Principles of managing delirium in adults
Ideally, prevent delirium, but if it occurs, the key principles of management are to identify and treat the cause(s), and start nonpharmacological management, including measures to prevent delirium, as soon as possible.
If a patient has a substitute decision-maker, keep them informed of the patient’s status and discuss management strategies with them—see also Informed consent.
A patient with delirium must be nursed in a quiet setting where they can be continuously observed—their behaviour may be unpredictable.
Approach a patient with delirium from the front, not the side—peripheral stimuli are more likely to be misinterpreted as hostile. Talk clearly and calmly and frequently orientate them (eg address them by name, explain the date and time, their location and your and other staff members’ roles and your purpose for approaching them). The patient is likely to be more settled in the presence of a familiar person (eg relative, friend, regular nursing staff member).
At minimum, review a patient with delirium daily.
Patients with delirium can accidentally harm themselves by pulling out medical lines and tubes (eg endotracheal tubes, intravascular and urinary catheters). If possible, remove these devices—this is usually more effective than trying to restrain the patient to avoid removal.
Delirium can deteriorate—be alert to signs of increasing agitation (eg persistently wanting to get out of bed and walk around). If nonpharmacological interventions have not calmed the patient:
- consider allowing the patient to wander (if it is safe to do so)
- reassure the patient (this may involve the assistance of a familiar person)
- reassess the delirium diagnosis; ensure all potential causes have been identified and adequately addressed
- consider pharmacological management—this is unnecessary for most patients, but may be required if the patient is significantly distressed, or considered to be a threat to themselves or others.
Only use physical restraint as a last resort—it usually adds to the patient’s distress and disorientation, and can cause harm. If physical restraint cannot be avoided, see here for advice.
Explain to the patient and their significant other(s), the nature of delirium and potential reasons for unusual behaviour to reduce distress. The Australian Commission on Safety and Quality in Healthcare (ACSQHC) Delirium Clinical Care Standard - Consumer fact sheet is a useful source of information.
Follow up patients with delirium.
For management of delirium: