Delirium primary prevention: Difference between revisions
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'''Cognitive decline''' | '''Cognitive decline''' | ||
:* Write names of care providers, the day’s schedule on board | :* Write names of care providers, the day’s schedule on board, | ||
:* Constantly reorient patients to surroundings | :* Constantly reorient patients to surroundings, | ||
:* Activities to stimulate cognitive unctions like discussion of current events, structured reminiscence, or word games | :* Activities to stimulate cognitive unctions like discussion of current events, structured reminiscence, or word games. | ||
'''Sleep impairment''' | '''Sleep impairment''' | ||
:* Reduce of noise | :* Reduce of noise , | ||
:* Relaxing activities such as music, back massage | :* Relaxing activities such as music, back massage. | ||
'''Immobility''' | '''Immobility''' | ||
:* Minimal use of catheter or other aids which promotes immobility | :* Minimal use of catheter or other aids which promotes immobility, | ||
:* Early mobilization | :* Early mobilization, | ||
:* Incorporation of an exercise regiment | :* Incorporation of an exercise regiment. | ||
'''Difficulties in sight''' | '''Difficulties in sight''' | ||
:* Use of visual aids, | :* Use of visual aids, | ||
:* Use of large fluorescent tapes or objects with illuminations to help in vision | :* Use of large fluorescent tapes or objects with illuminations to help in vision. | ||
'''Difficulties in hearing''' | '''Difficulties in hearing''' | ||
:* Use of aids | :* Use of aids, | ||
:* Ear care | :* Ear care. | ||
'''Dehydration''' | '''Dehydration''' | ||
:* Regular hydration | :* Regular hydration, | ||
:* Early recognition and prompt treatment<ref>{{Cite web | last = | first = | title = MMS: Error | url = http://www.nejm.org/doi/full/10.1056/NEJM199903043400901 | publisher = | date = | accessdate = }}</ref> | :* Early recognition and prompt treatment.<ref>{{Cite web | last = | first = | title = MMS: Error | url = http://www.nejm.org/doi/full/10.1056/NEJM199903043400901 | publisher = | date = | accessdate = }}</ref> | ||
===Pharmacological Interventions=== | ===Pharmacological Interventions=== | ||
Various pharmacological interventions have shown promising results in prevention of delirium, which are as follows, | Various pharmacological interventions have shown promising results in prevention of delirium, which are as follows, | ||
* Post operative delirium, | * Post operative delirium, | ||
:* [[Haloperidol]] | :* [[Haloperidol]], | ||
:* Second-generation [[antipsychotics]] | :* Second-generation [[antipsychotics]], | ||
:* Iliac fascia block | :* Iliac fascia block, | ||
:* [[Gabapentin]] | :* [[Gabapentin]], | ||
:* Lower levels of intraoperative [[propofol]] sedation | :* Lower levels of intraoperative [[propofol]] sedation, | ||
:* A single dose of [[ketamine]] during anesthetic induction | :* A single dose of [[ketamine]] during anesthetic induction, | ||
*Mechanically ventilated medical and surgical ICU patients, | *Mechanically ventilated medical and surgical ICU patients, | ||
:* Continuous intravenous infusion of [[dexmedetomidine]] | :* Continuous intravenous infusion of [[dexmedetomidine]] | ||
* Acutely ill general medical patients population, | * Acutely ill general medical patients population, | ||
:* Melatonin<ref>{{Cite web | last = | first = | title = http://ajp.psychiatryonline.org/article.aspx?articleID=1795082 | url = http://ajp.psychiatryonline.org/article.aspx?articleID=1795082 | publisher = | date = | accessdate = }}</ref> | :* Melatonin.<ref>{{Cite web | last = | first = | title = http://ajp.psychiatryonline.org/article.aspx?articleID=1795082 | url = http://ajp.psychiatryonline.org/article.aspx?articleID=1795082 | publisher = | date = | accessdate = }}</ref> | ||
===Haloperidol=== | ===Haloperidol=== | ||
Delirium possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-intubations. | 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. Following benefits were observed, | Low dose [[haloperidol]], if given prophylactically in lower doses, have a better prognosis than treatment of delirium. Following benefits were observed, | ||
* Lower mortality | * Lower mortality, | ||
* Lower delirium incidence | * Lower delirium incidence, | ||
* More delirium free days | * More delirium free days, | ||
* Patients are less likely to remove their tubes or catheters | * Patients are less likely to remove their tubes or catheters, | ||
* Patients with a higher risk of developing delirium benefited more | * Patients with a higher risk of developing delirium benefited more, | ||
* ICU readmission rate was lower | * ICU readmission rate was lower. | ||
====Drawbacks for Prophylactic Treatment with Haloperidol==== | ====Drawbacks for Prophylactic Treatment with Haloperidol==== | ||
* Unnecessary treatment to patients who were not destined to develop delirium | * Unnecessary treatment to patients who were not destined to develop delirium, | ||
* Side effects of treatment, however during clinical studies there was only marginal prolongation of [[QTc]] and no one developed [[ventricular arrhythmias]]. | * Side effects of treatment, however during clinical studies there was only marginal prolongation of [[QTc]] and no one developed [[ventricular arrhythmias]]. | ||
Targeted delirium prophylaxis is key to the future management of delirium. More studies are needed on this topic. | Targeted delirium prophylaxis is key to the future management of delirium. More studies are needed on this topic. | ||
Revision as of 18:57, 21 February 2014
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Delirium Microchapters |
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Diagnosis |
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Treatment |
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Delirium On the Web |
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American Roentgen Ray Society Images of Delirium |
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 to prevent recurrence of delirium once delirium has set it. This is why primary prevention is more important. Following are a few preventive strategies for delirium;
Cognitive decline
- Write names of care providers, the day’s schedule on board,
- Constantly reorient patients to surroundings,
- Activities to stimulate cognitive unctions like discussion of current events, structured reminiscence, or word games.
Sleep impairment
- Reduce of noise ,
- Relaxing activities such as music, back massage.
Immobility
- Minimal use of catheter or other aids which promotes immobility,
- Early mobilization,
- Incorporation of an exercise regiment.
Difficulties in sight
- Use of visual aids,
- Use of large fluorescent tapes or objects with illuminations to help in vision.
Difficulties in hearing
- Use of aids,
- Ear care.
Dehydration
- Regular hydration,
- Early recognition and prompt treatment.[1]
Pharmacological Interventions
Various pharmacological interventions have shown promising results in prevention of delirium, which are as follows,
- 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.[2]
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. 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 for 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 marginal prolongation of QTc and no one developed ventricular arrhythmias.
Targeted delirium prophylaxis is key to the future management of delirium. More studies are needed on this topic. [3]
Prediction of Delirium in ICU
Early prediction of development of delirium in intensive care is very crucial to start non pharmacological treatment and starting prophylactic haloperidol treatment. PRE-DELIRIC model is used to predict delirium in ICU. Automatic version of the PRE-DELIRIC model (Excel and web based) can be downloaded at http://www.umcn.nl/Research/Departments/intensive%20care/Documents/Pre-deliric%20model.htm?language=english, Complete information is available at http://www.umcn.nl/Research/Departments/intensive%20care/Pages/vandenBoogaard.aspx [4]
References
- ↑ "MMS: Error".
- ↑ "http://ajp.psychiatryonline.org/article.aspx?articleID=1795082". External link in
|title=(help) - ↑ "Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI".
- ↑ "Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI".