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The Pinch Me Pod – an MDT approach to delirium in hospital settings
This is the ‘Pinch Me Pod’, a podcast resource from the Northern Health and Social Care Trust, to help explore the topic of delirium in detail, and what the multidisciplinary team can do to recognise and manage delirium in the hospital setting.
Dr Stephen Collins, Doctor in Elderly Care Medicine, hosts this podcast series, alongside a panel of staff from across the acute hospitals in Antrim and Causeway, in Northern Ireland. Over the course of six episodes, we explore what delirium looks like for us in our own day-to-day work and the significant impact this condition has on patients, families and staff. As well as the lessons we have learned, we also discuss lots of tips on how you might be able to improve the level of care you provide to patients with delirium in your own work setting. We hope that this podcast will begin to answer some of the questions you may have and help you navigate the medical minefield that delirium can sometimes feel like.
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Pinch Me Pod - EP 3 – Management of Delirium
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This is the Pinch Me Pod, a podcast resource from the Northern Health and Social Care Trust to help you and your colleagues manage delirium better in the hospital setting.
Hi again, and welcome back for episode three of our podcast series, all about delirium, hosted by our wonderful multidisciplinary team of Northern Trust healthcare staff. My name is Stephen, and I'm an elderly care doctor from Causeway Hospital, and if you have listened to our first two episodes, you will already know most of the people sat around the table with me today.
But just as a little recap, I'll ask everyone to say hello and introduce themselves once more. Hi, I'm Nicola Loughlin, Delirium Nurse Coordinator. Hi there, my name's Julie Munn. I am Professional Lead Nurse for Medicine and Emergency Medicine. Hi, I'm Orla Matthews. I'm the Dementia Service Improvement Lead Nurse.
Hi, I'm Darren Bridges. I am the MCA Lead for Acute Hospitals in the Northern Trust. Hi, my name's Siofra O'Dolan and I am an Occupational Therapist working in Antrim Area Hospital on the Frailty Ward. Hi, my name is Jackie Greer. I am a doctor in the care of the elderly team in Antrim Hospital. Hello, my name is Julie Magee, I'm the lead pharmacist for older people in the Northern Trust. Hi, I'm Lorraine Gibson and I'm the falls coordinator for the Trust.
The last time we got together in episode two, we were discussing triggers for delirium and what might cause the acute confusional state we see in patients with delirium. And now today, we're moving on to the next step and focusing on management of delirium. How do we look after patients affected by delirium? Can we expect them to make a full recovery? And if so, how long does that process normally take? We'll be dipping into some strategies we can put into practice when looking after patients with delirium, such as therapeutic activities, cognitive stimulation, and effective communication skills, as well as exploring the role that medications play.
Lots of exciting topics for our team here to dive into and the first person we're going to go to for help in understanding how best to manage patients with delirium is Nicola, our delirium nurse coordinator for the Northern Trust Region.
I suppose one of the first questions is thinking is, is it possible for people to recover from delirium? And what I would say is yes, on the whole delirium is a temporary condition. And we would expect the majority of people to make a full recovery. However, some people may just make a partial recovery, especially if they've had a number of episodes of delirium in the past, and their baseline might change each time.
And there will also be a cohort, small cohort of people where their delirium may not resolve, and we will talk more about that in episode four. The difficulty is the time frame for recovery differs significantly from person to person and it depends on a myriad of factors. It often isn't a straightforward trajectory, and this is why the emphasis really is on that prompt assessment, recognition and diagnosing of delirium.
Because the quicker we recognize it, then the quicker we can take steps to treat it and manage it, and prevent symptoms from getting so severe. Some people can recover quite quickly, within a few days in some cases. But generally there is a lag in time from the underlying causes being treated until the delirium symptoms resolve. And this lag in time can be weeks or sometimes several months. And we're often in a situation where a person's delirium isn't fully resolved at the point of discharge. But it should be resolving to some degree. And when we think about how we manage delirium, there isn't just one thing that treats delirium. It requires a combination of approaches.
So if it's a combination of approaches coming together to manage cases of delirium that we see, what are some of these approaches? Quite often we talk in medicine about pharmacological and non pharmacological approaches. That means either using medications to treat someone or using other non medical strategies. Which should we use first in delirium? Here's Nicola again.
The emphasis first and foremost is on the non pharmacological approaches, which very much involve meeting the fundamental care needs, using skilled communication, focusing on the rehabilitation of the person, and also what is possible for us to do within an acute hospital setting to help the person engage in meaningful activities.
A very important aspect of supporting a person with delirium is that it requires a collaborative approach from all of us involved in health and social care, and that includes our doctors, nurses, pharmacists, OTs, physios and other allied health professionals and also our social work colleagues. So delirium is all of our responsibility and we all have a part to play.
One thing Nicola mentioned there was trying to help our patients with delirium engage in meaningful activities. And the people in our hospital team who are best placed to assess what meaningful activities might be for each patient and how best to keep them continuing doing these activities are our occupational therapy colleagues.
Siofra O’Dolan is an occupational therapist who works in the frailty ward in Antrim area hospital. Here she is to explain what these meaningful activities, or activities of daily living, often look like.
In order to manage delirium, we can promote routine back into patient’s daily activities. For example, getting up and washed and dressed at the same time they usually would at home. If they can do this independently at home, we would want the ward staff to encourage independence with activities of daily living, unless otherwise obviously requiring assistance. Not only are we trying to maximise abilities and independence back to the person's baseline, a key focus for all of us collectively is around how we prevent further deconditioning happening whilst the person is in hospital.
For example, thinking about promoting continence. If the person doesn't normally wear incontinence aids, we would discourage nursing staff from putting pads on patients or offering bedpans if they can manage their toileting needs independently or with some assistance out to the bathroom. I feel if we promote independence and attempt to keep activities of daily living as similar to possible to home, we can better manage the symptoms of delirium on a day to day basis.
Managing delirium in the ward can be simple ideas, such as a clock and a calendar with a date, encouraging consistent orientation to date and time. Ensuring that there is a focus on sensory optimization and that patients are wearing their hearing aids and glasses if they need them to help them make sense of their environment.
We as OTs will make an effort to get patients up and out of bed as much as possible. We will encourage getting dressed in normal clothes as opposed to pyjamas and we will encourage sitting out in a chair to eat breakfast, lunch and dinner. Movement and regular eating and drinking patterns are proved to be effective in managing delirium.
Various campaigns such as the End PJ Paralysis or Get Up, Get Dressed, Get Moving are great to help remind us of the importance of promoting independence and the importance of rehabilitation as we know there is actually potential to prevent delirium emerging in the first place and also can help delirium symptoms resolve.
But in order for us to reach the point where symptoms of delirium resolve, we need to try and establish what the underlying causes might be. Here's Jackie to help walk us through how we can assess for causes of delirium.
So delirium is quite often a multifactorial condition. So there's usually a number of different elements which come together. So it's really important to conduct a comprehensive review in a patient presenting with any acute change in their cognition. We sort of thought about some of the triggers last time, and the four big risk factors, so certainly two of those are potentially treatable, and that's acute illness or those who've had a fractured neck or femur.
We also thought about the PINCH ME mnemonic, and I suppose the important thing to think about is that we want to treat those things that we find and identify, not just identify them. So if we find that there's pain, we need to give analgesia. If someone's hypoxic, we give oxygen. If there's infection, we can consider antibiotics, laxatives for constipation or IV fluids for dehydration, for example. Some detective work is therefore required to consider why someone's become acutely confused or less responsive and try and identify the underlying cause or causes. This can be quite difficult to identify in some cases, so we have to sort of spread the net quite widely.
Like any other condition, we should start with a full history of the circumstances leading up to the change in cognition. Special attention should be given to things such as recent falls, changes in medication, any recent illnesses such as infection or any procedures, as the delirium can persist even after the illness itself has resolved.
Again, as we previously discussed, establishing a really accurate baseline is essential and asking specifically about any cognitive difficulties or previous episodes of delirium. It's also important to ask about any substance abuse such as alcohol, even in our older patients, and this is often forgotten about.
So once we've taken our full in depth history of the patient with delirium, from both the patient and collateral sources close to them, the next pieces of the puzzle just like with any other patients, are physical examination and investigations. Here's Jackie again to talk us through those next steps.
The next step is physical examination, which can give us some more clues, with signs of acute neurological abnormalities, which could prompt consideration of CT brain scanning. Clinical observations can reveal other clues such as pyrexia, hypotension or hypoxia, all of which should be treated appropriately.
And then we would move on to investigations, which can reveal things such as electrolyte abnormalities, hypo/hypernatremia, dehydration, raised inflammatory markers, and other scans such as a CT brain might show haemorrhage or ischemia. You sort of bring all those clues together to find out what things need to be treated and try and provide holistic care to the patient.
