Editing Delirium (section)

==Prevention==
Treating delirium that is already established is challenging and for this reason, preventing delirium before it begins is ideal. Prevention approaches include screening to identify people who are at risk, and medication-based and non-medication based (non-pharmacological) treatments.<ref name="Burton_2021">{{cite journal | vauthors = Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ | title = Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 11 | pages = CD013307 | date = November 2021 | pmid = 34826144 | pmc = 8623130 | doi = 10.1002/14651858.CD013307.pub3 }}</ref>

An estimated 30–40% of all cases of delirium could be prevented in cognitively at-risk populations, and high rates of delirium reflect negatively on the quality of care.<ref name="Inouye2006" /> Episodes of delirium can be prevented by identifying hospitalized people at risk of the condition. This includes individuals over age 65, with a cognitive impairment, undergoing major surgery, or with severe illness.<ref name="NICE" /> Routine delirium screening is recommended in such populations. It is thought that a personalized approach to prevention that includes different approaches together can decrease rates of delirium by 27% among the elderly.<ref>{{cite journal | vauthors = Martinez F, Tobar C, Hill N | title = Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature | journal = Age and Ageing | volume = 44 | issue = 2 | pages = 196–204 | date = March 2015 | pmid = 25424450 | doi = 10.1093/ageing/afu173 | doi-access = free }}</ref><ref name="Siddiqi2016" />

In 1999, [[Sharon K. Inouye]] at Yale University, founded the Hospital Elder Life Program (HELP)<ref>{{cite journal | vauthors = Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK | title = Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness | journal = The American Journal of Geriatric Psychiatry | volume = 26 | issue = 10 | pages = 1015–1033 | date = October 2018 | pmid = 30076080 | pmc = 6362826 | doi = 10.1016/j.jagp.2018.06.007 }}</ref> which has since become recognized as a proven model for preventing delirium.<ref name="ReferenceA">{{cite journal | vauthors = Waite LJ | title = The Demographic Faces of the Elderly | journal = Population and Development Review | volume = 30 | issue = Supplement | pages = 3–16 | date = 2004 | pmid = 19129925 | pmc = 2614322 }}</ref> HELP prevents delirium among the elderly through active participation and engagement with these individuals. There are two working parts to this program, medical professionals such as a trained nurse, and volunteers, who are overseen by the nurse. The volunteer program equips each trainee with the adequate basic geriatric knowledge and interpersonal skills to interact with patients. Volunteers perform the range of motion exercises, cognitive stimulation, and general conversation<ref>{{cite journal | vauthors = Zachary W, Kirupananthan A, Cotter S, Barbara GH, Cooke RC, Sipho M | title = The impact of Hospital Elder Life Program interventions, on 30-day readmission Rates of older hospitalized patients | journal = Archives of Gerontology and Geriatrics | volume = 86 | pages = 103963 | date = 2020 | pmid = 31733512 | doi = 10.1016/j.archger.2019.103963 | s2cid = 208086667 }}</ref> with elderly patients who are staying in the hospital. Alternative effective delirium prevention programs have been developed, some of which do not require volunteers.<ref>{{cite journal | vauthors = Ludolph P, Stoffers-Winterling J, Kunzler AM, Rösch R, Geschke K, Vahl CF, Lieb K | title = Non-Pharmacologic Multicomponent Interventions Preventing Delirium in Hospitalized People | journal = Journal of the American Geriatrics Society | volume = 68 | issue = 8 | pages = 1864–1871 | date = August 2020 | pmid = 32531089 | doi = 10.1111/jgs.16565 | doi-access = free }}</ref>

Prevention efforts often fall on caregivers. Caregivers often have a lot expected of them and this is where socioeconomic status plays a role in prevention.<ref>{{cite journal | vauthors = Tough H, Brinkhof MW, Siegrist J, Fekete C | title = Social inequalities in the burden of care: a dyadic analysis in the caregiving partners of persons with a physical disability | journal = International Journal for Equity in Health | volume = 19 | issue = 1 | pages = 3 | date = December 2019 | pmid = 31892324 | pmc = 6938621 | doi = 10.1186/s12939-019-1112-1 | author5 = for the SwiSCI Study Group | doi-access = free }}</ref> If prevention requires constant mental stimulation and daily exercise, this takes time out of the caregiver's day. Based on socioeconomic classes, this may be valuable time that would be used working to support the family. This leads to a disproportionate number of individuals who experience delirium being from marginalized identities.<ref name="ReferenceA"/> Programs such as the Hospital Elder Life Program can attempt to combat these societal issues by providing additional support and education about delirium that may not otherwise be accessible.

