Delirium - Clinical Management
The most important aspect of the clinical management of delirium is prompt diagnosis and treatment of the underlying cause or (more usually) causes. Sometimes the symptoms and behaviors of the delirium itself may need to be treated. The evidence base for this aspect of management is still very limited, and current approaches are based mainly on accumulated clinical experience. These strategies involve both pharmacological and nonpharmacological approaches. Regarding use of medication, there is always a risk that giving a powerful psychoactive drug to a delirious patient will make the problem worse, so this course of action should only be considered if the associated symptoms and behaviors are distressing or potentially dangerous to the patient and/or others. The drug treatment of delirium in elderly patients is similar to that of younger adults, although it is necessary to start with much lower doses. The drugs most commonly used in the management of delirium are neuroleptics (usually haloperidol), or benzodiazepines (e.g., diazepam, lorazepam, alprazolam) if the patient cannot tolerate a neuroleptic. The effects of the drug and its dosage need to be frequently reviewed, to ensure that it is not having any adverse effects. Once the delirium has resolved, the medication should be reduced and, if possible, discontinued over a period of a few days.
Nonpharmacological interventions in delirium are aimed at reducing the confusing, frightening, and disorienting aspects of the hospital or nursing home environment that aggravate the disorder. There is little evidence to inform the use of these strategies, but features such as good lighting, low noise levels, a visible clock, a window on the outside world, and, in particular, the reassuring presence of personal possessions and familiar individuals such as relatives are all thought to be beneficial. Any invasive intervention, including personal care tasks, should be explained simply, slowly, clearly, and repeatedly before it is carried out. Holding the patient's hand while talking helps to focus their attention, and provides reassurance.