Management of delirium includes a specific array of interventions by nursing, psychological, general medical, and psychiatric staff that can be broadly categorized as environmental interventions. The general goals are to reduce environmental factors that exacerbate delirium, confusion, and misperception while providing familiarity and an optimal level of environmental stimulation. While there is no empirical evidence that the environment by itself causes delirium, certain environmental conditions may exacerbate delirium.

"Timelessness" in hospital intensive care units (ICUs) (i.e., a similar environment regardless of the time of day) appears to contribute to disorganization of sleep-wake cycles, which in turn aggravates fatigue and confusion. Some ICUs have introduced windows, while others change the lighting to cue night versus day. The ICU can be a very noisy environment, with beeps, alarms, pumps, respirators, overhead paging, resuscitation efforts, etc. The confused patient with delirium may become overstimulated by too much noise, and efforts should be made to reduce this whenever possible. On the other hand, understimulation from the environment may leave the patient with delirium undistracted from his or her own internal disorganized perceptions and thoughts; too quiet an environment may exacerbate delirium. It is important to provide a regular amount of modest stimulation (vocal, visual, tactile) to the patient with delirium.

Delirium can also be aggravated by sensory impairments, including visual impairment (53) and auditory impairment (54). By restoring a patient's glasses or hearing aid, one may substantially reduce the manifestations of delirium. Ensuring that there is an analog clock and a calendar that the patient can see will further facilitate orientation. Steps that render the environment more familiar and less alien, such as bringing in family photographs or favorite objects from home (e.g., stuffed animals) or actually having family members there when possible, are also helpful. Especially in a room that may be dark at night, night-lights can help reduce anxiety.

There is some empirical evidence that these environmental interventions can reduce the severity of delirium and improve outcomes (55–58). While there are no large, rigorous, randomized controlled trials, these environmental interventions are widely endorsed because of clinical experience and the lack of adverse effects. Although the value of environmental interventions is widely recognized, they remain substantially underutilized (59).

Nursing, psychological, general medical, and psychiatric staff and family members can also provide cognitive-emotional support designed to strengthen any retained adaptive cognitive functioning that the patient possesses. The goal of these interventions is to reduce anxiety and the unfamiliar while providing understanding and support.

Central to providing cognitive and emotional support are efforts to deal with disorientation. All who come in contact with the patient should provide reorientation, which entails reminding the patient in an unpressured manner of where he or she is, the date and time, and what is happening to him or her.

The patient's emotional reaction to symptoms of delirium can itself be a significant aggravating factor. The patient should be told that the symptoms are temporary and reversible and do not reflect a persistent psychiatric disorder. Similarly, the perception of cognitive deficits may lead patients to conclude that they have suffered brain damage. Unless the delirium is thought to be due to a major stroke or injury or to another event that may cause permanent brain injury, all who have contact with the patient should reassure her or him that these deficits are common and reversible symptoms associated with the particular illness, surgery, or other treatment.

There have been no large clinical trials examining the efficacy of cognitive and emotional support in delirium. However, as with environmental interventions, increased use of these currently underutilized supportive measures has been encouraged on the basis of clinical experience, common sense, and lack of adverse effects (59).

Educating patients' friends and family about delirium is extremely helpful since they may have the same worries as the patient (e.g., the patient has a permanent psychiatric illness or is brain damaged) and become frightened and demoralized instead of being hopeful and encouraging the patient (60).

It may be useful to recommend that family and friends spend time in the patient's room and bring familiar objects from home to help orient the patient and help him or her feel secure.