=== Non-pharmacological ===
Delirium may be prevented and treated by using non-pharmacologic approaches focused on risk factors, such as constipation, dehydration, low oxygen levels, immobility, visual or hearing impairment, sleep disturbance, functional decline, and by removing or minimizing problematic medications.<ref name=NICE/><ref name="Oh_2017">{{cite journal | vauthors = Oh ES, Fong TG, Hshieh TT, Inouye SK | title = Delirium in Older Persons: Advances in Diagnosis and Treatment | journal = JAMA | volume = 318 | issue = 12 | pages = 1161–1174 | date = September 2017 | pmid = 28973626 | pmc = 5717753 | doi = 10.1001/jama.2017.12067 }}</ref> Ensuring a therapeutic environment (e.g., individualized care, clear communication, adequate reorientation and lighting during daytime, promoting uninterrupted [[sleep hygiene]] with minimal noise and light at night, minimizing room relocation, having familiar objects like family pictures, providing earplugs, and providing adequate nutrition, pain control, and assistance toward early mobilization) may also aid in preventing delirium.<ref name="Siddiqi2016" /><ref name=Inouye2006>{{cite journal | vauthors = Inouye SK | title = Delirium in older persons | journal = The New England Journal of Medicine | volume = 354 | issue = 11 | pages = 1157–1165 | date = March 2006 | pmid = 16540616 | doi = 10.1056/NEJMra052321 | url = http://nrs.harvard.edu/urn-3:HUL.InstRepos:13956255 | access-date = 2019-01-04 | url-status = live | s2cid = 245337 | archive-url = https://web.archive.org/web/20210828054457/https://dash.harvard.edu/handle/1/13956255 | archive-date = 2021-08-28 }}</ref><ref>{{cite journal | vauthors = Poongkunran C, John SG, Kannan AS, Shetty S, Bime C, Parthasarathy S | title = A meta-analysis of sleep-promoting interventions during critical illness | journal = The American Journal of Medicine | volume = 128 | issue = 10 | pages = 1126–1137.e1 | date = October 2015 | pmid = 26071825 | pmc = 4577445 | doi = 10.1016/j.amjmed.2015.05.026 }}</ref><ref>{{cite journal | vauthors = Flannery AH, Oyler DR, Weinhouse GL | title = The Impact of Interventions to Improve Sleep on Delirium in the ICU: A Systematic Review and Research Framework | journal = Critical Care Medicine | volume = 44 | issue = 12 | pages = 2231–2240 | date = December 2016 | pmid = 27509391 | doi = 10.1097/CCM.0000000000001952 | s2cid = 24494855 }}</ref> Research into pharmacologic prevention and treatment is weak and insufficient to make proper recommendations.<ref name="Oh_2017" />

=== Pharmacological ===
Melatonin and other pharmacological agents have been studied for delirium prevention, but evidence is conflicting.<ref name=Siddiqi2016 /><ref>{{cite journal | vauthors = Gosch M, Nicholas JA | title = Pharmacologic prevention of postoperative delirium | journal = Zeitschrift für Gerontologie und Geriatrie | volume = 47 | issue = 2 | pages = 105–109 | date = February 2014 | pmid = 24619041 | doi = 10.1007/s00391-013-0598-1 | s2cid = 19868320 }}</ref> Avoidance or cautious use of benzodiazepines has been recommended for reducing the risk of delirium in critically ill individuals.<ref name="pmid28190430">{{cite book |vauthors=Slooter AJ, Van De Leur RR, Zaal IJ |title=Critical Care Neurology Part II |chapter=Delirium in critically ill patients |volume=141 |pages=449–466 |year=2017 |pmid=28190430 |doi=10.1016/B978-0-444-63599-0.00025-9 |series=Handbook of Clinical Neurology |isbn=9780444635990 }}</ref> It is unclear if the medication [[donepezil]], a [[Cholinesterase inhibitors|cholinesterase inhibitor]], reduces delirium following surgery.<ref name="Siddiqi2016" /> There is also no clear evidence to suggest that [[citicoline]], [[methylprednisolone]], or [[antipsychotic]] medications prevent delirium.<ref name="Siddiqi2016" /> A review of intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery showed little or no difference in postoperative delirium according to the type of anaesthetic maintenance agents<ref>{{cite journal | vauthors = Miller D, Lewis SR, Pritchard MW, Schofield-Robinson OJ, Shelton CL, Alderson P, Smith AF | title = Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery | journal = The Cochrane Database of Systematic Reviews | volume = 8 | issue = 8 | pages = CD012317 | date = August 2018 | pmid = 30129968 | pmc = 6513211 | doi = 10.1002/14651858.CD012317.pub2 }}</ref> in five studies (321 participants). The authors of this review were uncertain whether maintenance of anaesthesia with [[propofol]]-based total intravenous anaesthesia (TIVA) or with inhalational agents can affect the incidence rate of postoperative delirium.

'''Interventions for preventing delirium in long-term care or hospital'''

The current evidence suggests that software-based interventions to identify medications that could contribute to delirium risk and recommend a pharmacist's medication review probably reduces incidence of delirium in older adults in long-term care.<ref name="Woodhouse_2019">{{cite journal | vauthors = Woodhouse R, Burton JK, Rana N, Pang YL, Lister JE, Siddiqi N | title = Interventions for preventing delirium in older people in institutional long-term care | journal = The Cochrane Database of Systematic Reviews | volume = 4 | issue = 4 | pages = CD009537 | date = April 2019 | pmid = 31012953 | pmc = 6478111 | doi = 10.1002/14651858.cd009537.pub3 }}</ref> The benefits of hydration reminders and education on risk factors and care homes' solutions for reducing delirium is still uncertain.<ref name="Woodhouse_2019" />

For inpatients in a hospital setting, numerous approaches have been suggested to prevent episodes of delirium including targeting risk factors such as sleep deprivation, mobility problems, dehydration, and impairments to a person's sensory system. Often a 'multicomponent' approach by an interdisciplinary team of health care professionals is suggested for people in the hospital at risk of delirium, and there is some evidence that this may decrease to incidence of delirium by up to 43% and may reduce the length of time that the person is hospitalized.<ref name="Burton_2021" />