The usefulness of bright light therapy for patients after oesophagectomy

Towards an evidence-based integrative lighting score: a proposed multi-level approach

Background: Human circadian clocks are synchronized daily with the external light-dark cycle and entrained to the 24-hour day. There is increasing evidence that a lack of synchronization and circadian entrainment can lead to adverse health effects. Beyond vision, light plays a critical role in modulating many so-called non-visual functions, including sleep-wake cycles, alertness, mood and endocrine functions. To assess (and potentially optimize) the impact of light on non-visual functions, it is necessary to know the exact 'dose' (i.e. spectral irradiance and exposure duration at eye level) of 24-hour light exposures, but also to include metadata about the lighting environment, individual needs and resources.

Problem statement: To address this problem, a new assessment tool is needed that uses existing metrics to provide metadata and information about light quality and quantity from all sources. In this commentary, we discuss the need to develop an evidence-based integrative lighting score that is tailored to specific audiences and lighting environments. We will summarize the most compelling evidence from the literature and outline a future plan for developing such a lighting score using internationally accepted metrics, stakeholder and user feedback.

Conclusion: We propose a weighting system that combines light qualities with physiological and behavioral effects, and the use of mathematical modelling for an output score. Such a scoring system will facilitate a holistic assessment of a lighting environment, integrating all available light sources.

Effectiveness of nurse-led non-pharmacological interventions on outcomes of delirium in adults: A meta-analysis of randomized controlled trials

BACKGROUND

Delirium is a common complication among adults. It is essential to improve the outcomes of delirium.

AIM

To systematically synthesize the evidence on the effectiveness of the nurse-led non-pharmacological interventions on outcomes of delirium in adults.

METHODS

Electronic databases including CINAHL, Cochrane Library, MEDLINE, EMBASE, PubMed, Web of Science, PsycINFO, and Clinical Trial Registration were searched comprehensively by the authors. The authors reviewed the full text and assessed the risk of bias using the Cochrane Risk of Bias Tool 2.0. The meta-analysis was performed using RevMan and Stata software. The forest plots showed the overall effect of the included study and the I2 test was used to assess the degree of heterogeneity between studies. Random effects models were used to analyze studies with significant heterogeneity.

RESULTS

A total of 32 studies (10,122 participants) were included in the meta-analysis. Nurse-led non-pharmacological interventions resulted in a significantly lower incidence of delirium compared with the usual care/control group (risk ratio = 0.74, p < .001) and reduced mortality in the hospital compared with usual care (risk ratio = 0.81, p = .04). However, the implementation of nurse-led, non-pharmacological interventions had no significant effect on the duration, severity of delirium, or length of hospital stay.

LINKING EVIDENCE TO ACTION

Our findings suggest that the nurse-led, non-pharmacological strategy was effective in reducing the incidence of delirium and mortality in the hospital. Multicomponent interventions were the most effective strategy for reducing the incidence of delirium in adults.

Functional intervention following cardiac surgery to prevent postoperative delirium in older patients (FEEL WELL study)

BACKGROUND

Postoperative delirium is a common complication in patients after cardiac surgery, especially in older patients, and can manifest as a disturbance of attention and consciousness. It can lead to increased postoperative morbidity, prolonged need for care, and mortality. The presented study investigates whether the occurrence of postoperative delirium after cardiac surgery can be prevented by a multisensory stimulation. It was conducted as a prospective, randomized, controlled, non-pharmacological intervention study in the years 2021 and 2022 at the University Hospital Bonn in Germany. A total of 186 patients over 65 years with elective cardiac surgery were enrolled. Patients were randomized either to the intervention or control group. In both groups, postoperative delirium was assessed with the 3-min diagnostic interview for confusion assessment method on the first 5 days after surgery and pain was assessed using the Numeric Rating Scale. Multisensory stimulation was performed 20 min a day for the first three postoperative days in the intervention group.

RESULTS

The incidence of postoperative delirium was 22.6% in the intervention group and 49.5% in the control group (p < 0.001). Duration of postoperative delirium was significantly shorter in the intervention group (p < 0.001). Stay in the intensive care unit was significantly longer in the control group (p = 0.006). In the regression model non-intervention, high pain scores, advanced age, and prolonged mechanical ventilation were associated with postoperative delirium (p = 0.007; p = 0.032; p = 0.006; p = 0.006, respectively).

