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==Overview==
==Overview==
It is important to prevent delirium as delirium is itself neurotoxic. It is associated with global brain atrophy and white matter disruption.  Various non pharmacological and pharmacological interventions are found to be effective to prevent delirium.
It is important to prevent [[delirium]] as [[delirium]] is itself [[neurotoxic]]. [[Delirium]] is associated with global [[brain]] atrophy and [[white matter]] disruption.  Various non pharmacological and pharmacological interventions are found to be effective to prevent [[delirium]]. [[Primary prevention]] sterategy for Post-operative [delirium]] include use of [[haloperidol]], second generation [[antipsychotics]], iliac fascia block, lower levels of intraoperative [[ propofol]]  for sedation, continuous intravenous infusion of [[dexmedetomidine]], [[Melatonin]]. [[ketamine]] is not useful in preventing postoperative [[delirium]]. Preoperative administration of [[gabapentin]] is not effective for prevention of postoperative [[delirium]].
 
==Primary Prevention==
==Primary Prevention==
Effective measures for the primary prevention of [[delirium]] include pharmacologic and nonpharmacologic approaches.
===Non Pharmacological Interventions===
===Non Pharmacological Interventions===
Targeted symptomatic intervention can help prevent the emergence of delirium, however, non pharmacological approaches can curtail the incidence of delirium and not effective to prevent recurrence of delirium once delirium has set it. This is why primary prevention is more important.  Following are a few preventive strategies for delirium;
*Nonpharmacological approaches may curtail the incidence of [[delirium]].  
* Following are a few preventive strategies for [[delirium]]:<ref name="pmid29997660">{{cite journal |vauthors=Ghaeli P, Shahhatami F, Mojtahed Zade M, Mohammadi M, Arbabi M |title=Preventive Intervention to Prevent Delirium in Patients Hospitalized in Intensive Care Unit |journal=Iran J Psychiatry |volume=13 |issue=2 |pages=142–147 |date=April 2018 |pmid=29997660 |pmc=6037578 |doi= |url=}}</ref>
 
'''Curtail [[cognitive]] decline'''
:* Write names of care providers, the day’s schedule on board
:* Constantly reorient [[patients]] to surroundings
:* Activities to stimulate [[cognitive]] actions like discussion of current events, structured [[reminiscence]], or word games
'''Curtail [[sleep]] impairment'''
:* Reduce [[environmental]] noise
:* Relaxing activities such as [[ music]], back massage
'''Curtail [[immobility]]'''
:* Minimal use of [[catheter]] or other aids which promotes immobility
:* Early mobilization
:* Incorporation of an [[exercise]] regiment
'''Manage difficulties in sight'''
:* Use of [[visual]] aids
:* Use of large fluorescent tapes or objects with illuminations to help in [[vision]]
'''Manage difficulties in [[hearing]]'''
:* Use of [[aids]]
:* [[Ear]] care
'''Avoid [[dehydration]]'''
:* Regular [[hydration]]
:* Early recognition and prompt [[treatment]].<ref>{{Cite web  | last =  | first =  | title = MMS: Error | url = http://www.nejm.org/doi/full/10.1056/NEJM199903043400901 | publisher =  | date =  | accessdate = }}</ref>


'''Cognitive decline'''
:* Write names of care providers, the day’s schedule on board,
:* Constantly reorient patients to surroundings,
:* Activities to stimulate cognitive unctions like discussion of current events, structured reminiscence, or word games.
'''Sleep impairment'''
:* Reduce of noise ,
:* Relaxing activities such as music, back massage.
'''Immobility'''
:* Minimal use of catheter or other aids which promotes immobility,
:* Early mobilization,
:* Incorporation of an exercise regiment.
'''Difficulties in sight'''
:* Use of visual aids,
:* Use of large fluorescent tapes or objects with illuminations to help in vision.
'''Difficulties in hearing'''
:* Use of aids,
:* Ear care.
'''Dehydration'''
:* Regular hydration,
:* Early recognition and prompt treatment.<ref>{{Cite web  | last =  | first =  | title = MMS: Error | url = http://www.nejm.org/doi/full/10.1056/NEJM199903043400901 | publisher =  | date =  | accessdate = }}</ref>
===Pharmacological Interventions===
===Pharmacological Interventions===
Various pharmacological interventions have shown promising results in prevention of delirium, which are as follows,
 
