Delirium primary prevention: Difference between revisions
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==Primary Prevention== | ==Primary Prevention== | ||
===Non Pharmacological Interventions=== | ===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 | 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; | ||
'''Cognitive decline''' | '''Cognitive decline''' | ||
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:* 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 | :* Reduce environmental noise | ||
:* Relaxing activities such as music, back massage | :* Relaxing activities such as music, back massage | ||
'''Immobility''' | '''Immobility''' | ||
Revision as of 02:23, 14 March 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 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;
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 environmental 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. 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. [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]
Risk Factors
Modifiable Risk Factors
- Sensory impairment (hearing or vision)
- Immobilization (catheters or restraints)
- Offending drugs (for example, sedative hypnotics, narcotics, anticholinergic drugs, corticosteroids, polypharmacy, withdrawal of alcohol or other drugs)
- Acute neurological pathology (for example, acute stroke [usually right parietal], intracranial hemorrhage, meningitis, enkephalitis)
- Intercurrent illness (for example, infections, iatrogenic complications, severe acute illness, anemia, dehydration, poor nutritional status, fracture or trauma, HIV infection)
- Metabolic impairment
- Surgery
- Stressful surroundings (for example, admission to an intensive care unit)
- Pain
- Emotional stress
- Lack of sleep
Non-Modifiable Risk Factors
- Cognitive impairment
- Older age (>65 years)
- History of delirium, stroke, neurological disease, falls or gait disorder
- Associating multiple medical aliments
- Gender: Male over females
- Renal or hepatic pathology[5]
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.[6] 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.
References
- ↑ "MMS: Error".
- ↑ "Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI".
- ↑ "Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI".
- ↑ "Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI".
- ↑ "Delirium in elderly adults: diagnosis, prevention and treatment".
- ↑ Inouye, SK (Mar 4, 1999). "A multicomponent intervention to prevent delirium in hospitalized older patients". The New England Journal of Medicine. 340 (9): 669–76. doi:10.1056/NEJM199903043400901. PMID 10053175. Unknown parameter
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