| Environmental Interventions | |
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The Problem: The emotional and physical environments of the ICU are generally far from conducive to a tranquil state of mind. Whether that reality is etiologically significant for the emergence of delirium is unknown. Most physicians concede that environmental manipulation such as frequent reorientation, maximizing uninterrupted sleep time, night lights, visible clocks and calendars may decrease the occurrence [but] once agitation occurs may not reduce or control symptoms. Although significant reconfiguration of intensive care units is improbable, simple measures such as encouraging staff to lower their voices, conducting patient conferences in private, lowering or prompt silencing of alarms, and placing pagers on vibrating mode may easily reduce the noise level and decrease the sensory barrage that assaults all ICU residents. Environmental modifications, which may be much more feasible in the ward setting, are abundant and well-described. They include restoration of normal day/night lighting patterns, reductions of noise, unfamiliar persons, and unfamiliar locations; placing familiar objects (eg, blanket, pictures) to create a sense of familiarity in a strange environment; improved privacy; and measures to promote sleep. Liberalizing both ICU and ward visitation policies to allow prolonged family presence at the bedside if it has a calming influence may be a highly desirable intervention. |
What We Do: Delirious patients should be allowed to use their hearing aids or glasses to improve the quality of their sensory input if it is safe for them to do so. Simple, clear language should be used with patients. Use of nouns and verbs, with few adverbs, adjectives, or other descriptors, is most effective. Communication should be simple, concrete, and face-to-face. Explanations that convey benefit to patient, rather than compliance with nurses, may be beneficial. Delusions should not be validated, defended, or corrected. Rather, uncomplicated and nonjudgmental acknowledgment and explanations may be useful in helping patients differentiate their internal and external realities. The role of physical restraint in the management of a florid agitated delirium is minor when compared with chemical restraint. Physical restraint, which may have emerged as a standard of care without scientific validation must be used judiciously, and only as a measure of last resort. Restraint use may increase injury risk and further disorganize cognition. This generalization must be tempered with the reality that at times physically restraining a patient may be lifesaving and necessary. Chronologic age remains the most powerful predictor of subsequent delirium. Older patients lack functional (physiologic) reserve and are more vulnerable to stress due to multiple age-related system changes. Predisposing conditions or best predictors for the development of delirium include brain disease and addiction to alcohol or other substances with functional impairment serving as a proxy indicator for quality of brain function. Opioids, benzodiazepines,
anticholinergics, nonsteroidal anti-inflammatory agents (NSAIDS), and alcohol
and sedative withdrawal are most strongly linked to drug-related delirium.
Benzodiazepines are the most widely used psychoactive agents, and their use is
highest in the elderly. |
| Authorship: Dr Valerie Taylor | Last Revised: 29 May 2002 |