Delirium primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]

Overview

It is important to prevent delirium as delirium is itself neurotoxic. It is associated with global brain atrophy and white matter disruption. Various non pharmacological and pharmacological interventions are found to be effective to prevent delirium.

Primary Prevention

Non Pharmacological Interventions

Targeted symptomatic intervention can help prevent the emergence of delirium, however, non pharmacological approaches can curtail the incidence of delirium and not effective in preventing recurrence of delirium once delirium has set it. This is why primary prevention is more important. Following are a few preventive strategies for delirium;

Curtail cognitive decline

• Write names of care providers, the day’s schedule on board
• Constantly reorient patients to surroundings
• Activities to stimulate cognitive actions like discussion of current events, structured reminiscence, or word games

Curtail sleep impairment

• Reduce environmental noise
• Relaxing activities such as music, back massage

Curtail immobility

• Minimal use of catheter or other aids which promotes immobility
• Early mobilization
• Incorporation of an exercise regiment

Manage difficulties in sight

• Use of visual aids
• Use of large fluorescent tapes or objects with illuminations to help in vision

Manage difficulties in hearing

• Use of aids
• Ear care

Avoid dehydration

• Regular hydration
• Early recognition and prompt treatment.

Pharmacological Interventions

• Post operative delirium

• Haloperidol
• Second-generation antipsychotics
• Iliac fascia block
• Gabapentin
• Lower levels of intraoperative propofol sedation
• A single dose of ketamine during anesthetic induction
• Mechanically ventilated medical and surgical ICU patients
• Continuous intravenous infusion of dexmedetomidine
• Acutely ill general medical patients population
• Melatonin

Haloperidol

Delirium possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-intubations. Low dose haloperidol, if given prophylactically in lower doses, have a better prognosis than treatment of delirium.

• The following benefits were observed:
• Lower mortality
• Lower delirium incidence
• More delirium free days
• Patients are less likely to remove their tubes or catheters
• Patients with a higher risk of developing delirium benefited more
• ICU readmission rate was lower.

• Drawbacks of prophylactic treatment with Haloperidol:

• Unnecessary treatment to patients who were not destined to develop delirium
• Side effects of treatment, however during clinical studies there was only a marginal prolongation of QTc and no one developed ventricular arrhythmias.