return home to a familiar, stable environment. This should be kept in mind so that someone is not placed in a nursing home prematurely.

Delirium may take weeks or even months to resolve. Therefore, even after an older adult with delirium returns home, there should be close monitoring and supervision to make sure that everyone involved is safe.

Pharmacologic treatment/medications

For older adults experiencing delirium, the basis of treatment is creating a safe, familiar, and supportive environment.  Medication treatment of delirium is often not necessary or desirable. But if the older adult is very agitated or aggressive and is behaving in a way that could hurt themselves or someone else, medications can be helpful.

Antipsychotic medications such as haloperidol can be used, but cautiously. Quetiapine is the preferred drug for people with Parkinson’s disease and certain types of dementia. Sedatives such as lorazepam are generally discouraged for the treatment of delirium, but may help in certain cases (including alcohol withdrawal).  Sedatives are almost never used in people who are already drowsy.  Common over-the-counter allergy drugs or sleep aids such as diphenhydramine can bring on delirium or make it worse, and should not be used.

 

Last Updated July 2020