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Abstract
Terminal restlessness and delirium are common clinical issues faced by patients at the end of life. For many providers, recognition and treatment of this condition can be challenging. This becomes increasingly difficult when the dying patient has end-stage Alzheimer's dementia and the patient is manifesting terminal restlessness. Use of both pharmacological and nonpharmacological modalities is often employed for this condition, but the degree of restlessness in this population may not always be readily apparent. In addition, pharmacological therapy, especially antipsychotics, has multiple adverse effects and many nonacute-care hospital facilities may have limitations on its use. Consideration of the use of robotic animal aids has recently been introduced to assist in treating terminal restlessness in this population. This case study describes the effectiveness of using a robotic cat to successfully assist in the treatment of a patient with terminal restlessness.
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Affiliation(s)
- David B Brecher
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, Tacoma, Washington
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52
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McKenzie J, Joy A. Family intervention improves outcomes for patients with delirium: Systematic review and meta‐analysis. Australas J Ageing 2019; 39:21-30. [DOI: 10.1111/ajag.12688] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 05/10/2019] [Accepted: 05/22/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Jessica McKenzie
- Occupational Therapy Occupational Therapist Eastern Health Melbourne Victoria Australia
| | - Anna Joy
- Advanced Occupational Therapy Senior Occupational Therapist Eastern Health Melbourne Victoria Australia
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53
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Delirium risk in non-surgical patients: systematic review of predictive tools. Arch Gerontol Geriatr 2019; 83:292-302. [PMID: 31136886 DOI: 10.1016/j.archger.2019.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/09/2019] [Accepted: 05/14/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Delirium is a common, serious condition associated with poor hospital outcomes. Guidelines recommend screening for delirium risk to target diagnostic and/or prevention strategies. This study critically reviews multicomponent delirium risk prediction tools in adult non-surgical inpatients. STUDY DESIGN Systematic review of studies incorporating at least two clinical factors in a multicomponent tool predicting risk of delirium during hospital admission. Derivation and validation studies were included. Study design, risk factors and tool performance were extracted and tabulated, and study quality was assessed by CHARMS criteria. DATA SOURCES PubMed, Embase, PsycINFO, and Cumulative Index to Nursing Health Literature (CINAHL) to 11th March 2018. DATA SYNTHESIS 22 derivation studies enrolling 38,874 participants (9 with a validation component) and 4 additional validation studies were identified, from a range of ward types. All studies had at least moderate risk of bias. Older age and cognitive, functional and sensory impairment were important predisposing factors. Precipitating risk factors included infection, illness severity, renal and electrolyte disturbances. Tools mostly did not differentiate between predisposing and precipitating risk factors mathematically or conceptually Most tools showed fair to good discrimination, and identified more than half of older inpatients at risk. CONCLUSIONS Several validated delirium risk prediction tools can identify patients at increased risk of delirium, but do not provide clear advice for clinical application. Most recommended cut-points are sensitive but have low specificity. Implementation studies demonstrating how risk screening can better direct clinical interventions in specific clinical settings are needed to define the potential value of these tools.
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54
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Redley B, Richardson B, Peel C, Ockerby C, Rawson H, Tomlinson E, Hutchinson A. Co-development of "BRAIN-TRK": Qualitative examination of acceptability, usability and feasibility of an App to support nurses' care for patients with behavioural and psychological symptoms of neurocognitive disorders in hospital. J Clin Nurs 2019; 28:2868-2879. [PMID: 30938865 DOI: 10.1111/jocn.14874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/13/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES (a) Describe the co-development of a point-of-care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital. BACKGROUND Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations. DESIGN Three-stage, mixed-methods, process and outcome evaluation. METHODS The App was co-developed with experts, nurse end-users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist. RESULTS The App included three components: cognition and risk assessment; tailored evidence-based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device-related factors. CONCLUSIONS The App provided an evidence-based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation. RELEVANCE TO CLINICAL PRACTICE Co-development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real-time access to assessment tools and tailored knowledge supported nurses' clinical decision-making; workload and unfamiliarity were barriers to use.
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Affiliation(s)
- Bernice Redley
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Ben Richardson
- Cairnmillar Institute, Hawthorn East, Victoria, Australia
| | - Charlotte Peel
- Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Cherene Ockerby
- Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Helen Rawson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Alison Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
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55
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Trajectory of severity of postoperative delirium symptoms and its prospective association with cognitive function in patients with gastric cancer: results from a prospective observational study. Support Care Cancer 2019; 27:2999-3006. [PMID: 30607674 DOI: 10.1007/s00520-018-4604-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 12/10/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Delirium is a common neurocognitive complication in cancer. Despite this, the studies examining the trajectory of the severity of delirium symptoms and its impact on health outcome in gastric cancer is rather limited. This study examined the trajectory of delirium symptom severity (DSS) following resection surgery for gastric cancer and its prospective association with cognitive function. METHODS A three-wave prospective observational study was conducted with 242 gastric cancer patients admitted for resection surgery at a teaching hospital in South Korea from May 2016 to November 2017. DSS was assessed by the clinical staff before and 1, 2, 3, and 7 days after surgery using the Delirium Rating Scale-Revised-98. A survey including the Functional Assessment of Cancer Therapy-Cognitive Scale (FACT-Cog) and Mini-Mental State Examination (MMSE) was administered before surgery (T0), 7 days after (T1), and 3 to 6 months after surgery (T2). RESULTS Out of 242 participants, 48.8% (118) completed the survey at all three time points, 43.4% (105) did so for two time points, and 7.9% (19) for one time point. No cases of full delirium were observed over four postoperative time points. Latent growth curve modeling analyses indicated that DSS declined over 3 days after surgery. Age and anesthesia time were positively associated with the initial level of DSS. A medication history for memory complaints was related to a slower recovery from delirium symptoms. While the use of propofol as an anesthetic agent was associated with lower initial DSS, it predicted a slower recovery from DSS. A higher initial DSS predicted a lower T1 MMSE score. CONCLUSIONS Severity of postoperative delirium symptoms predicts a short-term and objective cognitive function post-surgery. Monitoring and timely treatment of postoperative delirium symptoms is needed to diminish cognitive consequences in gastric cancer patients.
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56
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Bannon L, McGaughey J, Verghis R, Clarke M, McAuley DF, Blackwood B. The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1-12. [PMID: 30506354 DOI: 10.1007/s00134-018-5452-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/03/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the effect of non-pharmacological interventions versus standard care on incidence and duration of delirium in critically ill patients. METHODS We searched electronic and grey literature for randomised clinical trials up to March 2018. Two reviewers independently screened, selected and extracted data. Meta-analysis was undertaken using random effects modelling. RESULTS We identified 15 trials (2812 participants). Eleven trials reported incidence of delirium. Pooled data from four trials of bright light therapy showed no significant effect between groups (n = 829 participants, RR 0.45, 99% CI 0.10-2.13, P = 0.19, very low quality evidence). Seven trials of various individual interventions also failed to report any significant effects. A total of eight trials reported duration of delirium. Pooled data from two trials of multicomponent physical therapy showed no significant effect [n = 404 participants, MD (days) - 0.65, 99% CI - 2.73 to 1.44, P = 0.42, low quality of evidence]. Four trials of various individual interventions also reported no significant effects. A trial of family voice reorientation showed a beneficial effect [n = 30, MD (days) - 1.30, 99% CI - 2.41 to - 0.19, P = 0.003, very low quality evidence]. CONCLUSIONS Current evidence does not support the use of non-pharmacological interventions in reducing incidence and duration of delirium in critically ill patients. Future research should consider well-designed and well-described multicomponent interventions and include adequately defined outcome measures.
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Affiliation(s)
- Leona Bannon
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Rejina Verghis
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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57
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Harwood RH, Teale E. Where next for delirium research? Int J Geriatr Psychiatry 2018; 33:1512-1520. [PMID: 28271556 DOI: 10.1002/gps.4696] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 02/01/2017] [Indexed: 01/16/2023]
Abstract
Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.
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Affiliation(s)
- Rowan H Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Elizabeth Teale
- Academic Unit of Elderly Care and Rehabilitation, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
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58
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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59
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Duffy EI, Garry J, Talbot L, Pasternak D, Flinn A, Minardi C, Dookram M, Grant K, Fitzgerald D, Rubano J, Vosswinkel J, Jawa RS. A pilot study assessing the spiritual, emotional, physical/environmental, and physiological needs of mechanically ventilated surgical intensive care unit patients via eye tracking devices, head nodding, and communication boards. Trauma Surg Acute Care Open 2018; 3:e000180. [PMID: 30246152 PMCID: PMC6144907 DOI: 10.1136/tsaco-2018-000180] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 12/13/2022] Open
Abstract
Background Mechanically ventilated patients in the intensive care unit (ICU) are unable to communicate verbally. We sought to evaluate their needs via a communication board (CB) and a novel eye tracking device (ETD) that verbalizes selections made by gazing. Methods This was a pilot prospective study conducted in a tertiary care surgical ICU. Continuously mechanically ventilated adult surgical ICU patients with a Richmond Agitation-Sedation Scale score of −1 to +1, without cognitive impairment, were eligible. We asked patients four yes-or-no questions to assess basic needs regarding presence of pain, need for endotracheal suction, satisfactory room temperature, and position comfort. Patients were then asked if there was anything else that they wanted to communicate. All responses were confirmed by head nodding. Results The median accuracy of the CB (100% (IQR 100%–100%)) for basic needs communication (yes/no questions) was comparable with that of the ETD (100% (IQR 68.8%–100%); p=0.14) in the 12 enrolled patients. Notably, 83% of patients desired to communicate additional information, ranging from spiritual (eg, desire for prayer/chaplain), emotional (eg, frustration, desire for comfort), physical/environmental (eg, television), to physiological (eg, thirst/hunger) needs. Discussion The majority of patients desired to communicate something other than basic needs. Unless specifically assessed via an assistive communication device (eg, CB or ETD), some of these other needs would have been difficult to discern. Level of evidence IV therapeutic care/management.
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Affiliation(s)
- Erin I Duffy
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Jonah Garry
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Lillian Talbot
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - David Pasternak
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Ashley Flinn
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Casey Minardi
- Department of Inpatient Occupational Therapy, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Michele Dookram
- Department of Inpatient Occupational Therapy, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Kathleen Grant
- Department of Inpatient Occupational Therapy, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Debbie Fitzgerald
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Jerry Rubano
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - James Vosswinkel
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Randeep S Jawa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Stony Brook University School of Medicine, Stony Brook, New York, USA
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Rosa RG, Falavigna M, Robinson CC, da Silva DB, Kochhann R, de Moura RM, Santos MMS, Sganzerla D, Giordani NE, Eugênio C, Ribeiro T, Cavalcanti AB, Bozza F, Azevedo LCP, Machado FR, Salluh JIF, Pellegrini JAS, Moraes RB, Hochegger T, Amaral A, Teles JMM, da Luz LG, Barbosa MG, Birriel DC, Ferraz IDL, Nobre V, Valentim HM, Corrêa E Castro L, Duarte PAD, Tregnago R, Barilli SLS, Brandão N, Giannini A, Teixeira C. Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study). BMJ Open 2018; 8:e021193. [PMID: 29654049 PMCID: PMC5905750 DOI: 10.1136/bmjopen-2017-021193] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION NCT02932358.
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Affiliation(s)
- Regis Goulart Rosa
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | - Renata Kochhann
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | - Cláudia Eugênio
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | - Tarissa Ribeiro
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | - Fernando Bozza
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | | | - Flávia Ribeiro Machado
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | | | | | - Taís Hochegger
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Alexandre Amaral
- Intensive Care Unit, Hospital de Urgências de Goiânia, Goiânia, Brazil
| | | | | | | | | | - Iris de Lima Ferraz
- Intensive Care Unit, Hospital de Urgência e Emergência de Rio Branco, Rio Branco, Brazil
| | - Vandack Nobre
- Intensive Care Unit, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Péricles Almeida Delfino Duarte
- Intensive Care Unit, Hospital do Câncer de Cascavel, Cascavel, Brazil
- Intensive Care, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | | | | | - Nilton Brandão
- Department of Internal Medicine, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Ospedale dei Bambini - ASST Spedali Civili, Brescia, Italy
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
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Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis. J Gen Intern Med 2018; 33:500-509. [PMID: 29374358 PMCID: PMC5880753 DOI: 10.1007/s11606-017-4204-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. METHODS Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. RESULTS Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). DISCUSSION Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.
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Affiliation(s)
- Jennifer Watt
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada.,Institute for Health Policy Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Catherine Talbot-Hamon
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Ba' Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy Management Evaluation, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Camilla Wong
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Douglas Sinclair
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada. .,Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.
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Duque AF, Post ZD, Orozco FR, Lutz RW, Ong AC. A Proactive Approach to High Risk Delirium Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2018; 33:1171-1176. [PMID: 29174758 DOI: 10.1016/j.arth.2017.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Delirium is a common complication among elderly patients undergoing total joint arthroplasty (TJA). Its incidence has been reported from 4% to 53%. The Centers for Medicare and Medicaid Services consider delirium following TJA a "never-event." The purpose of this study is to evaluate a simple perioperative protocol used to identify delirium risk patients and prevent its incidence following TJA. METHODS Our group developed a protocol to identify and prevent delirium in patients undergoing TJA. All patients were screened and scored in the preoperative assessment, on criteria such as age, history of forgetfulness, history of agitation or visual hallucinations, history of falls, history of postoperative confusion, and inability to perform higher brain functions. Patients were scored on performance in a simple mental examination. The patients were classified as low, medium, or high risk. Patients who were identified as high risk were enrolled in a delirium avoidance protocol that minimized narcotics and emphasized nursing involvement and fluids administration. RESULTS Five of 7659 (0.065%) consecutive TJA patients from 2010 to 2015 developed delirium. A total of 422 patients were identified as high risk. All 5 patients who suffered delirium were within the high risk group. No low or medium risk patients suffered a delirium complication. Three (0.039%) patients suffered drug-induced delirium, 1 (0.013%) had delirium related to alcohol withdrawal, and 1 (0.013%) had delirium after a systemic infection. CONCLUSION This protocol is effective in identifying patients at high delirium risk and diminishing the incidence of this complication by utilizing a simple screening tool and perioperative protocol.
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Affiliation(s)
- Andres F Duque
- The Rothman Institute of Orthopaedics at Thomas Jefferson University, Egg Harbor Township, New Jersey
| | - Zachary D Post
- The Rothman Institute of Orthopaedics at Thomas Jefferson University, Egg Harbor Township, New Jersey
| | - Fabio R Orozco
- The Rothman Institute of Orthopaedics at Thomas Jefferson University, Egg Harbor Township, New Jersey
| | - Rex W Lutz
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Alvin C Ong
- The Rothman Institute of Orthopaedics at Thomas Jefferson University, Egg Harbor Township, New Jersey
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Babine RL, Hyrkäs KE, Hallen S, Wierman HR, Bachand DA, Chapman JL, Fuller VJ. Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation-wide interprofessional education. J Clin Nurs 2018; 27:e1429-e1441. [PMID: 29314374 DOI: 10.1111/jocn.14259] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2017] [Indexed: 11/29/2022]
Abstract
AIM AND OBJECTIVES To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation-wide interprofessional delirium education and practice change along with implementation of a policy. BACKGROUND Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%-56%, morbidity and mortality from 25%-33%. Recent studies report that 73%-96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases. DESIGN A descriptive, retrospective observational study using a pre/postdesign. METHODS Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009-2010 (98 fallers) and 2012 (108 fallers). An organisation-wide education was planned and implemented with monitoring of policy compliance. RESULTS After the education, documentation of the "diagnosis of delirium" and "no evidence of delirium" increased from 14.3%-29.5% and from 27.6%-44.4%. The documentation of "evidence of delirium" decreased significantly from 58.2%-25.9% (p < .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. CONCLUSION The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. RELEVANCE TO CLINICAL PRACTICE The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re-education, and the re-enforcement of learning along with the implementation of a policy.