It's really important to conduct a full assessment and not just stop when you find a potential cause because quite often there may be one thing which is contributing to the delirium. And the other thing is the assessment should be carried out on a regular basis because further features may develop while the patient is under our care and may drive the delirium moving forward.
So an example of that might be someone who's got a significant hypoactive delirium. Who has prolonged bed rest and poor oral intake, so they then may become more dehydrated, which can worsen the delirium, or indeed start to develop constipation, which can drive the delirium further. I suppose the other thing in terms of treatment is to try and reduce the risk of worsening delirium by avoiding moves, trying to orientate patients, stimulate those who are hypoactive and review their medications as we go along.
We all know that it can sometimes be difficult to try and reduce environmental factors like bed moves in a busy and fast paced hospital setting. Some patients can have three or four bed moves during just one hospital admission and that can often drive a delirium. Hospitals are very rarely a good place for someone with delirium to stay for a long time. Here's Siofra again to explain exactly why environmental changes can be so problematic for people experiencing delirium.
Firstly, it is important to recognise the impact the hospital environment itself can have. It can really be very disorientating to the patient. The unfamiliar environment, sounds, people, all can cause increased confusion and it unsettles their normal routine. Also, a patient often transfers wards or maybe moves about a ward from side room to a bay or vice versa. From experience, these simple moves can have a huge effect on orientation.
And it's this disorientation that we are so keen to minimise with our patients. One of the things we touched on last time was our PINCH ME mnemonic, to help us remember the most common causes of delirium. And here's Julie Munn to walk us through how we can use PINCH ME as a framework to draw up strategies for managing delirium better on the wards.
So looking at it, our P for pain management. It's vital for all new patients being admitted to hospital, and as before we discussed, is often missed at the onset, which can cause delays in treatment, as well as patient discomfort.
The I for Infection, simple tests, like a urinalysis early in the patient's journey, can enhance early diagnosis and treatment. Nutrition and hydration. The importance of nutrition and hydration is also recognized with the rollout of the Safety Pause. This safety initiative ensures the right patient gets the right diet, at the right time, with the right support. And it's about ensuring staff understand the importance of participating, observing and recording of these processes.
We're on to the C, for constipation. I was recently in an area where bowel charts were completed, yet the patient was nauseated and off their food. No one within the actual team had looked at the evidence and the need to commence treatment for the management of constipation, even though it was obvious looking at the patient for symptoms and the bowel chart.
On to the medications. We also have already discussed the importance of reviewing medication and reconciliation and medicines that can trigger delirium in our past session. Being proactive and ensuring prescriptions are in place when delirium management includes pharmacological interventions, especially during out of hours, is essential for patients and staff.
Moving on then to the last, the E for Environment. Most of us will have some experience of being in hospital, the multiple moves that can occur, the noise and the lack of sleep, new people in your sacred space and being frightened and vulnerable. We have a new initiative being rolled out within the Trust called EPCO, which is an enhanced patient care and observation tool.
This is for adult inpatients who require assessment and monitoring of distressed behaviours, involving family and care partners in completing the My Story. This booklet helps us to get to know and understand individual needs, preferences, and delivering patient centred care. So we can all see the importance of the daily activities of living, and these fundamentals ensure we are prioritising people, Practising effectively, preserving safety and promoting professionalism and trust when looking after and managing patients with delirium.
Here's Jackie once more to touch on why those fundamentals of care when managing delirium are so crucial. I think sometimes when we're trying to manage complex deliriums, we get so caught up with some of the medications and some of the difficult behavioural challenges that we're faced with that we forget that some of those fundamentals of care can be so, so important, such as managing pain or managing constipation. And I think it's really, really important just to get it back to basics and remember just the impact of intervening in that way can help to treat our patients.
Back to Nicola again. And I would even go on to say, Jackie, that how we communicate with our patients is so, so important as well. You know, from the very basics of ensuring we're conveying a warm, kind, friendly persona, you know, to demonstrate an empathic and compassionate approach.
I would actually say this is the bedrock in terms of excellent delirium care and I can't emphasise that enough. I think we need a real understanding of just how distressing delirium can be. That acute confusion that the person is experiencing. Not knowing where they are or what is going on. Not recognising anyone around them.
And everything just feeling so alien to them and just extremely overwhelming. I think the onus is on us to try to support the person. Just constantly orientating them to what is going on. Introducing ourselves even each time. You know, every time we approach the person it may seem like the first time they've seen us, so we just can't assume that they know who we are.