* Post operative delirium
* Primary prevention sterategy for Post operative [[ patients]] [[delirium]] include the following:<ref name="pmid31354253">{{cite journal |vauthors=Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L |title=Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis |journal=Clin Interv Aging |volume=14 |issue= |pages=1095–1117 |date=2019 |pmid=31354253 |pmc=6590846 |doi=10.2147/CIA.S201323 |url=}}</ref>
:* [[Haloperidol]]
:* [[Haloperidol]]
:* Second-generation [[antipsychotics]]
:* Second-generation [[antipsychotics]]
:* Iliac fascia block
:* [[Iliac]] fascia block<ref name="ScurrahShiner2018">{{cite journal|last1=Scurrah|first1=A.|last2=Shiner|first2=C. T.|last3=Stevens|first3=J. A.|last4=Faux|first4=S. G.|title=Regional nerve blockade for early analgesic management of elderly patients with hip fracture - a narrative review|journal=Anaesthesia|volume=73|issue=6|year=2018|pages=769–783|issn=00032409|doi=10.1111/anae.14178}}</ref>
:* [[Gabapentin]]
:* Lower levels of intraoperative [[propofol]] sedation<ref name="DjaianiSilverton2016">{{cite journal|last1=Djaiani|first1=George|last2=Silverton|first2=Natalie|last3=Fedorko|first3=Ludwik|last4=Carroll|first4=Jo|last5=Styra|first5=Rima|last6=Rao|first6=Vivek|last7=Katznelson|first7=Rita|title=Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery|journal=Anesthesiology|volume=124|issue=2|year=2016|pages=362–368|issn=0003-3022|doi=10.1097/ALN.0000000000000951}}</ref>
:* Lower levels of intraoperative [[propofol]] sedation
:* Continuous [[intravenous ]] infusion of [[dexmedetomidine]]<ref name="pmid30238227">{{cite journal |vauthors=Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M |title=Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis |journal=Ann Intensive Care |volume=8 |issue=1 |pages=92 |date=September 2018 |pmid=30238227 |pmc=6148680 |doi=10.1186/s13613-018-0437-z |url=}}</ref>
:* A single dose of [[ketamine]] during anesthetic induction
:* [[Melatonin]]<ref name="CampbellAxon2019">{{cite journal|last1=Campbell|first1=Ashley M.|last2=Axon|first2=David Rhys|last3=Martin|first3=Jennifer R.|last4=Slack|first4=Marion K.|last5=Mollon|first5=Lea|last6=Lee|first6=Jeannie K.|title=Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis|journal=BMC Geriatrics|volume=19|issue=1|year=2019|issn=1471-2318|doi=10.1186/s12877-019-1297-6}}</ref>
*Mechanically ventilated medical and surgical ICU patients
*[[ketamine]] is not useful in preventing postoperative [[delirium]]. <ref name="pmid28576285">{{cite journal |vauthors=Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, Veselis RA, Grocott HP, Emmert DA, Rogers EM, Downey RJ, Yulico H, Noh GJ, Lee YH, Waszynski CM, Arya VK, Pagel PS, Hudetz JA, Muench MR, Fritz BA, Waberski W, Inouye SK, Mashour GA |title=Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial |journal=Lancet |volume=390 |issue=10091 |pages=267–275 |date=July 2017 |pmid=28576285 |pmc=5644286 |doi=10.1016/S0140-6736(17)31467-8 |url=}}</ref>
:* Continuous intravenous infusion of [[dexmedetomidine]]  
* Preoperative administration of [[gabapentin]] is not effective for prevention of postoperative [[delirium]].<ref>{{cite journal|doi=10.1097/ALN.0000000000001804.}}</ref>
* Acutely ill general medical patients population
====[[Haloperidol]]====
:* Melatonin.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last = | first = | title = Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10327941 | publisher = | date =  | accessdate = }}</ref>
*[[Delirium]] possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-[[intubations]].
 