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Affiliation(s)
- Rhonda L Babine
- Center for Clinical & Professional Development, Maine Medical Center, Portland, ME, USA
| | - Kristiina E Hyrkäs
- Center of Nursing Research and Quality Outcomes, Maine Medical Center, Portland, ME, USA
| | - Sarah Hallen
- Maine Medical Partners, Maine Medical Center, Portland, ME, USA
| | - Heidi R Wierman
- Center for Clinical & Professional Development, Maine Medical Center, Portland, ME, USA
| | - Deborah A Bachand
- Adult Inpatient Orthopedic Neurosurgical Units, Maine Medical Center, Portland, ME, USA
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Abstract
Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, One Brigham Circle, 3rd Floor, Boston, MA 02120, USA.
| | - Sharon K Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University School of Medicine, Mason F. Lord Building, 5200 Eastern Avenue, 7th Floor, Room 721, Baltimore, MD 21224, USA
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65
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Brown EG, Josephson SA, Anderson N, Reid M, Lee M, Douglas VC. Evaluation of a multicomponent pathway to address inpatient delirium on a neurosciences ward. BMC Health Serv Res 2018; 18:106. [PMID: 29433572 PMCID: PMC5809949 DOI: 10.1186/s12913-018-2906-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 01/31/2018] [Indexed: 01/28/2023] Open
Abstract
Background Delirium is a frequent and detrimental complication of inpatient hospitalization. Multicomponent intervention in selected groups has been shown to prevent and treat delirium, though little data exists on the effect of intervention in neurological patients. We studied the efficacy of a multicomponent delirium care pathway implemented on a largely neurology and neurosurgery hospital ward among unselected patients. Methods We incorporated a multicomponent delirium care pathway into the workflow of a university hospital for patients older than 50 years. The pathway involved risk-stratification for development of delirium, delirium screening, and non-pharmacologic behavioral prevention and intervention. We then retrospectively reviewed admissions before and after implementation of the care pathway. Our primary endpoint was incidence of delirium; secondary endpoints included delirium days, length of stay, restraint use, readmission rates, and discharge disposition. Results Seven hundred ninety eight admissions from before the delirium care pathway went into effect and 797 admissions from afterwards were reviewed. Baseline characteristics between groups were similar. Delirium incidence between the two groups did not change (7.0% before vs 7.2% after, p = 0.89). Length of stay among delirious patients significantly decreased after implementation of the delirium care pathway (9.60 before vs 7.06 after, β = − 0.16, adjusted p-value = 0.001). Conclusion Implementation of a delirium care pathway on a neurosciences ward was not associated with changes in the rate of delirium development, though length of stay among delirious patients decreased. In a largely neurologic population, multicomponent intervention to prevent and treat delirium may not change delirium incidence, but may be effective in mitigating delirium complications.
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Affiliation(s)
- Ethan G Brown
- Department of Neurology, University of California, San Francisco, CA, USA.
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Noriko Anderson
- Department of Neurology, University of California, Irvine, USA
| | - Mary Reid
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Melissa Lee
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Vanja C Douglas
- Department of Neurology, University of California, San Francisco, CA, USA
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Martínez F, Donoso AM, Marquez C, Labarca E. Implementing a Multicomponent Intervention to Prevent Delirium Among Critically Ill Patients. Crit Care Nurse 2017; 37:36-46. [DOI: 10.4037/ccn2017531] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND
Delirium is common among the critically ill. Nonpharmacologic interventions are reportedly effective in reducing incident delirium, but limited data specific to this population exist.
OBJECTIVES
To assess the efficacy and describe the implementation strategy of a multicomponent intervention to prevent delirium in an intensive care unit.
METHODS
A before-and-after study was conducted in an intensive care unit between May 2014 through August 2015. Adult participants were enrolled consecutively, excluding only those who refused to participate. Tailored interventions took available evidence into consideration. Components included early mobilization, physical therapy, reorientation, cognitive stimulation, drug reviews, environmental stimulation, avoidance of sensory deprivation, pain control, restraint use avoidance, and family participation. Incident delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Multivariate logistic regression was used to control for confounders.
RESULTS
The study included 227 patients (54.7% male; mean [SD] age, 63.3 [18.3] years). Our strategy significantly reduced delirium (from 38% to 24%; relative risk, 0.62; 95% CI, 0.40–0.94; P = .02), an association that remained significant after adjusting for confounders. Adherence rates were more than 85% in all intervention domains (except daily reorientation) that were overseen by health care providers.
CONCLUSIONs
The strategy was successful in reducing delirium. Self-removals of invasive implements decreased, an observation that has not been previously described. No difference in mortality rate was seen, as has been reported in other studies. Early participation of the whole team, shared leadership, and the provision of concrete tasks were key to the success of this multicomponent intervention.
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Affiliation(s)
- Felipe Martínez
- Felipe Martínez is an intensive care physician at Unidad de Cuidados Intensivos Generales, Hospital Naval Almirante Nef, Viña del Mar, Chile, and a research coordinator at Area de Investigación y Estudios Clínicos, Clínica Ciudad del Mar, Viña del Mar, and a clinical researcher at Centro de Investigaciones Biomédicas, Escuela de Medicina, Universidad de Valparaíso, Centro de Investigaciones Biomédicas, Escuela de Medicina, Universidad de Valparaíso, Chile
| | - Ana María Donoso
- Ana María Donoso is an anesthesiologist at Unidad de Cuidados Intensivos Generales, Hospital Naval Almirante Nef
| | - Carla Marquez
- Carla Marquez is a clinical nurse at Unidad de Cuidados Intensivos Generales, Hospital Naval Almirante Nef
| | - Eduardo Labarca
- Eduardo Labarca is a senior intensivist at Unidad de Cuidados Intensivos Generales, Hospital Naval Almirante Nef
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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Chen CCH, Li HC, Liang JT, Lai IR, Purnomo JDT, Yang YT, Lin BR, Huang J, Yang CY, Tien YW, Chen CN, Lin MT, Huang GH, Inouye SK. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surg 2017; 152:827-834. [PMID: 28538964 DOI: 10.1001/jamasurg.2017.1083] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS). Objective To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery. Design, Setting, and Participants This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care. Interventions The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily. Main Outcomes and Measures Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record. Results Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04). Conclusions and Relevance For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery. Trial Registration clinicaltrials.gov Identifier: NCT01045330.
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Affiliation(s)
- Cheryl Chia-Hui Chen
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Ching Li
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, Sijhih Cathy General Hospital, New Taipei City, Taiwan
| | - Jin-Tung Liang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Rue Lai
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Yi-Ting Yang
- Taiwan Center for Disease Control, Taipei, Taiwan
| | - Been-Ren Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - John Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiung-Nien Chen
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Hua Huang
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew Senior-Life, Boston, Massachusetts
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Mailhot T, Cossette S, Côté J, Bourbonnais A, Côté MC, Lamarche Y, Denault A. A post cardiac surgery intervention to manage delirium involving families: a randomized pilot study. Nurs Crit Care 2017; 22:221-228. [PMID: 28371230 DOI: 10.1111/nicc.12288] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/28/2016] [Accepted: 01/23/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND As many delirium manifestations (e.g., hallucinations or fears) are linked to patients' experiences and personality traits, it is suggested that interventions should be tailored to optimize its management. The inclusion of family members, as part of an intervention, has recently emerged as a solution to developing individualised patient care, but has never been assessed in post-cardiac surgery intensive care unit where almost half of patients will present with delirium. AIMS To assess the feasibility, acceptability and preliminary efficacy of an nursing intervention involving family caregivers (FC) in delirium management following cardiac surgery. DESIGN A randomized pilot study. METHODS A total of 30 patient/FC dyads were recruited and randomized to usual care (n = 14) or intervention (n = 16). The intervention was based on the Human Caring Theory, a mentoring model, and sources informing self-efficacy. It comprised seven planned encounters spread over 3 days between an intervention nurse and the FC, each including a 30-min visit at the patient's bedside. During this bedside visit, the FC used delirium management strategies, e.g. reorient the person with delirium. The primary indicator of acceptability was to obtain consent from 75% of approached FCs. The preliminary effect of the intervention on patient outcomes was assessed on (1) delirium severity using the Delirium Index, (2) occurrence of complications, such as falls, (3) length of postoperative hospital stay and (4) psycho-functional recovery using the Sickness Impact Profile. The preliminary effect on FC outcomes was assessed on FC anxiety and self-efficacy. Data were analysed using descriptive statistics, ANCOVAs and logistic regressions. RESULTS The primary indicator of obtaining consent from FC was achieved (77%). Of the 14 dyads, thirteen (93%) dyads received all seven encounters planned in the experimental intervention. Intervention group patients presented better psycho-functional recovery scores when compared with control group patients (p = 0·01). Mean delirium severity scores showed similar trajectories on days 1, 2 and 3 in both groups. CONCLUSION The mentoring intervention was acceptable and feasible and shows promising results in improving patients and FC outcomes. RELEVANCE TO CLINICAL PRACTICE Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance.
