Dr. Eric Foreman: What if his behavior isn’t a side effect of the ondansetron? What if it’s a symptom?
Dr. Robert Chase: Thank you.
Dr. Eric Foreman: What causes delirium and nausea?
Dr. Chris Taub: He’s been stuck here in the hospital a few days. Nobody else is sick, so it can’t be environmental...
Dr. Richardson: Not exactly stuck. I snuck out. Freedom is my birthright.
House M.D. (2010), “Now What?”
Although delirium is common, it is a serious condition with many causes, which, left untreated, can have devastating outcomes. The good news is delirium is treatable and can mitigated or prevented altogether.
Preventing or reducing the impact of delirium begins with finding the associated cause or, more correctly, causes. Maneeton and Maneeton (2013) report:
Frequently, delirium is associated with multi-factorial etiology, all possible causes, therefore, should be investigated and corrected. Because behavioral and other psychiatric disturbances are also common, psychopharmacological and psychosocial interventions are also needed in most patients. Those include the control of behavioral disturbances, preventing complications (eg, accidents, falling) and supporting functional needs.
A number of medications can ease the effects of delirium. Haloperidol, a dopamine antagonist, is the gold standard because it has a variety of administration routes and has fewer negative side effects than other medications (Maneeton & Maneeton, 2013). Chlorpromazine has also been used to treat delirium successfully (Cavallazzi et al., 2012). Researchers are also studying other antipsychotics, such as risperidone, and finding favorable results (Yoon et al., 2013).
Cholinesterase inhibitors present an intriguing area of study because anticholinergic medications are correlated to drug-induced delirium and cholinergic medications can reduce symptoms of delirium in dementia. Unfortunately, results have been mixed, with some studies showing an increase in adverse effects (Marcantonio et al., 2011). Researchers are calling for further study on the use of cholinesterase inhibitors in patients with delirium (Maneeton & Maneeton, 2013 ). Studies have shown benzodiazepine to be less useful in controlling non-alcohol-related delirium. That said, it is considered the medication of choice to treat alcoholic withdrawal delirium (Maneeton & Maneeton, 2013).
Bernadette: “What happens to our neuroreceptors when we don’t get enough REM sleep?”
Sheldon: “They lose their sensitivity to serotonin and norepinephrine.”
Bernadette: “Which leads to . . .”
Sheldon: “Impaired cognitive function.”
The Big Bang Theory (2010), “The Einstein Approximation”
Delirium, despite its serious nature, can be reduced or eliminated through many relatively simple interventions. Several large, comprehensive studies as well as a number of websites list a variety of interventions that may mitigate or eliminate delirium (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Inouye et al., 1999; American Delirium Society, 2013; Hospital Elder Life Program, 2015; National Cancer Institute, 2015.
Let’s take a closer look at the most commonly cited interventions, which we’ve grouped into five categories.
As we’ve seen from the list of causes, there are many physiologic factors that can precipitate delirium. Establishing or maintaining vital signs, elimination habits, hydration and meal times to ensure adequate nutrition and fluid intake, and managing pain or discomfort are key to managing this condition. Areas to consider managing include:
Managing the patient’s environment can have an enormous impact on preventing or reducing the severity of delirium. This category is one frequently mentioned as a primary non-pharmacological intervention for those experiencing delirium. Environmental factors to consider are:
Interacting directly with the patient (or, in some cases, not interacting) can mitigate delirious episodes. Items to consider are:
The frequent presence of family members and a familiar team of care staff are correlated with positive outcomes:
Gentle reassurances and repetition of orienting facts by nursing staff and others can decrease agitation in delirious patients: