Emergency Room/Pre-operative Management
Assessment of premorbid functioning and any previous diagnosis of dementia.
- Assessment should routinely occur on every shift using standardized assessment tools for delirium screening such as the Confusion Assessment Method (CAM). In some cases, The Dementia Quick Screen may be helpful to identify the existence of cognitive impairments in the emergency room.
- Assessment of underlying causes of delirium may include B12, thyroid stimulating hormone (TSH), complete blood count (CBC), glucose, blood urea nitrogen, creatinine, and electrolytes (GBCL), and liver profile.
- In particular, the effectiveness of pain management requires regular assessment and use of standardized pain assessment tools.
Prevention and Management:
- Reduce delirium frequency and complications through a review of risk factors
- Regular (at least every shift) assessment of symptoms using a delirium screening tool such as the Confusion Assessment Method (CAM)
- Delirium prevention and intervention protocols which have been found to reduce frequency and complications should be implemented and include:
- Orientation protocols (daily and as needed),
- Early mobilization and encouragement of independence in activities of daily living
- Optimizing nutrition including appropriate assistance and positioning
- Avoidance of medications with high anticholinergics and/or sedating properties
- Non-pharmacological approaches to minimize the use of psychoactive drugs (e.g. benzodiazepines, antipsychotics)
- Optimal pain management with consideration for the use of regularly dosed acetaminophen and initiation of low dose narcotics as needed (avoiding meperidine)
- Avoidance of physical restraints
- Early removal of urinary catheters postoperatively and initiation of toileting protocols if incontinence is an issue
- Sleep hygiene using non-pharmacological interventions (e.g. warm milk; warm blankets; hand massages; low light; minimal noise and interruptions through the night)
- Adaptive equipment for vision and hearing impairment
- Restoration of serum electrolyte abnormalities
- Early intervention for volume depletion or overload
Proactive approaches using geriatric principles and where necessary, geriatric consultation, may reduce incidence and severity of delirium, and improve management of dementia in patients undergoing surgery for hip fracture.
Use of medication may be considered for some patients when experiencing only severe symptoms of delirium (e.g. disturbing hallucinations; aggressive behavior that is not manageable using non-pharmacological strategies) or behavioral issues of dementia. Low dose anti-psychotics are typically suggested as first line (assuming no contraindications).
Delirium algorithms should be effectively used to assist healthcare practitioners in effective detection, prevention and management of delirium for hip fracture patients including regional geriatric program of Ontario – Geriatric Interprofessional Practice and Interorganizational Collaboration (GIIC); Vancouver Island Health Authority.
Patient/family education resources help to improve understanding and provide direction about caring for people experiencing the 3D’s.