The primary effort is directed toward elimination of the underlying medical problem, particularly to discontinuing offending drugs or toxic agents. Other important objectives are to quiet the agitated patient and protect him from injury. A nurse, attendant, or member of the family should be with a seriously confused patient if this can be arranged. A room with adequate natural lighting will aid in creating a diurnal rhythm of activity and reduce “sundowning.” It is often better to let an agitated patient walk about the room than to restrain him in bed, which may increase his fright or excitement and cause him to struggle to the point of exhaustion, collapse, or self-harm. The less-active patient can be kept in bed by side rails, wrist restraints, or a restraining sheet or vest. Sensitive explanations of these restraints to the family should be made in terms that emphasize the patient’s health and safety. The fully awake but mildly confused patient should be permitted to sit up or walk about part of the day unless the primary disease contraindicates this.
All drugs that could possibly be responsible for the acute confusional state or delirium should be discontinued if this can be done safely. These include sedating, antianxiety, narcotic, anticholinergic, antispasticity, and corticosteroid medications, l-dopa, metoclopramide, and cimetidine, as well as antidepressants, antiarrhythmics, antiepileptics, and antibiotics. Despite the need to be sparing with medications in these circumstances, haloperidol, quetiapine, and risperidone are helpful in calming the severely agitated and hallucinating patient, but they too should be used in the lowest effective doses. An exception is alcohol or sedative withdrawal, in which chlordiazepoxide or other diazepines are favored by most physicians (see Chap. 41). In delirious patients, the purpose of sedation is to assure rest and sleep, avoid exhaustion, and facilitate nursing care, but one must be cautious in attempting to suppress delirium completely. Warm baths were also known in the past to be effective in quieting the delirious patient, but hospitals no longer have facilities for this valuable method of treatment.
It would seem obvious that attempts should be made to preempt the problem of confusion in the hospitalized elderly patient that includes early identification of those at risk, particularly individuals with incipient dementia, frequent reorientation to the surroundings with signs, verbal reminders, and a clock; mentally stimulating activities; ambulation several times a day or similar exercises when possible; and attention to providing visual and hearing aids in patients with these impairments. They recorded a 40 percent reduction in the frequency of a confusional illness in comparison to patients who did not receive this type of organized program. Preventive strategies of the type they outline are most important in the elderly, even those without overt dementia, but a routine plan is advisable so that nurses and ancillary staff are able to apply them consistently.
Finally, the physician should be aware of the benefit of many small therapeutic measures that allay fear and suspicion and reduce the tendency to hallucinations. The room should be kept dimly lighted at night, and, if possible, the patient should not be moved from one room to another. Every procedure should be explained to the patient, even such simple ones as the taking of blood pressure or temperature. It may be some consolation and also a source of professional satisfaction to remember that most confused and delirious patients recover if they receive competent medical and nursing care (and are almost always amnestic for the ordeal). The family may be reassured on this point but forewarned that improvement may take several days or weeks and that episodes of confusion may be exposing an underlying dementia. They must also understand that the patient’s abnormal behavior is not willful but rather symptomatic of a transitory brain disease. (See also Chap. 41 for specific aspects of management of delirium due to withdrawal of alcohol and other sedative-hypnotic drugs.)
Birmes P, Coppin D, Schmitt L, et al: Serotonin syndrome: a brief review. CMAJ 168:1439, 2003.