*Low dose [[haloperidol]], if given prophylactically in lower doses, have a better prognosis than treatment of [[delirium]].  
====Haloperidol====
* The following benefits were observed:
Delirium possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-intubations.
* Lower [[mortality]]
Low dose [[haloperidol]], if given prophylactically in lower doses, have a better prognosis than treatment of delirium. The following benefits were observed,
* Lower [[delirium]] incidence
* Lower mortality
* More [[delirium]] free days
* Lower delirium incidence
* [[Patients]] are less likely to remove their [[tubes]] or [[catheters]]
* More delirium free days
* [[Patients]] with a higher risk of developing [[delirium]] benefited more
* Patients are less likely to remove their tubes or catheters
* [[ICU]] readmission rate was lower.
* Patients with a higher risk of developing delirium benefited more
:*Drawbacks of [[prophylactic]] treatment with [[Haloperidol]]:
* ICU readmission rate was lower.
::* Unnecessary treatment to [[patients]] who were not destined to develop [[delirium]]
Drawbacks for prophylactic treatment with Haloperidol:
::* Side effects of treatment, however during clinical studies there was only a marginal prolongation of [[QTc]] and no one developed [[ventricular arrhythmias]].
* Unnecessary treatment to patients who were not destined to develop delirium,
<ref>{{Cite web  | last =  | first =  | title = Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23327295 | publisher =  | date =  | accessdate = }}</ref><ref name="Schrijverde Vries2014">{{cite journal|last1=Schrijver|first1=Edmée JM|last2=de Vries|first2=Oscar J|last3=Verburg|first3=Astrid|last4=de Graaf|first4=Karola|last5=Bet|first5=Pierre M|last6=van de Ven|first6=Peter M|last7=Kamper|first7=Ad M|last8=Diepeveen|first8=Sabine HA|last9=Anten|first9=Sander|last10=Siegel|first10=Andrea|last11=Kuipéri|first11=Esther|last12=Lagaay|first12=Anne M|last13=van Marum|first13=Rob J|last14=van Strien|first14=Astrid M|last15=Boelaarts|first15=Leo|last16=Pons|first16=Douwe|last17=Kramer|first17=Mark HH|last18=Nanayakkara|first18=Prabath WB|title=Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial|journal=BMC Geriatrics|volume=14|issue=1|year=2014|issn=1471-2318|doi=10.1186/1471-2318-14-96}}</ref>
* Side effects of treatment, however during clinical studies there was only a marginal prolongation of [[QTc]] and no one developed [[ventricular arrhythmias]].
Targeted delirium prophylaxis is key to the future management of delirium and more studies are needed on this topic.
<ref>{{Cite web  | last =  | first =  | title = Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23327295 | publisher =  | date =  | accessdate = }}</ref>
==Prediction of Delirium in ICU==
Early prediction of development of delirium in intensive care is very crucial to start non pharmacological treatment and starting prophylactic haloperidol treatment.
PRE-DELIRIC model is used to predict delirium in ICU.  Automatic version of the PRE-DELIRIC model (Excel and web based) can be downloaded at http://www.umcn.nl/Research/Departments/intensive%20care/Documents/Pre-deliric%20model.htm?language=english,