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Affiliation(s)
- Tanya Mailhot
- Montreal Heart Institute Research Center S-2490, University of Montreal, 5000 Belanger Street, Montreal (Quebec) H1T 1C8, Canada
| | - Sylvie Cossette
- University of Montreal, Montreal Heart Institute Research Center S-2510, 5000 Belanger Street, Montreal (Quebec) H1T 1C8, Canada
| | - José Côté
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, University of Montreal, PO Box 6128, Downtown Branch, Montréal (Québec) H3C 3J7, Canada
| | - Anne Bourbonnais
- University of Montreal, Chair of the Desjardins Research, Chair in Nursing Care for Older People and their Families, Centre de recherche de l'Institut universitaire de gériatrie de Montréal, PO Box 6128, Downtown Branch, Montréal (Québec) H3C 3J7, Canada
| | - Marie-Claude Côté
- Department of Psychosomatics, Montreal Heart Institute, 5000 Belanger Street, Montreal (Quebec) H1T 1C8, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, 5000 Belanger Street, Montreal (Quebec) H1T 1C8, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, 5000 Belanger Street, Montreal (Quebec) H1T 1C8, Canada
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Zhang W, Sun Y, Liu Y, Qiu W, Ye X, Zhang G, Zhang L. A nursing protocol targeting risk factors for reducing postoperative delirium in patients following coronary artery bypass grafting: Results of a prospective before-after study. Int J Nurs Sci 2017; 4:81-87. [PMID: 31406724 PMCID: PMC6626138 DOI: 10.1016/j.ijnss.2017.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
Objective The results of postoperative delirium (POD) warrant testing for prevention. The purpose of this study was to determine whether a nursing intervention targeting risk factors could decrease the incidence of POD among patients who had coronary artery bypass grafting (CABG) in China. Methods A prospective before-after study was conducted between April 2014 and April 2015. A nursing delirium intervention protocol targeting risk factors for delirium was performed for 141 patients undergoing CABG in a cardiothoracic ICU from November 2014 to April 2015. Intervention consisted of screening for delirium risk factors, followed by targeted risk factor modification, including pain control, early catheter removal, patient orientation using the 5W1H procedure, increased family visits, minimizing care-related interruptions, comfortable nursing and monitoring for sleeping difficulties. Outcomes of the Intervention Group were compared with those of the Control Group for 137 CABG patients from April 2014 to October 2014. Delirium was assessed using the confusion assessment method for the intensive care unit (CAM-ICU). The sample size was justified by PASS2000, based on previous data of delirium incidence in our institution (30%). Main results Delirium incidence during the first seven postoperative days was significantly lower in the Intervention Group at 13.48% (19/141) vs. 29.93% (41/137) for the Control Group (χ2 = 11.112, P = 0.001). In addition, POD in the Intervention Group occurred between the 3rd and 6th postoperative days, while POD in the Control Group mainly occurred on the first three days postoperatively. Delirium in the Intervention Group occurred later than delirium in the Control Group (χ2 = 12.743, P < 0.001). Length of ICU stay was reduced significantly (Z = −6.026, P < 0.001). Conclusion The application of a nursing protocol targeting risk factors in this study seems to be associated with a lower incidence of POD in patients after CABG. This finding suggests that managing the predictors properly is one of the effective strategies to prevent delirium. A nursing intervention program of postoperative delirium was cultivated for CABG patients. The study estimated the efficacy of the intervention through a before-after study. The risk-targeted nursing intervention may decrease delirium incidence in CABG patients.
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Affiliation(s)
- Weiying Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Sun
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yang Liu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wenjuan Qiu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Guihong Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Lingjuan Zhang
- Department of Nursing, Changhai Hospital, Second Military Medical University, Shanghai, China
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Zamoscik K, Godbold R, Freeman P. Intensive care nurses' experiences and perceptions of delirium and delirium care. Intensive Crit Care Nurs 2017; 40:94-100. [PMID: 28259522 DOI: 10.1016/j.iccn.2017.01.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/17/2016] [Accepted: 01/01/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To explore nurses' experiences and perceptions of delirium, managing delirious patients, and screening for delirium, five years after introduction of the Confusion Assessment Method for Intensive Care into standard practice. RESEARCH DESIGN AND SETTING Twelve nurses from a medical-surgical intensive care unit in a large teaching hospital attended two focus group sessions. The collected qualitative data was thematically analysed using Braun and Clarke's framework (2006). FINDINGS The analysis identified seven themes: (1) Delirium as a Secondary Matter (2) Unpleasant Nature of Delirium (3) Scepticism About Delirium Assessment (4) Distrust in Delirium Management (5) Value of Communication (6) Non-pharmacological Therapy (7) Need for Reviewed Delirium Policy. CONCLUSION Nurses described perceiving delirium as a low priority matter and linked it to work culture within the intensive care specialty. Simultaneously, they expressed their readiness to challenge this culture and to promote the notion of providing high-quality delirium care. Nurses discussed their frustrations related to lack of confidence in assessing delirium, as well as lack of effective therapies in managing this group of patients. They declared their appreciation for non-pharmacological interventions in treatment of delirium, suggested improvements to current delirium approach and proposed introducing psychological support for nurses dealing with delirious patients.
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Affiliation(s)
- Katarzyna Zamoscik
- Cambridge University Hospitals, Addenbrooke's Hospital, Intensive Care Unit, Hills Road, Cambridge, CB2 OQQ Cambridgeshire, UK.
| | - Rosemary Godbold
- University of Hertfordshire, Department of Adult Nursing and Primary Care, School of Health and Social Work, Room 2F287 (Wright Building), College Lane, Hatfield, AL10 9AB Hertfordshire, UK.
| | - Pauline Freeman
- University of Hertfordshire, Department of Adult Nursing and Primary Care, School of Health and Social Work, Room 2F279 (Wright Building), College Lane, Hatfield, AL10 9AB Hertfordshire, UK.
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Mitchell ML, Kean S, Rattray JE, Hull AM, Davis C, Murfield JE, Aitken LM. A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial. Intensive Crit Care Nurs 2017; 40:77-84. [PMID: 28254205 DOI: 10.1016/j.iccn.2017.01.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/07/2016] [Accepted: 01/01/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Family members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients. METHOD A single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective. RESULTS Recruitment rate was 28% of eligible patients (recruited n=90, attrition n=1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable. CONCLUSION The study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection.
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Affiliation(s)
- Marion L Mitchell
- NHMRC Centre for Research Excellence in Nursing, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; Princess Alexandra Hospital Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | - Susanne Kean
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK.
| | - Janice E Rattray
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK.
| | - Alastair M Hull
- Perth Royal Infirmary, NHS Tayside, Dundee, UK; Department of Psychiatry, University of Dundee, Dundee, UK.
| | - Chelsea Davis
- Princess Alexandra Hospital Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | - Jenny E Murfield
- Menzies Health Institute Queensland, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Griffith University, Nathan Campus, Brisbane, Queensland, Australia.
| | - Leanne M Aitken
- NHMRC Centre for Research Excellence in Nursing, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Griffith University, Nathan Campus, Brisbane, Queensland, Australia; Princess Alexandra Hospital Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Health Sciences, City University London, London, UK.