CONCLUSIONS

Results of the study imply that a multisensory stimulation done on the first 3 days after planned cardiac surgery can reduce the incidence and duration of postoperative delirium in older patients. Influence of the treatment on the incidence of delirium in other patient groups, the length of stay in the intensive care unit, and patients´ postoperative pain should be confirmed in further clinical studies.

TRIAL REGISTRATION

DRKS, DRKS00026909. Registered 28 October 2021, Retrospectively registered, https://drks.de/search/de/trial/DRKS00026909 .

Effectiveness of sleep interventions to reduce delirium in critically ill patients: A systematic review and meta-analysis

PURPOSE

To analyze the effectiveness of sleep interventions in reducing the incidence and duration of delirium in the ICU.

MATERIALS AND METHODS

We searched the PubMed, Embase, CINAHL, Web of Science, Scopus, and Cochrane databases for relevant randomized controlled trials from inception to August 2022. Literature screening, data extraction, and quality assessment were performed independently by two investigators. Data from the included studies were analyzed using Stata and TSA software.

RESULTS

Fifteen randomized controlled trials were eligible. Meta-analysis showed that the sleep intervention was associated with a reduced incidence of delirium in the ICU (RR = 0.73, 95% CI = 0.58 to 0.93, p < 0.001) compared to the control group. The results of the trial sequence analysis further confirm that sleep interventions are effective in reducing the occurrence of delirium. Pooled data from the three dexmedetomidine trials showed significant differences in the incidence of ICU delirium between groups (RR = 0.43, 95% CI = 0.32 to 0.59, p < 0.001). The respective pooled results of other sleep interventions (e.g., light therapy, earplugs, melatonin, and multicomponent nonpharmacologic treatments) did not find a significant effect on reducing the incidence and duration of ICU delirium (p > 0.05).

CONCLUSIONS

The current evidence suggests that non-pharmacological sleep interventions are not effective in preventing delirium in ICU patients. However, limited by the number and quality of included studies, future well-designed multicenter randomized controlled trials are still needed to validate the results of this study.

Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement

Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.

An Automated Algorithm for Determining Sleep Using Single-Channel Electroencephalography to Detect Delirium: A Prospective Observational Study in Intensive Care Units

The relationship between polysomnography-based objective sleep and delirium in the intensive care unit (ICU) is inconsistent across studies, suggesting limitations in manually determining the sleep stage of critically ill patients. We objectively measured 24-h sleep using a single-channel electroencephalogram (SleepScope [SS]) and an under-mattress sleep monitor (Nemuri SCAN [NSCAN]), both of which have independent algorithms that automatically determine sleep and wakefulness. Eighteen patients (median age, 68 years) admitted to the ICU after valvular surgery or coronary artery bypass grafting were included, and their sleep time was measured one day after extubation. The median total sleep times (TSTs) measured by SS (TST-SS) and NSCAN were 548 (48−1050) and 1024 (462−1257) min, respectively. Two patients with delirium during the 24-h sleep measurement had very short TST-SS of 48 and 125 min, and the percentage of daytime sleep accounted for >80% in both SS and NSCAN. This preliminary case series showed marked sleep deprivation and increased rates of daytime sleeping in ICU patients with delirium. Although data accuracy from under-mattress sleep monitors is contentious, automated algorithmic sleep/wakefulness determination using a single-channel electroencephalogram may be useful in detecting delirium in ICU patients and could even be superior to polysomnography.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Non-Pharmacological Nursing Interventions to Prevent Delirium in ICU Patients-An Umbrella Review with Implications for Evidence-Based Practice

Delirium in ICU patients is a complication associated with many adverse consequences. Given the high prevalence of this complication in critically ill patients, it is essential to develop and implement an effective management protocol to prevent delirium. Given that the cause of delirium is multifactorial, non-pharmacological multicomponent interventions are promising strategies for delirium prevention. (1) Background: To identify and evaluate published systematic review on non-pharmacological nursing interventions to prevent delirium in intensive care unit patients. (2) Methods: An umbrella review guided by the Joanna Briggs Institute was utilized. Data were obtained from PubMed, Scopus, EBSCO, Web of Science, Cochrane Library, and Google Scholar. The last search was conducted on 1 May 2022. (3) Results: Fourteen reviews met the inclusion criteria. Multicomponent interventions are the most promising methods in the fight against delirium. The patient's family is an important part of the process and should be included in the delirium prevention scheme. Light therapy can improve the patient's circadian rhythm and thus contribute to reducing the incidence of delirium. (4) Conclusions: Non-pharmacological nursing interventions may be effective in preventing and reducing the duration of delirium in ICU patients.

