RISK FACTORS: Advanced age, prior cognitive impairment, functional impairment, high BUN/Cr ratio, dehydration, malnutrition, hearing or vision impairment or any underlying medical condition that produces frailty
GENERAL MEASURES:
. There is little evidence to suggest that restraints decrease the risk of falls or injury and should be used only in the most difficult to manage patients, for as brief a time as possible
. Post-operative patients should be monitored and treated for:
. Myocardial infarction/ischemia
. Arrhythmias
. Pulmonary complications/pneumonia (especially if COPD present)
. Pulmonary embolism
. Urinary or stool retention (attempt urinary catheter removal by postoperative day 2)
. The route of anesthesia (general versus epidural) does not effect the risk of delirium
. Treatment is multifactorial, involving identification of contributing factors and preemptive care to avoid iatrogenic problems. Several areas of care deserve special attention in all patients:
. CNS oxygen delivery (attempt to attain the following)
- SaO2 > 90% with goal of SaO2>95%
- Systolic BP > 2/3 baseline or > 90 mmHg
- Hematocrit > 30%
. Fluid/electrolyte balance
- Sodium, potassium, and glucose normal (glucose < 300 mg/dl in diabetics)
- Treat fluid overload or dehydration
. Treat pain
- Scheduled acetaminophen at 1 gram QID if daily pain
- Morphine or oxycodone for breakthrough pain if acetaminophen ineffective
- Avoid meperidine (Demerol)
. Eliminate unnecessary medications
- Discontinue or minimize benzodiazepines, anticholinergics, and antihistamines
- Eliminate medication redundancies
- Investigate new patient symptoms as potential manifestation of medication side effect
. Regulate bowel/bladder function
- Bowel movement at least every 48 hours
- Screen for urinary retention or incontinence, especially after catheter removal
. Nutrition
- Dentures used properly
- Proper positioning for meals
- Assistance with meals when necessary
- Nutritional supplements (1-3 cans daily) if intake is poor
- Temporary nasogastric tube if unable to take food orally and bowels working
. Mobilization
- Out of bed on hospital day 2 (or postoperative day 1) if no contraindications
- Out of bed several hours daily if no contraindications
- Daily physical therapy if not ambulating independently
- Daily occupational therapy if not functionally independent Delirium
. Prevention of major hospital-acquired problems
- 6-inch thick foam mattress overlay if not on a special pressure reducing bed
- Avoid urinary catheter.
- Institute skin care program for patients with established incontinence
- Incentive spirometry if bed-bound
- Subcutaneous heparin 5000 units BID if bed-bound
. Environmental stimulation
- Glasses and hearing aids if used prior to illness
- Clock and calendar
- Soft lighting
- Radio, tapes, television if desired
. Sleep
- Quiet environment
- Soft music
- Therapeutic massage
- Medication if required: trazodone 25 mg qhs prn sleep; zolpidem (Ambien) 5 mg qhs prn sleep; no
diphenhydramine, no benzodiazepines
DRUG(S) OF CHOICE :
Nonpharmacological approaches are preferred for initial treatment. Medications often only treat the symptoms of delirium and do not address the underlying cause.
. Neuroleptics are the preferred medications
. Haloperidol (Haldol). Initially, 0.25-0.5mg PO/IM/IV unless urgent sedation is required such as with an
intubated patient
. Quetiapine (Seroquel). 25mg q/day bid
. Short acting benzodiazepines, if neuroleptics dont work or should be avoided
. Lorazepam (Ativan). Initially, 0.25-0.5mg PO/IM/IV
. Risperidone (Risperdal) 0.25-0.5mg
CONTRAINDICATIONS : Avoid neuroleptics in patients with parkinsonism or Parkinson disease
PRECAUTIONS:
β’ Neuroleptics may cause signifi cant extrapyramidal problems and benzodiazepines may lead to sedation.
Both may increase the risk of falls.
β’ Risperidone may be associated with hyperglycemia and ketoacidosis
PATIENT MONITORING : Patients should be monitored and mental status reassessed at least daily. Other monitoring depends upon the specifi c medical conditions present.
PREVENTION/AVOIDANCE : In patients at high risk for delirium due to age and/or frailty the approach to prevention is the same as for treatment of delirium.
POSSIBLE COMPLICATIONS: Falls, pressure ulcers, malnutrition, functional decline, oversedation,
polypharmacy.
EXPECTED COURSE/PROGNOSIS : Delirium is usually thought of as acute and hence usually improves with treatment of the underlying condition. However, it is not unusual for delirium to become chronic. In one study, only 42% of patients had resolution of their symptoms 6 months after discharge.