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74
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Álvarez EA, Garrido MA, Tobar EA, Prieto SA, Vergara SO, Briceño CD, González FJ. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. J Crit Care 2017; 37:85-90. [DOI: 10.1016/j.jcrc.2016.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/29/2016] [Accepted: 09/03/2016] [Indexed: 10/21/2022]
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Nonpharmacological Interventions Targeted at Delirium Risk Factors, Delivered by Trained Volunteers (Medical and Psychology Students), Reduced Need for Antipsychotic Medications and the Length of Hospital Stay in Aged Patients Admitted to an Acute Internal Medicine Ward: Pilot Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1297164. [PMID: 28164113 PMCID: PMC5259647 DOI: 10.1155/2017/1297164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/01/2016] [Accepted: 12/12/2016] [Indexed: 11/23/2022]
Abstract
Purpose. Effectiveness of nonpharmacological multicomponent prevention delivered by trained volunteers (medical and psychology students), targeted at delirium risk factors in geriatric inpatients, was assessed at an internal medicine ward in Poland. Patients and Methods. Participants were recruited to intervention and control groups at the internal medicine ward (inclusion criteria: age ≥ 75, acute medical condition, basic orientation, and logical contact on admission; exclusion criteria: life expectancy < 24 hours, surgical hospitalization, isolation due to infectious disease, and discharge to other medical wards). Every day trained volunteers delivered a multicomponent standardized intervention targeted at risk factors of in-hospital complications to the intervention group. The control group, selected using a retrospective individual matching strategy (1 : 1 ratio, regarding age, gender, and time of hospitalization), received standard care. Outcome Measures. Hospitalization time, deaths, falls, delirium episodes, and antipsychotic prescriptions were assessed retrospectively from medical documentation. Results. 130 patients (38.4% males) participated in the study, with 65 in the intervention group. Antipsychotic medications were initiated less frequently in the intervention group compared to the control group. There was a trend towards a shorter hospitalization time and a not statistically significant decrease in deaths in the intervention group. Conclusion. Nonpharmacological multicomponent intervention targeted at delirium risk factors effectively reduced length of hospitalization and need for initiating antipsychotic treatment in elderly patients at the internal medicine ward.
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Bélanger L, Bourbonnais A, Bernier R, Benoit M. Communication between nurses and family caregivers of hospitalised older persons: a literature review. J Clin Nurs 2016; 26:609-619. [PMID: 27539680 DOI: 10.1111/jocn.13516] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2016] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To review the literature concerning the feelings, thoughts and behaviours of nurses and family caregivers of hospitalised older persons when they communicate with one another. BACKGROUND Communication between nurses and family caregivers of hospitalised older persons is not always optimal. Improving the frequency and quality of this communication might be a way to make the most of available human capital in order to better care for hospitalised older people. DESIGN A literature review was carried out of qualitative, quantitative and mixed-design studies relating to communication between nurses and family caregivers. Findings were analysed thematically. RESULTS Family caregiver thoughts, feelings and behaviours relative to nurse control and authority, nurse recognition of their contribution, information received from and shared with nurses and care satisfaction could influence communication with nurses. Nurse thoughts regarding usefulness of family caregivers as care partners and their lack of availability to meet family caregiver demands could influence communication with family caregivers. CONCLUSIONS The thoughts, feelings and behaviours of family caregivers and nurses that might create positive or negative circular patterns of communication are evidenced. Further research is required to gain a more comprehensive understanding of the phenomenon. RELEVANCE TO CLINICAL PRACTICE Nurses must be trained in how to communicate with family caregivers in order to form a partnership geared to preventing complications in hospitalised older persons. Results could be used to inform policy regarding the care of hospitalised older persons.
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Affiliation(s)
| | - Anne Bourbonnais
- Faculté des sciences infirmières, Université de Montréal, Montréal, QC, Canada
| | | | - Monique Benoit
- Université du Québec en Outaouais, Saint-Jérôme, QC, Canada
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Bull MJ, Boaz L, Maadooliat M, Hagle ME, Gettrust L, Greene MT, Holmes SB, Saczynski JS. Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty. J Am Geriatr Soc 2016; 65:e13-e17. [PMID: 27861701 DOI: 10.1111/jgs.14535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To test the feasibility of a telephone-based intervention that prepares family caregivers to recognize delirium symptoms and how to communicate their observations to healthcare providers. DESIGN Mixed-method, pre-post quasi-experimental design. SETTING A Midwest Veterans Affairs Medical Center and a nonprofit health system. PARTICIPANTS Forty-one family caregiver-older adult dyads provided consent; 34 completed the intervention. INTERVENTION Four telephone-based education modules using vignettes were completed during the 3 weeks before the older adult's hospital admission for elective hip or knee replacement. Each module required 20 to 30 minutes. MEASUREMENTS Interviews were conducted before the intervention and 2 weeks and 2 months after the older adult's hospitalization. A researcher completed the Confusion Assessment Method (CAM) and a family caregiver completed the Family Version of the Confusion Assessment Method (FAM-CAM) 2 days after surgery to assess the older adults for delirium symptoms. RESULTS Family caregivers' knowledge of delirium symptoms improved significantly from before the intervention to 2 weeks after the intervention and was maintained after the older adult's hospitalization. They also were able to recognize the presence and absence of delirium symptoms in the vignettes included in the intervention and in the older adult after surgery. In 94% of the cases, the family caregiver rating on the FAM-CAM approximately 2 days after the older adult's surgery agreed with the researcher rating on the CAM. Family caregivers expressed satisfaction with the intervention and stated that the information was helpful. CONCLUSION Delivery of a telephone-based intervention appears feasible. All family caregivers who began the program completed the four education modules. Future studies evaluating the effectiveness of the educational program should include a control group.
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Affiliation(s)
- Margaret J Bull
- College of Nursing, Marquette University, Milwaukee, Wisconsin
| | - Lesley Boaz
- College of Nursing, Marquette University, Milwaukee, Wisconsin
| | - Mehdi Maadooliat
- Department of Mathematics, Statistics and Computer Science, Marquette University, Milwaukee, Wisconsin
| | - Mary E Hagle
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Lynn Gettrust
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | | | | | - Jane S Saczynski
- Department of Epidemiology, Northeastern University, Boston, Massachusetts
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Souza-Dantas VC, Póvoa P, Bozza F, Soares M, Salluh J. Preventive strategies and potential therapeutic interventions for delirium in sepsis. Hosp Pract (1995) 2016; 44:190-202. [PMID: 27223862 DOI: 10.1080/21548331.2016.1192453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/18/2016] [Indexed: 06/05/2023]
Abstract
Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.
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Affiliation(s)
| | - Pedro Póvoa
- b Polyvalent Intensive Care Unit, Hospital S. Francisco Xavier , Centro Hospitalar de Lisboa Ocidental (CHLO) , Lisbon , Portugal
- c Nova Medical School , CEDOC, New University of Lisbon , Portugal
| | - Fernando Bozza
- d Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
| | - Marcio Soares
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
| | - Jorge Salluh
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
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81
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Greenberger C, Mor P. Should Sabbath Prohibitions Be Overridden to Provide Emotional Support to a Sick Relative? Rambam Maimonides Med J 2016; 7:RMMJ.10250. [PMID: 27487314 PMCID: PMC5001795 DOI: 10.5041/rmmj.10250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a consensus among the halachic authorities that life-saving actions override Sabbath prohibitions. They are painstaking in securing that the sanctity of the Sabbath is maintained but that not a single life be lost. OBJECTIVE This manuscript examines if and when a relative's presence at the bedside of a seriously ill individual is potentially life-saving against the backdrop of the scientific literature. It specifically addresses the permissibility of traveling in a motorized vehicle, generally prohibited on the Sabbath, to be with one's relative in hospital for the provision of emotional support. METHODS Discourse of the halachic issues in the context of the scientific literature. RESULTS Stress, mental or physical, has been determined as a potentially life-threatening condition in many disease entities. The literature attests to both the patient's and the professionals' perception of the curative potential of the presence of loved ones by advocating for the patient and relieving stress in the hospital experience. Emotional support from a loved one is perceived by some patients as vital to survival. There is halachic consensus that a patient's perception of the emotional need for a relative's presence is sufficient to permit overriding rabbinic prohibitions. Torah prohibitions, which may be overridden for medical needs, may be overridden for emotional support, providing a health professional or family member attests to the fulfilment of this specific need as diminishing the danger to the patient's life. In certain cases, the latter contingency is unnecessary. CONCLUSIONS Emotional support has an impact on the patient's health status; the degree to which its impact is strong enough to save life is still being studied. As more data from scientific studies emerge, they may be relevant to sharpening the halachic rulings with respect to the issue at hand.
