Environmental and supportive interventions in the treatment of delirium

Aim: Our aim is to study the significance of environmental and supportive interventions in the treatment of delirium.

Material and Method: 60 patients admitted with delirium, according to the DSM IV criteria, were studied. All of them received standard pharmacological treatment (Haloperidol 1 to 10mg daily, Risperidone 1 to 4 mg daily, Olanzapine 5 to 10 mg daily) but 30 patients were randomly selected to receive additional environmental, supportive and educational interventions (in the patient, the relatives and the stuff). The evaluation of the patients was conducted using Delirium Rating Scale (DRS) and M.M.S.E.

Results: Patients with delirium have longer hospital stays and higher mortality rates. The application of environmental interventions such as providing support and orientation (giving repeated verbal reminders of the date, time, location, having familiar objects in the room, ensuring staff consistency etc.), providing an unambiguous environment (simplifying care area by removing unnecessary objects, ensuring adequacy of light, controlling sources of excess noise etc.), maintaining competence (Identification and correction of sensory impairments, proper treatment in order to provide uninterrupted sleep etc.) supporting and educating patients, family and stuff (informing all the former about the nature of delirium, the fact that it is temporary, that the symptoms are part of the organic disease, instructions to the nursing staff to attend patients frequently can significantly help everyone involved, resulting in better attendance for the patients). The patients pequire support after their release as well, as some of the delirium symptoms (disturbance of attention and orientation) are insistent. The prediction of risk factors (when these have been identified) helps avoid a future episode of delirium. Depression and PTSD have been reported. Many patients tend to forget the delirium episode but a significant minority retains a terrible memory. Psychiatric attendance may be required in order to cope with anxiety and depression. Due to the well-known shortcomings of our hospitals, about half of the above mentioned environmental interventions could not be applied to the majority of the patients. nevertheless, the interventions carried out did help the patients significantly. The patients who received these interventions had a better outcome, propably due to the enhanced care they received from nursing staff and relatives.

Conclusions: We found no reliable studies (Systematic Reviews or Randomized Controlled Trials) comparing combined treatments to medication alone in delirium. Our data suggest that simple environmental interventions in addition to staff and family training could be helpful and without side-effects, but we need more carefully designed studies implicating a large number of patients in order to prove this hypothesis.

Key words: Delirium, environmental, supportive, somatic, interventions.