For delirium, manage environment as well as meds

Providing adequate lighting and reducing clutter are two examples.

Margaret M. Beliveau, MD, FACP, once worked at an institution where orthopedic residents routinely ordered labs drawn at 2 a.m. They wanted the results to be available later in the morning, when they made rounds. But while this may have helped the residents, it didn't help their patients, Dr. Beliveau told her audience during a session titled “Delirium in the Hospitalized Patient” at Internal Medicine Meeting 2018.

Dr Beliveau Photo by Kevin Berne
Dr. Beliveau. Photo by Kevin Berne

“As you can imagine, if you're sound asleep and somebody comes in and wakes you up and sticks a needle in your arm in the middle of the night, I don't know, I'd probably get a little confused too,” she said.

Managing environment is an important part of dealing with delirium, which affects over 2.6 million adults in the U.S., leads to $164 billion in health care costs, and has a substantial negative impact on function and quality of life, including an increased risk for death, institutionalization, and dementia, Dr. Beliveau noted. She offered attendees several management tips, as well as some advice on pharmacologic therapy.

Provide adequate lighting. Low-level lighting at night, plus a quiet environment, is very important, said Dr. Beliveau, who is an associate professor of medicine and regional dean at Chicago Medical School at the Rosalind Franklin University of Health & Science and a member of the internal medicine residency faculty at the Billings Clinic in Billings, Mont. However, she noted, “Adequate lighting does not mean the bright overhead lights over their bed are on 24/7. That's actually probably worse. But there should be a nightlight available.”

Reduce clutter. “If there's a million things all over the room, there's IV bags that are hanging on poles and they're not going into the patient, all that junk should get out of there,” she said.

Make clocks and calendars available. But make sure they're correct, Dr. Beliveau said. “If there's snow on the ground and the calendar says it's July 4, that's probably not going to be helpful to the patient.”

Promote presence of family members. “This is a situation where I welcome family members to be as available as they possibly can,” she said.

Have familiar things in the room. “Have that afghan that Mom usually puts over her legs when she sits in a rocking chair ... a picture of a family member, all of those things are actually really important and really do help,” she said.

Maintain patients' sleep-wake cycles. Dr. Beliveau recommended implementing a sleep enhancement policy stating that patients should not be disturbed between 10 p.m. and 7 a.m. unless medically necessary.

“That doesn't mean you shut the door to their room and you never look at them all night long. But it means the nurses can go in, check them quietly, see if they're asleep, and if necessary do other things. But you don't wake up a sleeping patient,” she said.

Keep patients moving and promote self-care. “When you have a confused patient like this, I think it's very easy for the nurses to go in and say, ‘Hmm, let me just help you do a bed bath, whatever, and then we'll move on,’ but these patients need to be taking care of themselves as much as possible,” she said. “They need to be out of bed.”

Additional management tips include removing catheters as soon as possible, involving physical and occupational therapists to improve activities of daily living, and avoiding restraints at all costs. “Sitters are better than restraints,” Dr. Beliveau said.

A few other potential interventions, such as pet therapy, aromatherapy, and cognitive stimulation, are unproven but could provide benefit, Dr. Beliveau said. “Keep them oriented and try to engage them in conversation. Maybe get them doing small crossword puzzles, if they used to do that, or have somebody playing cards with them,” she said. “Those kind of cognitive activities might be helpful, and they're not harmful.”

When patients with delirium are so agitated that clinicians have difficulty caring for them, it is time to consider the use of antipsychotics, Dr. Beliveau said. She referred to recommendations from the American Geriatrics Society, which call for using the lowest effective dose for the shortest possible duration only in patients who are severely agitated, distressed, or threatening substantial harm to themselves, others, or both.

“If you don't take anything else away from this, please remember that,” Dr. Beliveau stressed. “We only use antipsychotics in patients who are threatening harm. Don't use them in any other circumstances.”

Physicians should “start low, go slow” when prescribing antipsychotics, she said. Use one drug, watch the QTc interval, and reassess every 24 hours, she advised. “Try to maintain an effective dose for a day or two, and then start to taper,” she said.

Drug options include quetiapine, 12.5 to 25 mg twice daily; olanzapine, 2.5 to 5 mg twice daily; risperidone, 0.5 to 1 mg twice daily; and haloperidol, oral or IV, 0.25 to 0.5 mg. “Risperidone, by the way, should not be used in patients with Lewy body dementia. It can actually make them worse,” Dr. Beliveau said.

She noted that her favorite of the antipsychotic options for managing delirium is haloperidol. “You can give very small doses, and you can give it either orally or IV or [intramuscularly], ... so you can gradually increase the dose without making the patient so sedated that you can't wake them up for eight hours,” she said. The maximum daily dose is about 3 to 5 mg, she said.

Data on use of antipsychotics in delirium are somewhat lacking, Dr. Beliveau acknowledged. She referred to a meta-analysis published in 2016 in the Journal of the American Geriatrics Society, which found that current evidence does not support use of the drugs for prevention or treatment of delirium in hospitalized adults.

“I will tell you, for prevention, I think that's absolutely true,” she said. “I think for treatment, we're kind of stuck, because we don't have a lot of other good options for managing these severely agitated patients.” Benzodiazepines, for example, are only indicated for management of delirium associated with alcohol or benzodiazepine withdrawal, she noted.

“Really, there is no FDA-approved drug for delirium,” Dr. Beliveau said. “So we cautiously use antipsychotics in patients who are threatening harm. We only use benzos in patients who have alcohol or benzo withdrawal. But there's really no good agents here.”