1st February 2024

Management

Generally, we follow a bio-psycho-social approach. Here, environmental and general measures take first place. Delirium will usually improve if a reason is identified and managed.

Non-pharmacological strategies

• A supportive and calm environment is the mainstay of management 
• Arranging hearing and visual aids if patient usually uses these
• Encouraging reorienting patient to their surroundings, the date, time and year. Reiterating the venue and the reason for admission.
• Arranging a 24-hour clock and calendar that can be visualised easily to support orientation
• Encouraging intake- both food and fluids
• Encouraging a good sleep routine
• Arranging a silent and corner room that is well-lit. The lighting should be natural during the day, with attenuated light at night to reduce misperceptions and illusions.
• Consistent care offered by the staff
• Avoid moving the patient to different wards or places
• Protecting the patient and others- safekeeping surroundings, removing dangerous objects, etc.
• Psychoeducation to the relatives to understand the illness and myths associated with the explanation of medications and non-medical treatment.
• Relatives can bring personal objects like pictures, blankets, books, and mugs that can help reorient the patient.
• Staff to maintain a calm and reassuring attitude towards the patients
• Encouraging walking and maintaining activity if feasible
• Avoid unnecessary interventions

Pharmacological measures

• Addressing the specific causes:
  • Infections> Antibiotics
  • Dehydration> Fluids
  • Urinary retention> Catheter if needed
  • Constipation> Laxatives
  • Pain> Painkillers
  • Medication changes or, recent addition or dose changes> May need to be rectified
  • Hypoglycemia, hypoxia, electrolyte imbalance> need correction
• Liaise with the Liaison Psychiatry for management of patients with challenging symptoms.
  • Antipsychotics: Haloperidol is licensed for delirium, but the evidence is very limited. There is a risk of side effects like Extrapyramidal side effects ( EPSE) and cardiac effects. Risperidone and Olanzapine are also given at the lowest doses, depending on the trust policy. The doses should be very low and, if needed, should be increased slowly. Antipsychotics can increase the risk of metabolic syndrome, weight gain, hyperlipidaemia and type 2 diabetes. They also carry a risk of stroke. 
  • Benzodiazepines (BZDs): Generally, these should be avoided. However, when antipsychotics are contraindicated, BZDs can be used. Small doses of Lorazepam can be considered based on trust guidelines. BZD can increase confusion, sedation and falls, as well as increase respiratory depression. Hence, the risks and benefits of treatment need to be carefully weighed. 
  • It is essential to monitor vitals every 30 minutes for 4 hours after giving an antipsychotic.
  • Covert medication can be considered in severe aggression
  • Medication needs to be reviewed regularly and discontinued when delirium resolves. 
  • An old age psychiatry specialist should be consulted if someone has dementia or cerebrovascular condition and is prescribed medication for delirium. 
  • If discharged with medication for delirium, the patient’s medication needs to be followed up with a discharging regime.

Social

• This has already been discussed as non-pharmacological approach. 
• Delirium can continue for a few months. Hence, continued vigilance is pertinent with regard to the environmental, sensory needs and pharmacological aspects.