Complete information is available at http://www.umcn.nl/Research/Departments/intensive%20care/Pages/vandenBoogaard.aspx
<ref>{{Cite web  | last = | first = | title = Development and validation of PRE-DELIRIC (PREdiction of... [BMJ. 2012] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/22323509 | publisher = | date = | accessdate = }}</ref>
===Risk Factors===
===Modifiable Risk Factors===
*Sensory impairment (hearing or vision)
*Immobilization (catheters or restraints)
*Offending drugs (for example, sedative hypnotics, narcotics, anticholinergic drugs, corticosteroids, polypharmacy, withdrawal of alcohol or other drugs)
*Acute neurological pathology (for example, acute stroke [usually right parietal], intracranial hemorrhage, meningitis, enkephalitis)
*Intercurrent illness (for example, infections, iatrogenic complications, severe acute illness, anemia, dehydration, poor nutritional status, fracture or trauma, HIV infection)
*Metabolic impairment
*Surgery
*Stressful surroundings (for example, admission to an intensive care unit)
*Pain
*Emotional stress
*Lack of sleep
===Non-Modifiable Risk Factors===
*Cognitive impairment
*Older age (>65 years)
*History of delirium, stroke, neurological disease, falls or gait disorder
*Associating multiple medical aliments
*Gender: Male over females
*Renal or hepatic pathology<ref>{{Cite web  | last = | first = | title = Delirium in elderly adults: diagnosis, prevention and treatment | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/ | publisher = | date = | accessdate = }}</ref>
===Precipitating factors===
Any acute factors that affect neurotransmitter, [[neuroendocrine]] or neuroinflammatory pathways can precipitate an episode of delirium in a vulnerable brain. Clinical environments can also precipitate delirium, and optimal nursing and medical care are key component of delirium prevention.<ref>{{cite journal|last=Inouye|first=SK|coauthors=Bogardus ST, Jr; Charpentier, PA; Leo-Summers, L; Acampora, D; Holford, TR; Cooney LM, Jr|title=A multicomponent intervention to prevent delirium in hospitalized older patients.|journal=The New England Journal of Medicine|date=Mar 4, 1999|volume=340|issue=9|pages=669–76|pmid=10053175|doi=10.1056/NEJM199903043400901}}</ref> Some of the most common precipitating factors are listed below:
*Metabolic
*[[Malnutrition]]
*[[Dehydration]]
*[[Electrolyte imbalance]]
*[[Anaemia]]
*[[Hypoxia]]
*[[Hypercapnoea]]
*[[Hypoglycaemia]],
*[[Endocrine disorders]] (e.g. [[SIADH]], [[Addison’s disease]], [[hyperthyroidism]], [[hypercalcaemia]])
*[[Infection]]
:*Especially respiratory and [[urinary tract infection]]
*Medication,
:*[[Anticholinergics]], [[dopaminergics]], [[opioids]], [[steroids]], recent polypharmacy
*Vascular,
:*[[Stroke]]/[[Transient ischaemic attack]]
:*[[Myocardial infarction]], [[arrhythmias]], decompensated [[heart failure]]
*Physical/psychological stress
*Pain
*Iatrogenic event, esp. post-operative, mechanical ventilation in ICU
*Chronic/terminal illness, esp. cancer
*Post-traumatic event, e.g. fall, fracture
*Immobilisation/restraint
*Substance withdrawal, esp. alcohol, [[benzodiazepines]]
*Substance intoxication
*Traumatic [[head injury]].


