Preventing and managing delirium

There are many things we can do to help older people and their families and carers understand, prevent and manage delirium. Here are some recommendations.

Communicate clearly and address sensory impairment

• Communicate effectively – use short sentences and ask single questions; use interpreters and liaison staff.
• Address sensory impairment – help patients wear their hearing and visual aids and check they are in good working order. Address reversible causes, such as impacted earwax.
• Give patients, their family and carers clear information about delirium. Explain the risk factors, what delirium is, the simple strategies that can prevent or manage delirium and how they can work with staff.
• Use a tool such as ‘This is me’, which has been adapted by some Victorian Hospitals and introduced as ‘A key to me’ or ‘About me’ to help reduce the older person’s agitation and improve their orientation and experience.
• Introduce the TOP5 Initiative, to encourage staff to:
  • Talk to the carer
  • Obtain the Information
  • Personalise the care
  • 5 Strategies developed.

“If we know the name of their football team or their granddaughter’s name it can help calm them – it doesn’t always work, but when it does work it’s really, really good.” (Nurse, Northern Health)

Minimise the patient’s confusion

• Provide orientation and reassurance - remind the person where they are, who you are and what time it is.
• Have large-font clock, calendars and signage on the ward.
• Light the room for that time of day.
• Promote cognitive stimulation, for example, talk about news or reminisce.
• Avoid room changes.
• Reduce environmental stimuli and invasive procedures to a minimum.
• Discourage daytime napping to aid night-time sleep.
• Encourage the family, carer and friends to be involved in patient care or to visit (if this is calming to the patient).

Encourage mobility and self-care

• Encourage independence in activities of daily living and minimise risk of falls.
• Encourage movement - to reduce the risk of experiencing falls, developing pressure areas, constipation and incontinence, and to promote normal sleep patterns.
• For patients who use a walking aid - make sure it is accessible and that they use it.
• For patients unable to walk – encourage them to do in-bed (range of motion) exercise.

Optimise nutrition, hydration and regular continence

• Encourage and help patients with eating and drinking to reduce the risk of constipation, dehydration and under-nutrition.
• Ensure dentures are well fitted and worn.

Minimise risk of injury and agitation

• Avoid using mechanical restraints.
• Consider relaxation techniques, music or massage (this may also help with sleep).
• Avoid using indwelling catheters as they are a source of infection.
• Consider one-to-one nursing care, for example for patients at high risk of falls.

Minimise use of antipsychotic medications

• Ask the doctor or pharmacist to conduct a full medication review and reconciliation – they will consider the type and number of medications taken, including any sudden withdrawal of medications.
• Reducing, ceasing or avoiding the use of psychoactive drugs is recommended as they may worsen the delirium.
• Pharmacological therapy – should only be considered in severe cases of behavioural or emotional disturbance because there is no strong evidence they effectively improve prognosis. They may prolong the duration of the delirium and associated cognitive impairments or simply switch the patient’s delirium from hyperactive to hypoactive¹. Always:
  • document the indications for using and stopping use of antipsychotic medication in the patient’s medical history
  • become familiar with the documented instructions regarding medication dosage, administration and the frequency with which a medical physician will review the patient’s status. It is recommended that only one antipsychotic medication is used at a time, start on a low dose, review frequently and use short term only.
  • review the use and effectiveness of any medications regularly by monitoring the patient for over-sedation, postural hypotension and Parkinsonism. These adverse effects increase the risk for falls and pressure injuries and should be managed by dose reduction rather than addition of other medications. Escalate adverse reactions to the doctor or pharmacist.
  • explain the rationale for starting or stopping any medications with the patient and their family and carer.

Monitor and respond to pain

• Check for pain – conduct a pain screen or look for non-verbal cues if the patient cannot communicate.
• Ensure that pain relief is adequate and that a pain management plan is in place.

Use night-time strategies to promote sleep

• Orient the patient to the time.
• Keep the environment quiet, for example, use vibrating pagers rather than call bells.
• Keep lighting to a minimum.
• Schedule procedures, rounds and observations to avoid disturbing sleep.
• Give family or carers the option of staying overnight.

1. Inouye, S.K., R.G.J. Westendorp, and J.S. Sacznski, Delirium in elderly people. The Lancet, 2014. 383: p. 911-922.