Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.
David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”
To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.
Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.
If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.
If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5
If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.
Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.
“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”
Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.
“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.