Also, a lot of our communication is non verbal. You know, how we approach the person, the speed, the actions that we take, the position we're standing or sitting in a patient, and then thinking about our paraverbal when we do speak. How are we actually saying it, and the tone of voice that we're using, the speed and the clarity.
So it's so important to explain what we're doing slowly. Thinking about our language, is it pitched that that person can understand and, you know, are we checking that they are actually processing or understanding what it is we're saying? And we can often see that on their facial expression.
Communication is a skill and it's a skill that all of us can develop. It's a skill that can help in the process of helping someone's delirium resolve. But it is difficult, especially given the very busy environments that people are working in. This need to try and get things done quickly, but no matter what time we have, should it be five minutes or one minute, or what pressures we're under, you know, that saying, make every contact count, is so important for us all to think about.
We've all seen how true that statement from Nicola is. Every contact counts. One tool that might be useful for us all to utilize more often are the My Story booklets mentioned earlier by Julie. These simple booklets can help us develop an understanding of the person behind the delirium and give our patients something to latch on to when we're speaking with them. But there are lots of forms of therapeutic engagement and different cognitive stimulating activities that we can try. And here is Orla, the dementia service improvement lead nurse, to help talk us through some of these.
It sounds like a big academic psychological activity that you have to have training in when you think of the terminology therapeutic engagement and cognitive stimulating activities but it's not. It's something that we actually do every day. I'm thinking of the NICE guidelines for meaningful activity and it just means that it includes physical and social activities that are tailored to a person's needs and preferences.
They can be structured, it can be spontaneous, it can be one on one with another person, it can be in a group setting, but it's what are we meeting, what needs are we meeting of the patient, and that can be their emotional, their creative, intellectual, and their spiritual needs for stimulation, so it's broad, but it's actually really, really, really important.
Siofra, our occupational therapist, talked about deconditioning and we, we acknowledge the effects of deconditioning on our patients, especially our older patients when they're in a hospital stay. And again, we often think of the physical effects of deconditioning. But we don't think about the cognitive decline.
So we know our older patients in particular are at risk of depression when they've been in hospital for a long stay. And they're at risk of boredom. And they're at risk of delirium. And the trigger itself could be boredom. It could be that cognitive decline, that lack of stimulation. You know, sitting in a single side room, not having any visitors, staring at four walls, and nobody's talking to you. And you can imagine that absolute disorientation, maybe those hallucinations, but you're in a room and there's no one there. There's no one there to help reorientate you to actually what's going on, to reassure you. So that's part of therapeutic engagement. I often think that people think sometimes it's the ‘airy fairy’ side of management of delirium, but it's actually one of the most important things. What can we do to provide this patient with reassurance, with comfort, but also with a stimulation that gives them something to do, that gives them a sense of purpose.
Let's go through our PINCH ME acronym one more time. Pain, Infection, Nutrition, Constipation, Hydration, Medications and Environment. And when we're thinking about environmental change during a hospital stay, one of the biggest things that can suffer is a patient's sleep pattern. It's not easy to get your 8 hours a night when you're in a 6 bedded bay full of unwell patients. What effect can that have on a delirium? Here's Orla again.
Sleep hygiene in a hospital setting is so, so, so, bad. With the noisy environment and getting your observations checked. But you'll hear people saying their nights and days are mixed up. If someone is getting cognitive stimulating activity during the day and you are supporting them by preventing deconditioning, but you're also keeping their brain stimulated. Then they're going to sleep better at night as well. But simple things like if someone's getting up and they're moving about, well what is it they're doing? They're usually seeking meaningful activity. The person is bored. Can you get up and walk with them? That's how simple it is. You know, can you walk them outside of the room, up and down the corridor?
Could you bring them to a window where they can look outside and see what's going on and they can see, well, what season is it? What day of the week is it? Is it raining? Is it snowing? Where am I? You know, if someone is up and they're over at other patient's clothes or whatever, you know, are they bored? Could they help you? Could they actually help you fold clothes? Could they help sort socks? Could you give them something to do? So you can deliver cognitive stimulating activity with what's in front of you.
And therapeutic engagement is the exact same. It's actually sitting down and listening to your patient. I can see that you're upset. Tell me what's going on. I think our older population can often easily fall into an area of where they feel that they are a burden. And no more so when they're in a hospital setting and they can see how busy the staff are. They see the nurses whizzing past, the doctors whizzing past.