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Affiliation(s)
- Chaya Greenberger
- Dean, Faculty of Life and Health Sciences, Jerusalem College of Technology, Jerusalem, Israel
- Chair, Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
- To whom correspondence should be addressed. E-mail:
| | - Pnina Mor
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
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82
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Nagaraj G, Burkett E, Hullick C, Carpenter CR, Arendts G. Is delirium the medical emergency we know least about? Emerg Med Australas 2016; 28:456-8. [DOI: 10.1111/1742-6723.12639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Guruprasad Nagaraj
- Emergency Department; Hornsby and Royal North Shore Hospitals; Sydney New South Wales Australia
| | - Ellen Burkett
- Emergency Department; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Carolyn Hullick
- Emergency Department; John Hunter Hospital; Newcastle New South Wales Australia
| | | | - Glenn Arendts
- Harry Perkins Institute for Medical Research; The University of Western Australia; Perth Western Australia Australia
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Abstract
Delirium is a common, disabling medical condition that is associated with numerous adverse outcomes. A number of inter-related factors, including pre-existing cognitive impairment, usually contribute to the development of delirium in a particular susceptible individual. Non-pharmacological approaches to prevention typically target multiple risk factors in a systematic manner (multicomponent interventions). There is generally good evidence that multicomponent interventions reduce the incidence of delirium in hospital populations but there are limited data in people with dementia and those living in the community. It is likely that there is a differential effect of specific interventions in those with cognitive impairment (e.g. people with dementia may respond better to simpler, more pragmatic interventions rather than complex procedures) but this cannot be determined from the existing data. Targeted interventions focussed on hydration, medication rationalization and sleep promotion may also be effective in reducing the incidence of delirium, as well as the active involvement of family members in the care of the elderly hospitalized patient. Hospitalization itself is a potential risk factor for delirium and promising data are emerging of the benefits of home-based care as an alternative to hospitalization but this is restricted to specific sub-populations of patients and is reliant on these services being available.
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Affiliation(s)
- Andrew H Ford
- Western Australian Centre for Health & Ageing (M573), Harry Perkins Institute of Medical Research, University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
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84
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Bannon L, McGaughey J, Clarke M, McAuley DF, Blackwood B. Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research. Syst Rev 2016; 5:75. [PMID: 27146132 PMCID: PMC4855765 DOI: 10.1186/s13643-016-0254-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 04/25/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Critically ill patients have an increased risk of developing delirium during their intensive care stay. To date, pharmacological interventions have not been shown to be effective for delirium management but non-pharmacological interventions have shown some promise. The aim of this systematic review is to identify effective non-pharmacological interventions for reducing the incidence or the duration of delirium in critically ill patients. METHODS We will search MEDLINE, EMBASE, CINAHL, Web of Science, AMED, psycINFO and the Cochrane Library. We will include studies of critically ill adults and children. We will include randomised trials and controlled trials which measure the effectiveness of one or more non-pharmacological interventions in reducing incidence or duration of delirium in critically ill patients. We will also include qualitative studies that provide an insight into patients and their families' experiences of delirium and non-pharmacological interventions. Two independent reviewers will assess studies for eligibility, extract data and appraise quality. We will conduct meta-analyses if possible or present results narratively. Qualitative studies will also be reviewed by two independent reviewers, and a specially designed quality assessment tool incorporating the CASP framework and the POPAY framework will be used to assess quality. DISCUSSION Although non-pharmacological interventions have been studied in populations outside of intensive care units and multicomponent interventions have successfully reduced incidence and duration of delirium, no systematic review of non-pharmacological interventions specifically targeting delirium in critically ill patients have been undertaken to date. This systematic review will provide evidence for the development of a multicomponent intervention for delirium management of critically ill patients that can be tested in a subsequent multicentre randomised trial. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015016625.
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Affiliation(s)
- Leona Bannon
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland.
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, BT12 6BJ, Northern Ireland
| | - Daniel Francis McAuley
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Bronagh Blackwood
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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Finucane AM, Lugton J, Kennedy C, Spiller JA. The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review. Psychooncology 2016; 26:291-300. [PMID: 27132588 PMCID: PMC5363350 DOI: 10.1002/pon.4140] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/07/2016] [Accepted: 03/25/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To explore the experiences of caregivers of terminally ill patients with delirium, to determine the potential role of caregivers in the management of delirium at the end of life, to identify the support required to improve caregiver experience and to help the caregiver support the patient. METHODS Four electronic databases were searched-PsychInfo, Medline, Cinahl and Scopus from January 2000 to July 2015 using the terms 'delirium', 'terminal restlessness' or 'agitated restlessness' combined with 'carer' or 'caregiver' or 'family' or 'families'. Thirty-three papers met the inclusion criteria and remained in the final review. RESULTS Papers focused on (i) caregiver experience-distress, deteriorating relationships, balancing the need to relieve suffering with desire to communicate and helplessness versus control; (ii) the caregiver role-detection and prevention of delirium, symptom monitoring and acting as a patient advocate; and (iii) caregiver support-information needs, advice on how to respond to the patient, interventions to improve caregiver outcomes and interventions delivered by caregivers to improve patient outcomes. CONCLUSION High levels of distress are experienced by caregivers of patients with delirium. Distress is heightened because of the potential irreversibility of delirium in palliative care settings and uncertainty around whether the caregiver-patient relationship can be re-established before death. Caregivers can contribute to the management of patient delirium. Additional intervention studies with informational, emotional and behavioural components are required to improve support for caregivers and to help the caregiver support the patient. Reducing caregiver distress should be a goal of any future intervention.© 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.
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Affiliation(s)
| | - Jean Lugton
- Marie Curie Hospice Edinburgh, Edinburgh, UK
| | - Catriona Kennedy
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, UK
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Rizk P, Morris W, Oladeji P, Huo M. Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery. Geriatr Orthop Surg Rehabil 2016; 7:100-5. [PMID: 27239384 PMCID: PMC4872181 DOI: 10.1177/2151458516641162] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.
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Affiliation(s)
- Paul Rizk
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William Morris
- Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Philip Oladeji
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael Huo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Bull MJ, Boaz L, Jermé M. Educating Family Caregivers for Older Adults About Delirium: A Systematic Review. Worldviews Evid Based Nurs 2016; 13:232-40. [PMID: 26970229 DOI: 10.1111/wvn.12154] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium in older adults is considered a medical emergency; it contributes to a cascade of functional decline and to increased mortality. Early recognition of delirium symptoms is critical to prevent these negative consequences. Family caregivers who are educated about delirium could partner with nurses and other healthcare professionals in early recognition of delirium symptoms. Before implementing such partnership models, it is important to examine the effectiveness of educating family caregivers about delirium. AIMS To examine whether providing education on delirium to family caregivers improved their knowledge, emotional state, or response in reducing the incidence of delirium in older adults. METHODS For this systematic review, we conducted literature searches in CINAHL, Cochrane Library, Medline, PsycINFO, Web of Science, Social Sciences in ProQuest, Dissertations and Theses, and the Virginia Henderson Global Nursing eRepository for studies published in the English language between January 2000 and June 2015. Criteria for inclusion were: (a) primary focus on educating family caregivers for older adults about delirium; (b) use of experimental, quasi-experimental, or comparative design; (c) measured family caregiver outcomes of delirium knowledge, emotional state, or response in reducing delirium incidence in older adults; and (d) published in the English language. Articles were appraised using Melnyk's rapid critical appraisal guides. RESULTS Seven studies met the review criteria. Four studies found that family caregivers' delirium knowledge increased; two noted that delirium incidence in older adults declined; and one study reported less distress following receipt of education. LINKING EVIDENCE TO ACTION Providing family caregivers with information about delirium can be beneficial for both family caregivers and older adults. However, rigorous evaluation of education programs for family caregivers about delirium is needed.
