Clinical management

Caring for delirious patients on the busy general wards of overstretched hospitals often presents problems. In most situations in developed countries, the initial assessment and treatment is the responsibility of physicians.

The role of the liaison psychiatrist is to help where the diagnosis is unclear and to advise on treatment, including the organization of consistent nursing care. It is often necessary to explain the diagnosis and likely prognosis to ward staff, who may believe the patient is 'going mad' or 'becoming psychotic', and seek their inappropriate removal to psychiatric care/4)

Doctors are often asked to assess delirium as an urgent clinical problem. Although it is essential to treat immediate problems effectively, it is also necessary to establish a continuing, but flexible, regime of management over a period of days. This requires regular medical and nursing review. The main principles are summarized in Table 3.

Table 3 Management of delirium

In all patients, good general medical and nursing care is required. This includes adequate hydration, and measures to control fever if present. Bowel and pressure area care are important.

• Special one-to-one nursing is often needed, sometimes in a side-room. The use of bright light may help patients with prominent visual hallucinations.

• Patients need reassurance and reorientation to reduce anxiety and disorientation; this should be repeated frequently.

• Relatives find delirium upsetting and they require a clear explanation for the disorder so as to relieve their own anxiety and to help them to join in reassuring and reorienting the patient.

• In hospital, a predicable and consistent routine should be planned. It may be that this is best provided by nursing the patient in a quiet single room. Relatives and friends should be encouraged to visit frequently and help to reassure the patient. There should be enough light throughout the night to enable the patient to know easily where he is but not so much that sleep is disturbed.

• It is important to give as few drugs as possible, since these may worsen the delirium.

Sedation should not be used merely because the patient has delirium. If he is drowsy and underactive, or if he merely has muddled thinking or perceptual disturbance, medication should be avoided as the drugs themselves will tend to make the patient drowsy and therefore militate against recovery from the delirium itself.

However, medication may be necessary if the patient is severely distressed or in danger of injuring himself or others. (4) In acute situations, it may be necessary to start with injected medication or with relatively large oral doses in liquid form, but the aim should be to move towards regular oral doses, which are reviewed daily. The drug of choice depends on patient characteristics. Response is unpredictable and the prescriber should be prepared to modify the type of drug and dosage as necessary.

Major tranquillizers may be the first choice. Haloperidol is the preferred drug of some authorities, (3) although this does not seem to be based on randomized trial evidence of superiority. Delirious patients are very susceptible to parkinsonian side-effects, and so starting doses should be low, especially in the elderly. Among the phenothiazines, promazine is a useful sedative with less anticholinergic action than chlorpromazine and so is less prone to add to cognitive problems.

Benzodiazepines are an alternative; they may be also be helpful in re-establishing the sleep-wake cycle, but often at the cost of increased daytime drowsiness. Therefore a short-acting agent should usually be chosen.

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