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.

Pharmacologic Strategies

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).

Simple Interventions

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.

Physiologic Supports

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:

• Temperature
• Blood pressure
• Fluids/electrolytes
• Blood Glucose
• Oxygenation
• Nutrition
• Elimination
• Pain management (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Maneeton & Maneeton, 2013; van Rompaey et al., 2009)

Environment

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:

• Light. Make sure light is adequate to see well, but not harsh.
• Sound. Reduce noise. TV or music may be promote relaxation and orientation, but monitor the patient as sound can also be a stimulant.
• Familiar objects from home. Encourage family members to bring familiar objects from home such as pictures, books, or religious accessories. (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Cavallazzi et al., 2012; American Delirium Society, 2013; Hospital Elder Life Program, 2015)

Physical Supports

Interacting directly with the patient (or, in some cases, not interacting) can mitigate delirious episodes. Items to consider are:

• Avoiding restraints. Almost all studies reviewed for this course stated that restraints should be avoided if at all possible.
• Avoiding catheters. Like restraints, several studies called for the avoidance of urinary catheters or reduce their use.
• Establishing mobility. Several studies and resources cite the importance of establishing mobility after surgery, even if the patient is still on a ventilator, to reduce or prevent delirium
• Sleep/wake habits. Access to daylight during the day and reduced at night to maintain sleep/wake patterns was an important protocol cited in several studies, especially for those in the ICU. Other studies suggested scheduling medication administration to different times to reduce disruption of sleep.
• Glasses, hearing aids, dentures. Having the patient’s eyeglasses, hearing aids, and/or dentures were key interventions reported in several studies as these simple aids helped to keep patients oriented to their surroundings. (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Cavallazzi et al., 2012; van Rompaey et al., 2009)

Social Supports

The frequent presence of family members and a familiar team of care staff are correlated with positive outcomes:

• Family members. Family members are encouraged to visit as often as possible. Having loved ones sit with the patient around the clock, if possible, has proven beneficial.
• Care team. Maintain a consistent care team to minimize confusion. (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Van Rompaey et al., 2009)

Orientation/Communication Techniques

Gentle reassurances and repetition of orienting facts by nursing staff and others can decrease agitation in delirious patients:

• Orientation. Along with environmental cues, placing a clock and calendar where the patient can see them helps with maintaining orientation. Repeat reminders about the date, time, and location if it seems to calm the patient.
• Simple instructions. Keep instructions simple and clear. Repeat instructions as necessary, but allow enough time to respond.
• Reassurance. Provide reassurance to the patient to reduce agitation. (Registered Nurses’ Association of Ontario, 2010; Canadian Coalition for Seniors’ Mental Health, 2006; Cavallazzi et al., 2012)