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Affiliation(s)
- Margaret J Bull
- Professor, Marquette University College of Nursing, Milwaukee, WI
| | - Lesley Boaz
- Assistant Professor, Marquette University College of Nursing, Milwaukee, WI
| | - Martha Jermé
- Health Sciences Librarian, Marquette University, Milwaukee, WI
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Avendaño-Céspedes A, García-Cantos N, González-Teruel MDM, Martínez-García M, Villarreal-Bocanegra E, Oliver-Carbonell JL, Abizanda P. Pilot study of a preventive multicomponent nurse intervention to reduce the incidence and severity of delirium in hospitalized older adults: MID-Nurse-P. Maturitas 2016; 86:86-94. [PMID: 26921934 DOI: 10.1016/j.maturitas.2016.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although multicomponent interventions are the gold standard for delirium management, few nurse-led interventions in Acute Geriatric Units (AGU) are described. OBJECTIVES To analyze if a preventive multicomponent non-pharmacologic nurse-led intervention randomized clinical trial (MID-Nurse Study) is feasible (pilot study), and can reduce the incidence, duration, and severity of delirium in hospitalized older adults in an AGU. DESIGN Parallel-group double-blind randomized clinical trial (pilot Study). SETTING AGU Complejo Hospitalario Universitario, Albacete (Spain). PARTICIPANTS 50 patients ≥65 years hospitalized in the AGU. Intervention group (IG) 21, control group (CG) 29. INTERVENTION After risk factor analysis, all participants in the IG received a daily multicomponent non-pharmacologic intervention (orientation, sensorial deficit, sleep, mobilization, hydration, nutrition, drug chart review, elimination, oxygenation, pain) by the intervention nurses. The CG received usual care. MEASUREMENTS Daily delirium presence with the Confusion Assessment Method (CAM), and severity with the Delirium Rating Scale-Revised-98 (DRS). Outcome measures were delirium incidence, prevalence, severity, and number of days with delirium, mortality, length of stay, use of physical restraint measures, and use of drugs for delirium control. RESULTS Mean age 86.5 (48% women). 21 participants presented delirium during hospitalization (14CG and 7 IG). Process, resources, management, and scientific objectives were considered positive, making the study feasible. Delirium prevalence (33.3% vs 48.3%) and incidence (14.3% vs 41.4%; p=0.039) were reduced in the IG compared to CG. Total delirium severity was lower in the IG compared to the CG (35.0 vs 65.0; p=0.040). Mortality was not different between groups (CG 17.2% vs IG 19.0%). CONCLUSION The MID-Nurse Study is feasible, and a multicomponent nurse-led intervention on patients with delirium in an AGU can reduce delirium prevalence, incidence, and severity. The clinical trial registration number ClinicalTrials.gov ID: NCT02558777.
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Affiliation(s)
| | - Nuria García-Cantos
- Geriatrics Department, Complejo Hospitalario Universitario of Albacete, Albacete, Spain
| | | | | | | | | | - Pedro Abizanda
- Geriatrics Department, Complejo Hospitalario Universitario of Albacete, Albacete, Spain.
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Cognitive Impairment in Hospitalized Seniors. Geriatrics (Basel) 2016; 1:geriatrics1010004. [PMID: 31022800 PMCID: PMC6371190 DOI: 10.3390/geriatrics1010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 11/16/2022] Open
Abstract
Cognitive disorders are highly prevalent in hospitalized seniors, and can be due to delirium, dementia, as well as other disorders. Hospitalization can have adverse cognitive effects, and cognitive dysfunction adversely affects hospital outcomes. In this article, the literature is reviewed on how hospitalization affects cognitive function and how cognitive impairment affects hospital outcomes. Possible interventions in cognitively impaired hospitalized seniors are reviewed.
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91
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Restrepo Bernal D, Niño García JA, Ortiz Estévez DE. [Delirium Prevention]. REVISTA COLOMBIANA DE PSIQUIATRIA 2016; 45:37-45. [PMID: 26896403 DOI: 10.1016/j.rcp.2015.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/06/2015] [Accepted: 06/30/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Delirium is the most prevalent neuropsychiatric syndrome in the general hospital. Its presence is a marker of poor prognosis for patients. Its prevention could be the most effective strategy for reducing its frequency and its complications. OBJECTIVE To review recent findings and strategies for the prevention of delirium. METHODOLOGY A non-systematic review of scientific articles published in the last ten years in Spanish and English. A search was made in databases such as MEDLINE, Cochrane, EMBASE, Ovid, and ScienceDirect, for articles that included the terms, delirium and prevention. RESULTS Identification of predisposing and precipitating factors for delirium and a better understanding of the pathophysiological mechanisms underlying the onset of delirium have enabled the implementation of various pharmacological and non-pharmacological strategies in patients at high risk to develop hospital delirium. The studies to prevent delirium have focused on surgical patients. The current evidence supports the daily implementation of non-pharmacological measures to prevent delirium, as they are easy and cost effective. The available evidence is still limited to recommend the daily use of pharmacological strategies in delirium prophylaxis, and there is a consensus against the modest use of antipsychotic drugs in surgical patients and dexmedetomidine in patients in intensive care. CONCLUSIONS New high-quality clinical trials and studies involving non-surgical patients are needed to provide more evidence about this subject.
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Abraha I, Rimland JM, Trotta F, Pierini V, Cruz-Jentoft A, Soiza R, O'Mahony D, Cherubini A. Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series. J Nutr Health Aging 2016; 20:927-936. [PMID: 27791223 DOI: 10.1007/s12603-016-0719-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
DESCRIPTION The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium. OBJECTIVES To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations. METHODS A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations. RESULTS The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards). CONCLUSIONS Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.
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Affiliation(s)
- I Abraha
- Y Iosief Abraha, Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy, E-mail: (IA)
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Prevention of delirium (POD) for older people in hospital: study protocol for a randomised controlled feasibility trial. Trials 2015; 16:340. [PMID: 26253332 PMCID: PMC4529724 DOI: 10.1186/s13063-015-0847-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/02/2015] [Indexed: 01/28/2023] Open
Abstract
Background Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme. Methods/Design The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; in-hospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience. Discussion This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial. Trial registration ISRCTN01187372. Registered 13 March 2014.
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94
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Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 2015; 15:69. [PMID: 26108254 PMCID: PMC4478641 DOI: 10.1186/s12877-015-0070-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 06/10/2015] [Indexed: 11/30/2022] Open
Abstract
Background Room transfers are suspected to promote the development of delirium in hospitalized elderly patients, but no studies have systematically examined the relationship between room transfers and delirium incidence. We used a case–control study to determine if the number of room transfers per patient days is associated with an increased incidence of delirium amongst hospitalized elderly medical patients, controlling for baseline risk factors. Methods We included patients 70 years of age or older who were admitted to the internal medicine or geriatric medicine services at St. Michael’s Hospital between October 2009 and September 2010 for more than 24 h. The cases consisted of patients who developed delirium during the first week of hospital stay. The controls consisted of patients who did not develop delirium during the first week of hospital stay. Patients with evidence of delirium at admission were excluded from the analysis. A multivariable logistic regression model was used to determine the relationship between room transfers and delirium development within the first week of hospital stay. Results 994 patients were included in the study, of which 126 developed delirium during the first week of hospital stay. Using a multivariable logistic regression model which controlled for age, gender, cognitive impairment, vision impairment, dehydration, and severe illness, room transfers per patient days were associated with delirium incidence (OR: 9.69, 95 % CI (6.20 to15.16), P < 0.0001). Conclusions An increased number of room transfers per patient days is associated with an increased incidence of delirium amongst hospitalized elderly medical patients. This is an exploratory analysis and needs confirmation with larger studies.
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Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, Pierini V, Dessì Fulgheri P, Lattanzio F, O’Mahony D, Cherubini A. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One 2015; 10:e0123090. [PMID: 26062023 PMCID: PMC4465742 DOI: 10.1371/journal.pone.0123090] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/27/2015] [Indexed: 01/08/2023] Open
Abstract
Background Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making. Methods and Findings We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I2=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I2=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium. Conclusions In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.
