It is recognised from research done in the aged care population that environmental aspects of hospitals contribute to delirium, and environmental alterations can prevent delirium. [1] It has been suggested that rates of delirium are potentially relevant as proxy measures of the quality of in patient care.

A number of studies in aged care settings use multicomponent interventions to attempt to prevent delirium in patients at high risk. Provision of specialist geriatric medical / nursing interventions have been studied. Environmental interventions have focused on normalising sleep patterns, regular activities to maintain cognitive stimulation, limiting the use of catheters and restraints, encouraging mobilisation, regularly reorienting patients, maintaining hydration, and providing and using vision and hearing aids. These interventions involve changes in the organisation of care, and institutionalising these changes is a significant challenge. [2, 3]

A similar approach has not been studied in the palliative care setting. Questions about how settings of care affect the mental state of cognitively vulnerable palliative care patients, which aspects of the organisation of care may contribute to the incidence of delirium in palliative care patients, and how delirium impacts on patients’ ability to be cared for in different settings (including at home) have not yet been studied.

What is known

• A Cochrane review of interventions to prevent delirium identified only one study which was adequately powered to give a clinically useful result [4].  This study showed that there was a reduction in incidence and severity of delirium in patients undergoing surgery for hip fracture when a proactive geriatric consultation was provided, with a number needed to treat of 5.6. However further well planned studies are needed to understand the role of preventive strategies for delirium. [5] There are no studies of preventive approaches in a palliative care population.

What it means in practice

• There is evidence for the impact of environmental factors on cognitively vulnerable patients. [5]  It is important to consider clinical practices and features of the palliative care environment which may increase the risk or severity of delirium, or worsen disorientation, and to minimise these (eg, room and staff changes, day / night disruption, avoidable immobilisation and catheterisation, making sure patients have their hearing aids and glasses, and so on).
• This includes minimising the medication burden wherever possible, with special attention to psychoactive drugs. [6] A careful assessment of benefit and burden of any medications given to treat palliative care symptoms is necessary.
• Educating and counselling caregivers is an important aspect of managing patients at risk for delirium, or when delirium is diagnosed.

Finding out more
Guidelines

• Clinical Practice Guidelines for the Management of Delirium in Older People 
  Clinical Epidemiology & Health Services Evaluation Unit, Melbourne Health in collaboration with the Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People. Melbourne: AHMAC Health Care of Older Australians Standing Committee; 2006.

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased

Overview article

• Delirium in older people 
  Young J, Inouye SK. Delirium in older people. BMJ. 2007 Apr 21;334(7598):842-6

Related CareSearch pages

End-of-life care
Suffering

References

1. Inouye SK, Bogardus ST Jr, Charpentier JA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine. 1999 Mar 4;340(9):669-76.  
2. Inouye SK, Bogardus ST Jr, Williams CS, Leo-Summers L, Agostini JV. The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial. Archives of Internal Medicine. 2003 Apr 28;163(8):958-64.  
3. Bradley EH, Webster TR, Schlesinger M, Baker D, Inouye SK. Patterns of diffusion of evidence-based clinical programmes: a case study of the Hospital Elder Life Program. Quality and Safety in Health Care. 2006 Oct;15(5):334-8.   
4. Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database of Systematic Reviews. 2007 Apr 18;(2): CD005563.  
5. Clinical Epidemiology & Health Services Evaluation Unit, Melbourne Health in collaboration with the Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People.  Melbourne: AHMAC Health Care of Older Australians Standing Committee; 2006.  
6. Gaudreau JD, Gagnon P, Roy MA, Harel F, Tremblay A. Association between psychoactive medications and delirium in hospitalized patients: a critical review. Psychosomatics. 2005 Jul-Aug;46(4):302-16.  

This page was created on 2 September 2008 and is due for review in September 2010
Last updated 30 September 2008