Efficacy of EWINDOW for prevention of delirium at intensive care units: A protocol for systematic review and meta-analysis

BACKGROUND

Critically ill patients in intensive care units (ICUs) have restricted exposure to natural light throughout the day. As a result, they are more prone to undergo disruptions in circadian rhythmicity and sleep patterns, which may contribute to the development of delirium. As a measure to synchronize to the patterns of natural sunlight, EWINDOW has been proved to prevent delirium in some studies. Hence, the aim of this systematic review to evaluate the effectiveness of EWINDOW so as to prevent delirium.

METHODS

From January 2012 to December 2021, electronic databases such as China National Knowledge Infrastructure Database, Excerpta Medica database, PubMed, Cochrane Central Register of Controlled Trials, Wan Fang, and Cumulative Index of Nursing and Allied Health Literature are aimed to look for appropriate randomized controlled trials to evaluate the therapeutic impact of EWINDOW on delirium prevention. To be more exact, related studies are chosen, data is retrieved and the risk of bias is examined, then a meta-analysis is carried out in order.

RESULTS

The goal of this study is to show how effective EWINDOW is at preventing delirium in ICU. The incidence and duration of delirium are included in our outcome measures.

CONCLUSIONS

This review evaluates related studies on the therapeutic effects of EWINDOW on the prevention of delirium in the ICUs.

DISSEMINATION AND ETHICS

The findings of this study will be published in a peer-reviewed journal. As the study relies on publicly available data, no ethical approval is required. Furthermore, throughout the data analysis procedure, anonymity is protected.OSF Registration: https://osf.io/NP3EW/.

Clinical outcomes of light therapy in hospitalized patients - A systematic review

Light therapy and the effects on biological function have been known and investigated for decades. Light therapy is used to compensate for the lack of exposure to sunlight, which is thought to be linked to major depressive disorder with seasonal patterns. It is applied as sessions with bright light mimicking natural sunlight. Lack of bright light during daytime is not the only factor to maintain the circadian rhythm, also lack of exposure to bright light at night is important. A new modality called naturalistic light shows promise, mimicking daylight by dynamically changing intensity and wavelengths throughout the day. Evidence of clinical effects, besides bright light effects on depression, is still limited, especially in hospital populations, and present review aims to extract results of the effect of any optical light intervention on hospitalized patients. Through database search, 29 trials were included, of which 8 trials used a variation of naturalistic light. Trials were heterogeneous regarding designs, populations, interventions, methods and outcomes. In 14 out of 17 studies investigating sleep duration, quality and circadian alignment, along with decreased fatigue and improved mood in daytime, light therapy had a significant effect. Circadian rhythm and rhythmicity were affected as well. The effect on mood and cognition was inconsistent across studies. Trials showed more significant outcomes when conducted in non-intensive care units and with duration >5 days. Lux was reported in and compared across 24 studies and did not appear to be correlated to outcome, rather the distribution of wavelengths should be considered when conducting trials in the future. Of the 8 trials investigating naturalistic light, 4 trials had significant outcomes and 3 had adverse outcomes compared to one in the standard light regime. The overall effect of light therapy is beneficial, but evidence for the effect of naturalistic light is still insufficient to be recommended before other modalities. Future research in this area should be conducted in facilities where naturalistic light is installed, with a focus on the spectral distribution.

Association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit

Background

Patients in the intensive care unit (ICU) have increased risks of delirium, which is associated with worse outcomes. As pharmacologic treatments for delirium are ineffective, prevention is important. Nonpharmacologic preventive strategies include exposure to natural light and restoring circadian rhythm. We investigated the effect of exposure to natural light through windows on delirium in the ICU.

Methods

This retrospective cohort study assessed all patients admitted to the medical ICU of a university-affiliated hospital between January and June 2020 for eligibility. The ICU included 12 isolation rooms, six with and six without windows. Patients with ICU stays of >48 hours were included and were divided into groups based on their admission to a single room with (window group) or without windows (windowless group). The primary outcome was the cumulative incidence of delirium. The secondary outcomes were the numbers of delirium- and mechanical ventilation-free days, ICU and hospital length of stay, and in-ICU and 28-day mortalities.

Results

Of the 150 included patients (window group: 83 [55.3%]; windowless group: 67 [44.7%]), the cumulative incidence of delirium was significantly lower in the window group than in the windowless group (21.7% vs. 43.3%; relative risk, 1.996; 95% confidence interval [CI], 1.220–3.265). Other secondary outcomes did not differ between groups. Admission to a room with a window was independently associated with a decreased risk of delirium (adjusted odds ratio, 0.318; 95% CI, 0.125–0.805).

Conclusions

Exposure to natural light through windows was associated with a lower incidence of delirium in the ICU.

Hospital Admission to a Window-Side Bed Does Not Prevent Delirium: A Retrospective Cohort Study of Older Medical Inpatients in General Wards

Background: Delirium in older inpatients is a serious problem. The presence of a window in the intensive care unit has been reported to improve delirium. However, no study has investigated whether window-side bed placement is also effective for delirium prevention in a general ward. Objectives: This study aims to clarify the association between admission to a window-side bed and delirium development in older patients in a general ward. Design: This research is designed as a retrospective cohort study of older patients admitted to the internal medicine departments of Shinshu University Hospital, Japan. Participants: The inclusion criteria were the following: (1) admitted to hospital internal medicine departments between April 2009 and December 2018, (2) older than 75 years, (3) admitted to a multi-patient room in a general ward, and (4) unplanned admission. The number of eligible patients was 1,556. Exposure: This study is a comparison of 495 patients assigned to a window-side bed (window group) with 1,061 patients assigned to a non-window-side bed (non-window group). When patients were transferred to the other type bed after admission, observation was censored. Main Measures: The main outcome of interest was "delirium with event" (e.g., the use of medication or physical restraint for delirium) within 14 days after admission as surveyed by medical chart review in a blinded manner. Key Results: The patients had a median age of 80 years and 38.1% were female. The main outcome was recorded in 36 patients in the window group (10.7 per thousand person-days) and 84 in the non-window group (11.7 per thousand person-days). Log-rank testing showed no significant difference between the groups (p = 0.78). Multivariate analysis with Cox regression modeling also revealed no significant association for the window group with main outcome development (adjusted hazard ratio 0.90, 95% confidence interval of 0.61-1.34). Conclusions: Admission to a window-side bed did not prevent delirium development in older patients admitted to a general ward.

Delirium in critical illness: clinical manifestations, outcomes, and management

Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.

Non-Pharmacological Nursing Interventions for Prevention and Treatment of Delirium in Hospitalized Adult Patients: Systematic Review of Randomized Controlled Trials

Delirium is a common neurobehavioral complication in hospitalized patients that can occur in the acute phase and lead to poor long-term outcomes. The purpose of this study was to identify non-pharmacological nursing interventions for the prevention and treatment of delirium in hospitalized adult patients. We conducted a systematic review to synthesize the findings of published studies. We searched the PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL databases for randomized controlled trials in January 2021. We report this systematic review according to the PRISMA 2009 checklist. The study was registered on PROSPERO (CRD42021226538). Nine studies were systematically reviewed for non-pharmacological nursing interventions for the prevention and treatment of delirium. The types of non-pharmacological nursing interventions included multicomponent intervention, multidisciplinary care, multimedia education, music listening, mentoring of family caregivers concerning delirium management, bright light exposure, ear plugs, and interventions for simulated family presence using pre-recorded video messages. These results could help nurses select and utilize non-pharmacological nursing interventions for the prevention and treatment of delirium in clinical nursing practice.

The Nexus Between Sleep Disturbance and Delirium Among Intensive Care Patients

Sleep in intensive care is hampered due to many factors; the clinical environment itself exacerbates sleep disturbance. Research suggests that interventions aimed at improving sleep quality have produced positive effects in reducing incidences and duration of delirium. Sleep disturbance is well documented among intensive care patients; however, its prognostic impact is not fully understood. Delirium, disproportionally prevalent among intensive care patients, has significant prognostic factors related to patient outcomes, in which sleep disturbance often is present. The relationship between sleep disturbance and delirium is complex, sharing commonalities in relation to neurobiological and neurohormonal alterations, which may contribute to a bidirectional relationship.

