Prevention

Key Point

• Prevalence of delirium in high-risk settings mandates uniform implementation of unit-wide or facility-wide preventive programs.

An evaluation of risk allows caregivers to apply preventive strategies to avoid development of delirium in high-risk individuals (Box 48-5). However, given the high prevalence in hospitalized elderly patients and in long-term care patients, and the benign nature of many of the strategies for prevention, a standardized facility-wide prevention program may be more appropriate and effective. Prevention involving nonpharmacologic strategies attempts to maintain or normalize sleep patterns, stimulate physical and mental activity consistent with the elderly person's function, maintain or restore orientation to time/person/place, avoid or correct fluid and electrolyte disturbances, maximize the accuracy of sensory perceptions, and minimize the use of catheters and physical restraints.

Benzodiazepines and anticholinergic medications are best avoided when possible. Appropriate pain relief must be balanced with the risk of narcotic-induced delirium. Meperidine creates high risk from short analgesic effect but prolonged elimination of a nonanalgesic but CNS-toxic metabolite. Trials of proactive geriatrics consultation (Marcantonia et al., 2001), nurse-led IDT protocol-based interventions (Milsen et al., 2001), and preemptive low-dose haloperidol (Kalisvaart et al., 2005) have demonstrated decreases in delirium severity in elderly patients hospitalized for repair of hip fractures.

Box 48-4 Drugs that May Cause or Contribute to Delirium

KEY TREATMENT

Geriatrics consultation, nurse-led interdisciplinary programs, and preemptive low-dose haloperidol decreased delirium severity (but not incidence) in randomized controlled trials (RCTs) or pre/post trials (Kalisvaart et al., 2005; Marcantonia et al., 2001; Milsen et al., 2001) (SOR: B).

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