The use of environmental strategies and psychotropic medication in the management of delirium

Background. This paper examines the pattern and frequency of implementation of environmental strategies and the use of psychotropic medication in the management of patients with delirium in an acute hospital setting. Method. The study involved 46 consecutive referrals to a consultation psychiatry service each of whom met ICD-10 criteria for delirium. Patients were subdivided into hyperactive, hypoactive and mixed subtypes of delirium and assessed regarding severity of delirium, the use of psychotropic medication prior to consultation and the implementation of environmental measures in their management. Results. Mean age was 60.1 years. Thirty per cent of patients were of the hyperactive subtype, 24% hypoactive and 46% mixed. Psychotropic medication was given to 56.5% prior to consultation and this is significantly associated with severity of delirium and in particular, with hyperactive delirium subtype. Of eight environmental strategies only four were instituted in over 50% of the patients prior to consultation. The application of these strategies was associated with overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance. It was not significantly associated with severity of disorientation or with disturbed perception/thinking. Conclusion. Simple environmental strategies such as limiting changes in staff, minimising noise levels and involving relatives in re-orientation are frequently overlooked in the management of patients with delirium. Our study suggests that the implementation of environmental strategies occurs primarily in response to behavioural challenges rather than to limit the core features of delirium.