Non-pharmacological management

Evidence summary

It is recognised from research in the aged care population that environmental aspects of hospitals contribute to delirium, and environmental alterations can prevent delirium. [1]

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. [1,2]

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 a patients’ ability to be cared for in different settings (including at home) are being studied.

A systematic review demonstrated that a multicomponent non-pharmacological approach to patient care reduced the incidence of delirium in hospitalised older people. [1] This research did not specially look at patients receiving palliative care. A study involving palliative care patients examined the use of multicomponent non-pharmacological interventions to reduce the incidence and severity of delirium. [3] The study examined the effects of orientation techniques, cognitive stimulation on patients as well supportive advice for family members and information for staff. The authors were unable to establish a clear benefit to these approaches but given the low risk, cost and acceptability of these techniques a recent systematic review recommends their implementation. [4]

Practice implications

• There is evidence for the impact of environmental factors on cognitively vulnerable patients. [1,5] 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. [7,8]