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Affiliation(s)
- Iosief Abraha
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
- * E-mail:
| | - Fabiana Trotta
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Joseph M. Rimland
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | | | | | - Roy L. Soiza
- Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, United Kingdom
| | - Valentina Pierini
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Paolo Dessì Fulgheri
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Denis O’Mahony
- Department of Medicine, University College Cork, Cork, Ireland
| | - Antonio Cherubini
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
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Moon KJ, Lee SM. The effects of a tailored intensive care unit delirium prevention protocol: A randomized controlled trial. Int J Nurs Stud 2015; 52:1423-32. [PMID: 26032729 DOI: 10.1016/j.ijnurstu.2015.04.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND A decreased incidence of delirium following the application of non-pharmacologic intervention protocols to several patient populations has been previously reported. However, few studies have been conducted to examine the effects of their application to intensive care unit (ICU) patients. OBJECTIVES To examine the effects of applying a tailored delirium preventive protocol, developed by the authors, to ICU patients by analyzing its effects on delirium incidence, in-hospital mortality, ICU readmission, and length of ICU stay in a Korean hospital. DESIGN A single-blind randomized controlled trial. SETTINGS A 1049-bed general hospital with a 105-bed ICU. PARTICIPANTS Sixty and 63 ICU patients were randomly assigned to the intervention and control groups, respectively. METHODS The researchers applied the delirium prevention protocol to the intervention group every day for the first 7 days of ICU hospitalization. Delirium incidence, mortality, and re-admission to the ICU during the same hospitalization period were analyzed by logistic regression analysis; the 7- and 30-day in-hospital mortality by Kaplan-Meier survival and Cox proportional hazard regression analysis; and length of ICU stay was assessed by linear regression analysis. RESULTS Application of the protocol had no significant effect on delirium incidence, in-hospital mortality, re-admission to the ICU, or length of ICU stay. Whereas the risk of 30-day in-hospital mortality was not significantly lower in the intervention than in the control group (OR: 0.33; 95% CI: 0.10-1.09), we found a significantly decreased 7-day in-hospital mortality in the intervention group after protocol application (HR: 0.09; 95% CI: 0.01-0.72). CONCLUSIONS Application of a tailored delirium prevention protocol to acute stage patients during the first 7 days of ICU hospitalization appeared to reduce the 7-day in-hospital risk of mortality only for this patient population.
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Affiliation(s)
- Kyoung-Ja Moon
- Department of Nursing, Ulsan College, Ulsan, Republic of Korea
| | - Sun-Mi Lee
- College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea.
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Bull MJ, Avery JS, Boaz L, Oswald D. Psychometric Properties of the Family Caregiver Delirium Knowledge Questionnaire. Res Gerontol Nurs 2015; 8:198-207. [PMID: 25893726 DOI: 10.3928/19404921-20150409-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/18/2015] [Indexed: 11/20/2022]
Abstract
A valid, reliable measure of family caregivers' knowledge about delirium was not located in the literature; such an instrument is essential to assess learning needs and outcomes of education provided. The purpose of the current study was to (a) develop a family Caregiver Delirium Knowledge Questionnaire (CDKQ) based on the Symptom Interpretation Model; and (b) establish validity and reliability of the measure. The 19-item CDKQ was developed and administered to 164 family caregivers for community-dwelling older adults. Descriptive statistics were examined for all variables. Psychometric testing included confirmatory factor analysis, item-to-total correlations, and internal consistency reliability. A three-factor model provided the best fit for the data. The findings support initial validity and reliability of the CDKQ with family caregivers. Although the CDKQ was developed for use with family caregivers, it has potential for use with other caregivers, such as home health aides.
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Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, Inouye SK. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 2015; 175:512-20. [PMID: 25643002 PMCID: PMC4388802 DOI: 10.1001/jamainternmed.2014.7779] [Citation(s) in RCA: 452] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these strategies for preventing subsequent adverse outcomes has been limited to small studies to date. OBJECTIVE To evaluate available evidence on multicomponent nonpharmacological delirium interventions in reducing incident delirium and preventing poor outcomes associated with delirium. DATA SOURCES PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews from January 1, 1999, to December 31, 2013. STUDY SELECTION Studies examining the following outcomes were included: delirium incidence, falls, length of stay, rate of discharge to a long-term care institution (institutionalization), and change in functional or cognitive status. DATA EXTRACTION AND SYNTHESIS Two experienced physician reviewers independently and blindly abstracted data on outcome measures using a standardized approach. The reviewers conducted quality ratings based on the Cochrane risk-of-bias criteria for each study. MAIN OUTCOMES AND MEASURES We identified 14 interventional studies. The results for outcomes of delirium incidence, falls, length of stay, and institutionalization were pooled for the meta-analysis, but heterogeneity limited our meta-analysis of the results for change in functional or cognitive status. Overall, 11 studies demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58). Four randomized or matched trials reduced delirium incidence by 44% (OR, 0.56; 95% CI, 0.42-0.76). The rate of falls decreased significantly among intervention patients in 4 studies (OR, 0.38; 95% CI, 0.25-0.60); in 2 randomized or matched trials, the rate of falls was reduced by 64% (OR, 0.36; 95% CI, 0.22-0.61). Length of stay and institutionalization also trended toward decreases in the intervention groups, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) day shorter and the odds of institutionalization 5% lower (OR, 0.95; 95% CI, 0.71-1.26). Among higher-quality randomized or matched trials, length of stay trended -0.33 (95% CI, -1.38 to 0.72) day shorter, and the odds of institutionalization trended 6% lower (OR, 0.94; 95% CI, 0.69-1.30). CONCLUSIONS AND RELEVANCE Multicomponent nonpharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization. Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts2Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu
| | - Esther Oh
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Margaret Puelle
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sarah Dowal
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Thomas Travison
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts5Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts5Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing 2015; 44:196-204. [PMID: 25424450 DOI: 10.1093/ageing/afu173] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Delirium is a complex neuropsychiatric syndrome that is common among elderly inpatients. It has been associated with increased mortality, longer hospital stays, cognitive and functional decline and increased institutionalisation rates. Multicomponent interventions, a series of non-pharmacological strategies frequently handled by nursing staff, might be useful for prevention. OBJECTIVES To assess the efficacy of multicomponent interventions in preventing incident delirium in the elderly. METHODS A systematic review of randomised trials was undertaken. Two independent reviewers performed iterative literature searches in seven databases without language restrictions. Grey literature repositories were considered as well. The quality of included trials was assessed by using the criteria established by the Cochrane Collaboration. When possible, data were synthesised into a meta-analysis. Heterogeneity was assessed using the χ2 and I2 tests. FINDINGS A total of 21,788 citations were screened, and seven studies of diverse quality were included in the review, comprising 1,691 participants. Multicomponent interventions significantly reduced incident delirium (relative risk [RR] 0.73, 95% confidence interval [CI] 0.63-0.85, P<0.001) and accidental falls during the hospitalisation (RR 0.39, 95% CI 0.21, 0.72, P=0.003), without evidence of differential effectiveness according to ward type or dementia rates. Non-significant reductions in delirium duration, hospital stay and mortality were found as well. INTERPRETATION Multicomponent interventions are effective in preventing incident delirium among elderly inpatients. Effects seemed to be stable among different settings. Due to the limited amount of data, potential benefits in survival need to be confirmed in further studies. Future research should be aimed at contrasting different multicomponent programmes to select the most useful interventions.
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Affiliation(s)
- Felipe Martinez
- Centro de Investigaciones Biomedicas, Universidad de Valparaiso, Valparaiso, Chile Departamento de Salud Publica, Universidad de Valparaiso, Valparaiso, Chile
| | - Catalina Tobar
- Departamento de Medicina Interna, Universidad de Valparaiso, Valparaiso, Chile Escuela de Medicina, Universidad de Valparaiso, Valparaiso, Chile
| | - Nathan Hill
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, Deiner S, Fick D, Hutchison L, Johanning J, Katlic M, Kempton J, Kennedy M, Kimchi E, Ko C, Leung J, Mattison M, Mohanty S, Nana A, Needham D, Neufeld K, Richter H. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Coll Surg 2015; 220:136-48.e1. [DOI: 10.1016/j.jamcollsurg.2014.10.019] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 12/17/2022]
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