Managing Delirium in Care Homes

Introduction to Delirium Management

The American College of Physicians recommends immediately implementing a multicomponent nonpharmacologic intervention protocol while simultaneously conducting a focused medical evaluation to identify and treat the underlying cause of delirium, with high strength of evidence 1

The Confusion Assessment Method (CAM) should be used to confirm delirium presence, which takes only 2-5 minutes and has the highest psychometric properties for detection, according to the American Geriatrics Society 1
Cardinal features of delirium include acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness, as stated by the American Psychiatric Association 1
Underlying medical causes of delirium, such as medications, infections, metabolic derangements, alcohol or drug withdrawal, and pain, should be identified and treated, as recommended by the Society of Hospital Medicine 1

Multicomponent nonpharmacologic interventions can prevent or reverse approximately one-third of delirium cases and should be implemented immediately, with moderate strength of evidence, according to the American College of Physicians 1, 2

Regular reorientation using visible clocks and calendars should be provided, as recommended by the American Geriatrics Society 2
Adequate lighting and clear signage should be ensured, according to the American Institute of Architects 2
Room changes should be minimized and care team consistency should be maintained, as stated by the Society of Hospital Medicine 2
Noise and interruptions during sleep hours should be reduced to maintain normal day-night cycles, with high strength of evidence, according to the American Academy of Sleep Medicine 3, 2

Hearing aids and eyeglasses should be available, used, and in good working order, as recommended by the American Speech-Language-Hearing Association 3, 2
Reversible sensory impairments, such as impacted ear wax, should be resolved, according to the American Academy of Otolaryngology 3

Early mobilization and rehabilitation should be promoted, with moderate strength of evidence, according to the American Physical Therapy Association 2, 4
Adequate hydration and nutrition should be ensured, as recommended by the Academy of Nutrition and Dietetics 2, 4
Hypoxia should be addressed and oxygenation should be optimized, according to the American Thoracic Society 2
Infections should be treated promptly, as stated by the Infectious Diseases Society of America 2
Pain should be managed effectively, preferably with nonopioid medications, with high strength of evidence, according to the American Pain Society 2, 4

Nursing or medical procedures during sleeping hours should be avoided when possible, as recommended by the American Academy of Sleep Medicine 5, 3
Medication rounds should be scheduled to avoid disturbing sleep, according to the American Society of Health-System Pharmacists 5, 3
Noise should be reduced to a minimum during sleep periods, with high strength of evidence, according to the American Academy of Sleep Medicine 5, 3

Antipsychotics and benzodiazepines should be avoided for routine delirium treatment, particularly for hypoactive delirium, with high strength of evidence, according to the American Psychiatric Association 1, 2
Low-dose antipsychotics should be considered only for severely agitated patients with distressing psychotic symptoms, patients threatening substantial harm to themselves or others, or symptoms refractory to nonpharmacologic interventions, as recommended by the American College of Physicians 1, 4
The lowest effective dose of antipsychotics should be used for the shortest possible duration and discontinued immediately following resolution of distressing symptoms, with moderate strength of evidence, according to the American Geriatrics Society 4

Benzodiazepines should not be used as sleep enhancers, as they may be associated with causing delirium, with high strength of evidence, according to the American Academy of Sleep Medicine 5, 3
Medications with high risk for precipitating delirium should be avoided, as recommended by the American College of Physicians 2

Mental status should be reassessed regularly using the CAM and interventions should be adjusted based on symptom control and patient distress, with moderate strength of evidence, according to the American Geriatrics Society 1, 2
Educational support and written information about delirium should be provided to families, as recommended by the American Medical Association 1, 2
Medication side effects, particularly extrapyramidal symptoms if antipsychotics are used, should be monitored, according to the American Psychiatric Association 2

Delirium is associated with increased mortality, prolonged hospitalization, and development of long-term cognitive impairment, with high strength of evidence, according to the American College of Physicians 1
The multicomponent nonpharmacologic approach is cost-effective and improves health outcomes compared with usual care, as stated by the American College of Physicians 2
Care homes have particularly high risk for delirium due to clustering of risk factors, especially older age and dementia, making prevention and early intervention critical, with moderate strength of evidence, according to the American Geriatrics Society 5, 3