==References==
==References==

Latest revision as of 11:15, 22 April 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]

Overview

It is important to prevent delirium as delirium is itself neurotoxic. Delirium is associated with global brain atrophy and white matter disruption. Various non pharmacological and pharmacological interventions are found to be effective to prevent delirium. Primary prevention sterategy for Post-operative [delirium]] include use of haloperidol, second generation antipsychotics, iliac fascia block, lower levels of intraoperative propofol for sedation, continuous intravenous infusion of dexmedetomidine, Melatonin. ketamine is not useful in preventing postoperative delirium. Preoperative administration of gabapentin is not effective for prevention of postoperative delirium.

Primary Prevention

Effective measures for the primary prevention of delirium include pharmacologic and nonpharmacologic approaches.

Non Pharmacological Interventions

  • Nonpharmacological approaches may curtail the incidence of delirium.
  • Following are a few preventive strategies for delirium:[1]

Curtail cognitive decline

  • Write names of care providers, the day’s schedule on board
  • Constantly reorient patients to surroundings
  • Activities to stimulate cognitive actions like discussion of current events, structured reminiscence, or word games

Curtail sleep impairment

Curtail immobility

  • Minimal use of catheter or other aids which promotes immobility
  • Early mobilization
  • Incorporation of an exercise regiment

Manage difficulties in sight

  • Use of visual aids
  • Use of large fluorescent tapes or objects with illuminations to help in vision

Manage difficulties in hearing

Avoid dehydration

Pharmacological Interventions

Haloperidol

  • Unnecessary treatment to patients who were not destined to develop delirium
  • Side effects of treatment, however during clinical studies there was only a marginal prolongation of QTc and no one developed ventricular arrhythmias.

[10][11]

References

  1. ↑ Ghaeli P, Shahhatami F, Mojtahed Zade M, Mohammadi M, Arbabi M (April 2018). "Preventive Intervention to Prevent Delirium in Patients Hospitalized in Intensive Care Unit". Iran J Psychiatry. 13 (2): 142–147. PMC 6037578. PMID 29997660.
  2. ↑ "MMS: Error".
  3. ↑ Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L (2019). "Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis". Clin Interv Aging. 14: 1095–1117. doi:10.2147/CIA.S201323. PMC 6590846 Check |pmc= value (help). PMID 31354253.
  4. ↑ Scurrah, A.; Shiner, C. T.; Stevens, J. A.; Faux, S. G. (2018). "Regional nerve blockade for early analgesic management of elderly patients with hip fracture - a narrative review". Anaesthesia. 73 (6): 769–783. doi:10.1111/anae.14178. ISSN 0003-2409.
  5. ↑ Djaiani, George; Silverton, Natalie; Fedorko, Ludwik; Carroll, Jo; Styra, Rima; Rao, Vivek; Katznelson, Rita (2016). "Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery". Anesthesiology. 124 (2): 362–368. doi:10.1097/ALN.0000000000000951. ISSN 0003-3022.
  6. ↑ Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M (September 2018). "Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis". Ann Intensive Care. 8 (1): 92. doi:10.1186/s13613-018-0437-z. PMC 6148680. PMID 30238227.
  7. ↑ Campbell, Ashley M.; Axon, David Rhys; Martin, Jennifer R.; Slack, Marion K.; Mollon, Lea; Lee, Jeannie K. (2019). "Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis". BMC Geriatrics. 19 (1). doi:10.1186/s12877-019-1297-6. ISSN 1471-2318.
  8. ↑ Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, Veselis RA, Grocott HP, Emmert DA, Rogers EM, Downey RJ, Yulico H, Noh GJ, Lee YH, Waszynski CM, Arya VK, Pagel PS, Hudetz JA, Muench MR, Fritz BA, Waberski W, Inouye SK, Mashour GA (July 2017). "Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial". Lancet. 390 (10091): 267–275. doi:10.1016/S0140-6736(17)31467-8. PMC 5644286. PMID 28576285.
  9. ↑ . doi:10.1097/ALN.0000000000001804. Check |doi= value (help). Missing or empty |title= (help)
  10. ↑ "Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI".
  11. ↑ Schrijver, Edmée JM; de Vries, Oscar J; Verburg, Astrid; de Graaf, Karola; Bet, Pierre M; van de Ven, Peter M; Kamper, Ad M; Diepeveen, Sabine HA; Anten, Sander; Siegel, Andrea; Kuipéri, Esther; Lagaay, Anne M; van Marum, Rob J; van Strien, Astrid M; Boelaarts, Leo; Pons, Douwe; Kramer, Mark HH; Nanayakkara, Prabath WB (2014). "Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial". BMC Geriatrics. 14 (1). doi:10.1186/1471-2318-14-96. ISSN 1471-2318.

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