So they'll sit and they'll not say, I'm actually really sore, I need a painkiller. And they'll not say, I need to go to the toilet. They'll not say, I'm actually really, really cold, could we get another blanket? They don't want to be seen as a burden. What are they communicating to us that's non verbal? You know, if someone's wincing when they stand up, are they sore? If they're shivering, are they cold? You know, and if they're up and walking about and sort of a bit distracted, can we give them, are they looking something to do? Most wards now have the activity trolleys and they also have the RITA, which is the Reminiscence Interactive Therapy activities electronic tool as well.
Whether it's jigsaw puzzles, arts and crafts, music, movies. It's physiotherapy activities, relaxation, all of these things that you can do that if someone either has a delirium or you're trying to reduce the risk of the delirium that we're engaging with the patient. We need to be thinking of what can we do to help this patient in terms of therapeutic engagement before we're thinking about what tablet can we reach. And also opportune moments, as Nicola said, every contact counts, but when you're delivering therapeutic engagement to your patient, that's a really, really ideal moment to try to figure out what is going on.
Another member of our team is Darren, the Mental Capacity Act lead for the Northern Trust. And here he explains to us about the importance of reassurance when caring for people with delirium. The communication skills and those fundamentals of care are all the things that stop us getting to the stage of seeing agitation and aggression. And it's being prepared to repeat that process multiple, multiple times for the benefit of the patient because they may not retain that information, but that reassurance might just be all that they need.
Here's Orla once more. I probably should say that we need to be mindful of overstimulation. So we know that stimulation is really, really important for patients of hypoactive delirium. But if our patients have a hyperactive delirium that, you know, once they're showing a disinterest, it's like the jigsaw puzzle, it's not getting to the end and finishing the jigsaw puzzle, it's a moment of human engagement and connection and talking. And if the person gets bored of it, then they can move on. Or if they're in a moment where they just need a bit of rest and peace. But sometimes if they've had a hyperactive delirium or those real confusing and disorientating hallucinations, they'll actually go somewhere nice and quiet, somewhere where there isn't an over stimulation and for you just to be there with them, to comfort them, held hand might just be all the need as well.
Here's Jackie again, to highlight the value in keeping families of patients on side and using them as a helpful resource in the care that you provide on the wards. I think this is an area where we can also really involve family members. Giving them the freedom to maybe go for a walk with their loved one if they're able enough. Or play a game with them as well as Orla suggested or something and actually be involved in their, in their therapy and in a very positive way by someone who knows them the best can be really, really positive.
And this can feel like a real change in how we do medicine on the wards. Often we can feel so under pressure with jobs that we feel there's a conflict where we'd love to sit down and have that 10 minute conversation which could be so helpful for someone with delirium. But also feel that we don't have the time. But it really is a case of reshaping the interactions we have with patients, where we're constantly asking ourselves, how do I make this contact count? Here are some of Julie's thoughts on that.
I'd agree, everybody feels that. We've all got the conflict and priorities. But it is stripping it back as if it was you or your own family and it is those basics, you know, taking that extra five minutes will probably save us a lot of time and pain and unsettlement for the patients in the future.
So, we've explored quite a lot in today's episode about the non pharmacological approaches that we can take. And in our next episode, we'll be focusing more on how we can use medications to help with symptoms of delirium. So lots to learn together when we get to our next episode. But just before we wrap up today, here's our resident pharmacist, Julie Magee, to tell us about medications reviews and how we can avoid creating problems for our patients by the medications we're giving.
A medication review is really important for those with delirium. The NICE Delirium Guidelines, CG103 recommend carrying out a medication review for people taking multiple drugs. This should be done by following the seven steps of medication review. I'm not going to go into them all because it would take me way too long, but you can find them in Scottish guidelines at www.polypharmacy. scot. nhs. uk. So in episode two, we talked about medication with anticholinergic burden. There's several scales available as well for calculating someone's total anticholinergic burden score and if the score's three or more, this can increase the risk of confusion, falls and death. So it's therefore important to consider this burden score when you're carrying out your medication review.
Deprescribing is an important part of medication review, which involves reducing doses or stopping medicines with the goal of improving outcomes by managing any inappropriate polypharmacy. In hypoactive delirium, a patient can be withdrawn quiet and sleepy, so for these patients it's really important to review are they on a lot of sedating medicines that may need to be reviewed if they're making the situation worse.
