Interventions to prevent delirium

If you are at risk of developing delirium, your clinicians will offer care to prevent it from happening. They may do things such as checking and changing your medicines, giving you more fluids or helping you stay as mobile as possible. Your family or carers will be encouraged to be involved in your care and will be given information about delirium and how to prevent it. You will also receive regular checks on your physical condition, thinking and memory (cognition).

Cognition is the ability to put your thoughts together and communicate them.

Develop a delirium prevention plan, in partnership with the patient and family or carer, as part of a comprehensive care plan for those at risk of developing delirium.

Offer at-risk patients appropriate multicomponent interventions to prevent delirium, while considering clinical risk factors and the setting. Discuss the interventions being put in place and encourage family or carers to be involved (for example, to orient and reassure the patient). Ask the family or carer to alert the healthcare team to any changes in the patient’s mental or physical condition. Educate patients and family or carers about delirium before it occurs, to reduce distress if it does occur.

Monitor patients regularly, at least daily for changes in cognition and behaviour, and for clinical deterioration. Risk of delirium is increased post-operatively. Conduct medication reconciliation before patients are transferred between locations, or phases of care (such as before moving between wards or transferring to another facility).

Interventions for preventing delirium are listed below. These also apply to patients with delirium:

• Communicate clearly. Identify yourself and explain to the patient what is happening. You may need to repeat yourself
• Use eye contact when culturally appropriate – for example, this may be viewed as disrespectful or aggressive in Aboriginal and Torres Strait Islander culture
• Review medicines to identify any that may increase the risk of delirium and to discontinue them if appropriate
• Reconcile medicines before any transfers of care
• Perform mobilisation activities at least once or twice daily, and mobilise a patient early after a procedure
• Sit out of bed for meals
• Help patients who usually wear hearing or visual aids, and ensure that they are in good working order
• Maintain optimal hydration and nutrition, and encourage or help the patient as necessary (confirm dentures are in place)
• Regulate bladder and bowel function
• Regularly reorientate and reassure the patient
• Avoid moving the person within and between wards
• Use activities that help increase cognition – for example, reminiscence
• Use non-pharmacotherapy measures to help promote sleep (such as relaxation techniques, and using earplugs in the intensive care unit [ICU])
• Maintain a quiet environment
• Make a clock and calendar available to the patient. This may be a clock on the wall or a familiar one from home
• Provide lighting that is appropriate to the time of day
• Use effective pain management. Assess pain regularly and provide pain relief strategies
• Provide oxygen therapy where appropriate.

Ensure that policies, procedures and protocols are in place to enable clinicians to provide patients at risk of delirium with a set of preventive strategies and to conduct regular monitoring. Ensure processes are in place for clinicians to partner with patients and their family or carers when determining and implementing interventions. Ensure that staff are trained and competent in providing care to prevent and manage delirium. Identify and implement a format for prevention plans for high-risk patients.

Ensure that systems are in place for medication reconciliation to occur whenever patients are transferred between locations of care, especially when transferring out of ICU or before discharge. This is to reduce the inappropriate continuation of short-term medicines.

Ensure that policies and procedures support environmental care strategies, such as reducing noise and avoiding ward moves wherever possible for patients at risk of delirium or with delirium.

Ensure that equipment and devices, such as call bells, signs, calendars and clocks, are available to help orientate patients to decrease the risk of, or effectively manage, delirium.

Some tools for assessing delirium may not be appropriate for repeat measurement and monitoring. Tools suitable for monitoring for incident delirium include:

• Confusion Assessment Method ICU (CAM-ICU)
• Delirium Observation Screening (DOS) scale (13-item)
• Recognising Acute Delirium as Part of Your Routine (RADAR)
• Modified Richmond Agitation-Sedation Scale (mRASS)
• Single Question in Delirium (SQiD)
• Nursing Delirium Screening Scale (Nu-DESC).

Other resources include:

• NSW ACI Aged Health Network: Care of Confused Hospitalised Older Persons (CHOPS)
• Canterbury District Health Board: THINK Delirium: Preventing delirium among older people in our care. Tips and strategies from the Older Persons’ Mental Health THINK Delirium Prevention Project.