Delirium primary prevention

Delirium Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Delirium from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Criteria
History and Symptoms
Physical Examination
Laboratory Findings
CT
MRI
Other Diagnostic Studies
Treatment
Medical Therapy
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case #1
Delirium On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Delirium All Images X-rays Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Delirium
CDC on Delirium
Delirium in the news
Blogs on Delirium
Directions to Hospitals Treating Delirium
Risk calculators and risk factors for 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.

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.

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 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 a marginal prolongation of QTc and no one developed ventricular arrhythmias.

Targeted delirium prophylaxis is key to the future management of delirium and more studies are needed on this topic.

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

Risk Factors

• Older age
• Cognitive impairment / dementia
• Physical comorbidity (biventricular failure, cancer, cerebrovascular disease)
• Psychiatric comorbidity (e.g. depression)
• Sensory impairment (vision, hearing)
• Functional dependence (e.g. requiring assistance for self-care and/or mobility)
• Dehydration / Malnutrition
• Drugs and drug-dependence
• Alcohol dependence.

Precipitating factors

Any acute factors that affect neurotransmitter, neuroendocrine or neuroinflammatory pathways can precipitate an episode of delirium in a vulnerable brain. Clinical environments can also precipitate delirium, and optimal nursing and medical care are key component of delirium prevention. Some of the most common precipitating factors are listed below:

• Metabolic
• Malnutrition
• Dehydration
• Electrolyte imbalance
• Anaemia
• Hypoxia
• Hypercapnoea
• Hypoglycaemia,
• Endocrine disorders (e.g. SIADH, Addison’s disease, hyperthyroidism, hypercalcaemia)
• Infection

• Especially respiratory and urinary tract infection

• Medication,

• Anticholinergics, dopaminergics, opioids, steroids, recent polypharmacy

• Vascular,

• Stroke/Transient ischaemic attack
• Myocardial infarction, arrhythmias, decompensated heart failure

• Physical/psychological stress
• Pain
• Iatrogenic event, esp. post-operative, mechanical ventilation in ICU
• Chronic/terminal illness, esp. cancer
• Post-traumatic event, e.g. fall, fracture
• Immobilisation/restraint
• Substance withdrawal, esp. alcohol, benzodiazepines
• Substance intoxication
• Traumatic head injury.