What about when someone is so affected by delirium that they're refusing their medications? What can we do then? How do we rationalise someone's list of medications? Here's Julie again. So if they're on 30 medicines in their Kardex and they're refusing to take medication, take away their folic acid for those few days and try and prioritize maybe them taking their anti epileptic drug or their Parkinson's medication.
And if they refuse to take those or can't take any oral medications at all, it's important to think about alternative routes for essential medication and this should be discussed with the medical staff and the pharmacist. Also really important to say not to alter any medication, for example crushing it or giving it covertly without discussion with medical staff or permission for this first.
And also advice on altering medication from the pharmacist because not all medicines can be crushed or altered and they'll advise you on which can and can't and what alternatives there could be then if they can't be. And we are going to talk about pharmacological management of delirium in episode 4 where non pharmacological methods have failed, and the patient poses a risk to themselves or others.
And when medications are given appropriately to treat the cause of a delirium, such as giving laxatives in constipation, antibiotics in acute infection, or even IV fluids in dehydration, sometimes deliriums can lift quite quickly. Here are a few final thoughts from Orla.
There's something actually so lovely about that as a nurse, you know, when you've seen a patient come from ED to your ward and you can see how distressed they are in the delirium and how distressed their family members are to see them so confused. And you come in the next day again and it is just like this person's back to normal and the lovely quick resolving deliriums when the acute illness has been treated is lovely to watch.
Just before we leave, I want to introduce one special guest for today's episode, and that's Lorraine Gibson, our falls coordinator for the Northern Trust. And here she is to briefly highlight the link that there can be between delirium and falls, and how we can reduce the risk of falls in patients with delirium on our wards.
There's a fundamental relationship between delirium and falls. Behaviours such as restlessness can increase the exposure to falling and reduced activity levels seen in hypoactive delirium may lead to deconditioning, affecting muscle strength and balance. There's also a link between gait and balance impairments within delirium and that then can obviously impact their risk of falling.
Delirium is an important and potentially modifiable risk factor for falls. Some points to consider for your patient if they are in hospital with a delirium is the actual hospital environment. It's important to keep the area clutter free and have personal items in reach so that they're not over stretching which can then increase them falling.
It's important to assess your patient's ability to use their call bell. A patient with delirium may not be able to use their call bell, may forget about the call bell, or may not understand why they need to use it. So then we need to think about other measures to put in place, such as the use of assistive technology, so we know if a patient's going to get up, or frequent checks on the patient. It's also important to consider your patient's location, especially if they have delirium and you identify them as an increased risk of falls. If you're concerned that they will attempt to get up unaided and they need assistance, where possible ensure that they're visible to the nursing staff and if need be consider doing frequent checks on the patient.
Also consider your enhanced observation tools and the use of EPCO and then consider the types of interventions that you may use if the patient is displaying certain behaviours that increase their risk. You know, is the patient getting out of their chair or out of their bed? And why really? So are they hungry?
Are they cold? Are they thirsty? Are they in pain? Do they need to use the bathroom? Or are they tired and do they want to get back into bed? Or is the patient in the chair and actually they're trying to get up and walk because they're bored and they want to go and start to mobilise. And also ensure then that we encourage safer mobility. The patient does need to go to the bathroom, walk with them to the bathroom instead of always taking them in the commode, you know, and get them to get up and moving. We really need to attempt to try and reduce our deconditioning within our patients in the hospital setting.
But remember that they may be unsteady on their feet and forget to use their walking aid, especially with a patient with delirium. So make sure that it's either beside them or continue to remind them that they need that assistance.
So many immensely helpful bits of insight there from our team. As a quick reminder of what we've just gone through, the management of delirium is multifaceted and it is crucial that we aim to identify and treat the underlying causes. Each case is unique and we must keep our approach patient centred, and remember to include patients families as care partners. Communication is key and we should always look to offer clear introductions of who we are and what we are doing at any given time. We should aim to maximise independence with our patients and promote routine wherever possible on the wards.
Therapeutic activities can be extremely helpful in delirium too, such as activity trolleys and other means of promoting cognitive stimulation. And finally, don't forget to look at those medications to ensure that we're not contributing to the delirium with what we're giving them. But, even still, despite our very best efforts using all of the methods we've just mentioned today, sometimes cases of delirium do not easily resolve and we see patients experiencing complex prolonged delirium, often with significant agitation and distress.
So what do we do in these complex cases? Well, tune in next time for episode four, because that is exactly what we're going to be looking at then. In the meantime, thanks for tuning in and we look forward to chatting with you again very soon.