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prevention of delirium

Management: 1) identification of risk factors - risk prediction tool (the PRE-DELIRIC) used in the 1st 24 hours of the ICU stay may be of benefit [2] - risk factors include - age is the greatest risk factor in this model [2] - case type: neurologic > trauma > medical > surgical - severity of illness (APACHE-II score) - Glasgow coma scale - use of narcotics or sedatives - metabolic acidosis - renal failure 2) employ non-pharmcologic measures, minimize polypharmacy [10] 3) treat medical disorders 4) avoid dehydration 5) postoperative: keep hematocrit >= 30% 6) optimize the senses a) visual impairment (eyeglasses) b) hearing impairment (hearing aids) 7) provide orientation a) familiarize surroundings b) minimize distractions c) adequate lighting d) consistency of staff e) calendar, clock, name of facility visible 8) prevent sleep deprivation - ramelteon, a melatonin receptor agonist used to promote sleep onset, may prevent delirium in hospitalized elderly [3,9] - melatonin 0.5 mg QHS [4,5] better than ramelteon 9) supportive environment a) reduce clutter & noise b) provide adequate lighthing c) bring objects from home 10) emotional support a) caring attitude & patience b) family access c) communicate clearly - compensate for sensory loss, speak slowly - avoid jargon - reinforce with gestures d) patient & family education 11) avoid restraints 12) vigilance for urinary retention - avoid unnecessary use of urinary catheter or other unneeded catheters 13) encourage mobility ASAP with appropriate assistance & supervision 14) evidence does not support use of antipsychotics, cholinesterase inhibitors or melatonin for prevention of delirium [7,8] 15)

General

prophylaxis (prevention, ppx)

References

  1. Mahler ME, In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
  2. Van den Boogaard M, Pickkers P, Slooter AJC, et al. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicenter study. BMJ 2012; 344:e420 PMID: 22323509
  3. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Hatta K, Kishi Y, Wada K et l Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry. 2014 Apr;71(4):397-403 PMID: 24554232
  4. De Rooij SE, van Munster BC, de Jonghe A. Melatonin prophylaxis in delirium: panacea or paradigm shift? JAMA Psychiatry. 2014;71:364-365. PMID: 24554149
  5. Al-Aama T, Brymer C, Gutmanis I, et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26:687-694 PMID: 20845391
  6. Holroyd-Leduc JM, Khandwala F, Sink KM. How can delirium best be prevented and managed in older patients in hospital? CMAJ. 2010;182:265-270. PMID: 19687107
  7. Neufeld KJ, Yue J, Robinson TN, et al. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705 PMID: 27004732 Free PMC Article
  8. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016; Issue 3. Art. No.: CD005563 PMID: 26967259
  9. Wu YC, Tseng PT, Tu YK et al. Association of delirium response and safety of pharmacological interventions for the management and prevention of delirium: A network meta-analysis. JAMA Psychiatry 2019 Feb 27; [e-pub]. PMID: 30810723 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2726609 - Blazer DG. Pharmacologic intervention for the treatment and prevention of delirium: Looking beneath the modeling. JAMA Psychiatry 2019 Feb 27 PMID: 30810716 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2726605
  10. Herling SF, Greve IE, Vasilevskis EE et al Interventions for preventing intensive care unit delirium in adults. Cochrane Database Syst Rev. 2018 Nov 23;11(11):CD009783. PMID: 30484283 PMCID: PMC6373634 Free PMC article. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009783.pub2/full