Non-pharmacological approaches are used to encourage sleep, such as warm milk, herbal tea, back rubs and relaxation music. Noise levels are minimised and medication and treatment schedules are coordinated to prevent sleep deprivation. If prevention fails and delirium develops (as it still does, even using the best preventative strategies, albeit at a lower rate), then a concerted effort must be made to discover and treat precipitating factors.
Prompt action can prevent further, potentially fatal, complications. Continuing assessment is important to gauge the effectiveness of therapeutic interventions. Patients who develop delirium should be managed, if possible, with a non-pharmacological approach using methods similar to those proposed for prevention (Inouye 2000). Inouye (2000) warns that medications with psychoactive effects (including sedative-hypnotics, narcotics, and anticholinergic drugs) are among the most frequent contributors to delirium. The use of these and other medications should always be reviewed whenever a patient displays signs of acute confusion.
Physical or chemical restraints are considered last-resort and short-term management strategies, used only with patients who become severely agitated or who pose a danger to themselves or staff (Flaherty 2003, Inouye 2000). Physical restraints are likely to compound the psychological distress already felt by acutely confused patients and may well contribute to the confusional state (Fletcher 1996). Chemical restraints may result in masking underlying problems, they may also have unwanted sedative effects or they may interact with already prescribed medications (Fletcher 1996). It is much better to manage agitated, confused patients with imagination and intelligence.
Conclusion
Elders are prone to develop acute confusion after being admitted to hospital. However, this condition is seldom diagnosed and rarely treated in a rational fashion by health care workers. Too often acute confusion is considered to be a natural occurrence that accompanies old age. Failure to assess risk factors and address underlying causes can result in extended periods of illness, and increased mortality.
Older patients who are admitted to hospital should be assessed for predisposing vulnerabilities so that appropriate therapeutic measures can be introduced. Levels of hydration, electrolyte imbalances, nutritional status, sensory deficits, infections, chronic illnesses, medication usage, and cognitive function should all be addressed as they are known to affect vulnerability to delirium. In addition, preventative measures that maintain cognitive function, encourage mobility, and orient the elder patient to the ward should be standard practice.
If delirium develops, precipitating factors should be immediately suspected and investigated. Prompt action at this stage can prevent further, potentially fatal, complications. Additional supportive measures based on old-fashioned empathy and care and the avoidance of physical or chemical restraints are recommended to help confusion abate and restore normal cognitive function.
References
Aditya BS, & Sharma JC 2003 Predictors of a nursing home placement from a non-acute geriatric hospital. Clinical Rehabilitation 17:108-113 American Psychiatric Association 1999 Practice guideline for the treatment of patients with delirium. (On line accessed August 12, 2003) URL: http://www.psych.org/clin_res/pg_delirium_1.cfm Baker H 1999 Medication issues. In: Nay R & Garratt S (eds) Nursing older people: Issues and innovations, MacLennan and Petty, Sydney: 266-280