Delirium – Gold Standard Nonpharmacologic Treatment Checklist

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Delirium – Gold Standard Nonpharmacologic Treatment Checklist

geriguidesOctober 13, 2021List of Guides 0

Pearl: These nonpharmacologic interventions are the gold standard to delirium care in the hospital and have been found to prevent delirium by 30-40%! (Postoperative delirium in older adults: best practice statement from the American Geriatrics Society)

Address underlying medical issues

Treat the precipitant(s) of delirium

Assess and treat pain

  • Consider acetaminophen 1g TID (or 650 mg TID if cirrhosis) as pain is often underreported
  • Consider low dose opioid, if necessary

Enhance hydration and nutrition

  • Consider nutrition consult
  • If there is underlying dementia, consider a speech therapy consult for education on optimal ways to present meals

Avoid constipation and urinary retention

  • Consider scheduling a bowel regimen (avoid docusate monotherapy)
  • Consider a bladder scan
Review for deliriogenic medications and adjust appropriately

Pay particular attention to anticholinergics, sedatives, and muscle relaxants (which often have high anticholinergic burden)

Review for deliriogenic medications

Reorient frequently and provide reassurance

Encourage family at the bedside or the presence of a patient care attendant who can provide simple communications to prevent escalation of behavior

Consider occupational or speech therapy consult to assist with reorientation strategies

Keep white board updated

Ensure glasses, hearing aids/PocketTalkers are present, if needed

Maintain safe mobility

Remove nonessential tethers

Mobilize at least 2-3x per day

Consult physical and occupational therapy early in hospital course

Optimize sleep

Keep lights on and keep active during the day

  • Avoid napping
  • Consider cognitive stimulation as tailored to patient interests and abilities. Consider “Care Square”, chaplain visits, music/pet therapy, etc
  • Consider physical activity and frequent daytime mobilization

Reduce nighttime interruptions

  • Consider limiting labs and vitals overnight (such as 11 pm to 5 am)

If needed, can consider melatonin 3 mg qhs or the judicious use of trazodone

What about the Intensive Care Unit?

While the above recommendations are generally for floor patients, the ICU’s ABCDEF bundle (see SCCM information here) incorporates many of these elements and is associated with decreased risk of delirium (OR = 0.60; CI 0.49-0.72), hospital death within 7 days, physical restraint use, and discharge to facility other than home.

  • Assess, prevent, and manage pain
  • Both spontaneous awakening trials (SAT) and Spontaneous Breathing Trials (SBT)
  • Choice of analgesia and sedation
  • Delirium: Assess, prevent, and manage
  • Early mobility and exercise
  • Family engagement and empowerment