Mohammed T. Abou-Saleh

DELIRIUM—AN OVERVIEW 181Table 35.2Risk factors for delirium and intervention protocolsTargeted risk factor and eligible patients Standardized intervention protocols Targeted outcome for reassessmentCognitive impairment*All patients, protocol once daily; patients withbase-line MMSE score of 520 or orientationscore of 58, protocol three times dailySleep deprivationAll patients; need for protocol assessed once dailyImmobilityAll patients; ambulation whenever possible, andrange-of-motion exercises when patientschronically non-ambulatory, bed- or wheelchairbound,immobilized (e.g. because of extremityfracture or deep venous thrombosis), or whenprescribed bed restVisual impairmentPatients with 520/70 visual acuity on binocularnear-vision testingHearing impairmentPatients hearing 46 of 12 whispers on Whisper TestDehydrationPatients with BUN:creatinine ratio 418,screened for protocol by geriatric nurse-specialistOrientation protocol: board with names of care-teammembers and day’s schedule; communication toreorientate to surroundingsTherapeutic activities protocol: cognitivelystimulating activities three times daily(e.g. discussion or current events, structuredreminiscence or word games)Non-pharmacologic sleep protocol: at bedtime,warm drink (milk or herbal tea), relaxation tapesor music, and back massageSleep enhancement protocol: unit-wide noisereduction strategies (e.g. silent pill crushers,vibrating beepers and quiet hallways) and scheduleadjustments to allow sleep (e.g. rescheduling ofmedications and procedures)Early mobilization protocol: ambulation or activerange of motion exercises three times daily; minimaluse of immobilizing equipment (e.g. bladdercatheters or physical restraints)Vision protocol: visual aids (e.g. glasses or magnifyinglenses) and adaptive equipment (e.g. large illuminatedtelephone keypads, large-print books andfluorescent tape on call bell), with daily reinforcementof their useHearing protocol: portable amplifying devices, earwaxdisimpaction, and special communication techniques,with daily reinforcement of these adaptationsDehydration protocol: early recognition of dehydrationand volume repletion (i.e. encouragement oforal intake of fluids)Change in orientation scoreChange in rate of use of sedative drugfor sleep {Change in Activities of Daily LivingscoreEarly correction of vision, 448 hoursafter admissionChange in Whisper Test scoreChange in BUN:creatinine ratio*The orientation score consisted of results on the first 10 items on the Mini-Mental State Examination (MMSE).{ Sedative drugs included standard hypnotic agents, benzodiazepine and antihistamines, used as needed for sleep.Finally, delirium is a mental disorder and as such comes underthe English Mental Health Act. Very occasionally, therefore, itmay be legitimate to use the Mental Health Act to facilitate thetreatment of delirium.SUMMARYDelirium remains a common, under-diagnosed symptom ofunderlying physical illness in older people. This alone makes itan important health economic issue. Primary prevention ofdelirium is now of proved efficacy and, generally, the prognosisof delirium is that of the underlying physical disorder.REFERENCES1. Inouye SK, Viscoli CM, Horwitz RI et al. A predictive model fordelirium in hospitalised elderly medical patients based upon admissioncharacteristics. Ann Intern Med 1993; 119: 474–81.2. Stevens LE, de Moore GM, Simpson JM. Delirium in hospital: does itincrease length of stay? Aust NZ J Psychiat 1998; 32(6): 805–8.3. Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors inelderly hospitalised patients. J Gen Int Med 1998; 13(3): 204–12.4. Robertsson B, Blennow K, Gottfris CG, Walkin A. Delirium indementia. Int J Geriat Psychiat 1998; 13(1): 49–56.5. 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