Hospitalist Offers Tips on Recognizing, Preventing, and Treating Delirium

   According to Brian Huang, MD, Assistant Professor of Medicine in the Division of Hospital Medicine at the University of California at San Diego, key to treating agitation and delirium in the hospital is to avoid benzodiazepines. He spoke at Internal Medicine 2011, the annual meeting of the American College of Physicians in San Diego.

   Likewise, evidence is scant for the use of antipsychotics in patients with mild, non-agitated delirium. For those with significant delirium/agitation, he noted a Cochrane review that found haloperidol is best. But “You may want to take a baseline EKG to look at the QT interval before prescribing this drug," Dr. Huang said.

   Before treatment comes diagnosis, of course, and that's not always easy. Between 15% and 50% of patients have delirium in the hospital, and it’s thought to be more common in the postoperative setting. Yet the condition is unrecognized in most.

   Risk factors include age greater than 65, dementia, functional dependence or immobility, multiple comorbidities and medications, visual or hearing impairment, and chronic renal disease. High-risk situations for delirium include dehydration, infection at admission, electrolyte abnormalities, hypoxia, hypoglycemia, neurologic disorder, and untreated pain, Dr. Huang said. Some drugs carry a higher risk of delirium, including anticholinergics, antidepressants, opiates, steroids, benzodiazepines, anticonvulsants, and insomnia medications

   Clinical features of delirium include disturbances of consciousness, arousal and awareness; attention, perceptual and cognitive disturbances; disorientation; disorganized thinking; delusions; psychomotor disturbances; sleep-wake cycle disturbances; and acute onset.

   "A nurse or family member can help inform as to whether what you are observing is baseline behavior, or there has been a shift,” Dr. Huang said.

   According to him, hospital staff can take a number of actions to help prevent delirium in those at risk. These include removing physical restraints and encouraging early mobilization for patients with immobility; providing orienting communication to those with cognitive impairment; using appropriate aids for those with visual and/or hearing impairment; preventing and correcting dehydration; and providing uninterrupted sleep to those with sleep deprivation.

   Mobilization is especially important. “One of my pet peeves is doctors who order bed rest for patients with delirium,” Dr. Huang said. “I think in many cases activity with assistance is best indicated.”

   To avoid disturbing the sleep-wake cycle, physicians should prescribe medications to be taken as infrequently as possible during the 24-hour cycle, and locate the patient’s bed closer to a window to provide a better sense of day and night, he added.