Assessment and Monitoring of Sleep in the Intensive Care Unit

Sleep affects physiologic and psychological recovery throughout critical illness. Patients often describe poor sleep as a major source of distress while hospitalized in an intensive care unit. The intensive care unit environment poses unique challenges for sleep assessment and monitoring. The purpose of this literature review is to discuss methods of assessment and monitoring of sleep within the intensive care unit setting. The advantages and disadvantages of physiologic monitoring of sleep (eg, polysomnography, bispectral index, and actigraphy) are compared with those of subjective measures of sleep quality (eg, validated patient-oriented sleep questionnaires, and informal nursing assessments).

Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis

PURPOSE

To compare the effects of prevention interventions on delirium occurrence in critically ill adults.

METHODS

MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects.

RESULTS

Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha₂ agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care.

CONCLUSION

Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.

Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis

OBJECTIVE

To compare non-pharmacological interventions in their ability to prevent delirium in critically ill patients, and find the optimal regimen for treatment.

METHODS

Literature searches were conducted using PubMed, Embase, CINAHL, and Cochrane Library databases until the end of June 2019. We estimated the risk ratios (RRs) for the incidence of delirium and in-hospital mortality and found the mean difference (MD) for delirium duration and the length of ICU stay. The probabilities of interventions were ranked based on clinical outcomes. The study was registered on PROSPERO (CRD42020160757).

RESULTS

Twenty-six eligible studies were included in the network meta-analysis. Studies were grouped into seven intervention types: physical environment intervention (PEI), sedation reducing (SR), family participation (FP), exercise program (EP), cerebral hemodynamics improving (CHI), multi-component studies (MLT) and usual care (UC). In term of reducing the incidence of delirium, the two most effective interventions were FP (risk ratio (RR) 0.19, 95% confidence interval (CI) 0.08 to 0.44; surface under the cumulative ranking curve (SUCRA) = 94%) and MLT (RR 0.43, 95% CI 0.30 to 0.57; SUCRA = 68%) compared with observation. Although all interventions demonstrated nonsignificant efficacy in regards to delirium duration and the length of the patient's stay in the ICU, MLT (SUCRA = 78.6% and 71.2%, respectively) was found to be the most effective intervention strategy. In addition, EP (SUCRA = 97.2%) facilitated a significant reduction in hospital mortality, followed in efficacy by MLT (SUCRA = 73.2%), CHI (SUCRA = 35.8%), PEI (SUCRA = 34.8%), and SR (SUCRA = 31.8%).

CONCLUSIONS

Multi-component strategies are overall the optimal intervention techniques for preventing delirium and reducing ICU length of stay in critically ill patients by way of utilizing several interventions simultaneously. Additionally, family participation as a method of patient-centered care resulted in better outcomes for reducing the incidence of delirium.

Circadian Disruption in Critical Illness

Circadian rhythms play a vital role in metabolic, hormonal, and immunologic function and are often disrupted in patients in the ICU. Circadian rhythms modulate the molecular machinery that responds to injury and illness which can impact recovery. Potential factors contributing to the alteration in circadian rhythmicity in intensive care unit (ICU) patients include abnormal lighting, noise, altered feeding schedules, extensive patient care interactions and medications. These alterations in circadian rhythms in ICU patients may affect outcomes and therefore, normalization of circadian rhythmicity in critically ill patients may be an important part of ICU care.

Effectiveness of complementary and alternative medicine interventions for sleep quality in adult intensive care patients: A systematic review

BACKGROUND

Pharmacological interventions for sleep (analgesic, sedative and hypnotic agents) can both disrupt and induce sleep and have many negative side effects within the intensive care population. The use of complementary and alternative medicine therapies to assist with sleep has been studied but given the variety of modalities and methodological limitations no reliable conclusions have been drawn.

OBJECTIVE

To synthesise research findings regarding the effectiveness of using complementary and alternative medicine interventions within the domains of mind and body practices (relaxation techniques, acupuncture) and natural biologically based products (herbs, vitamins, minerals, probiotics) on sleep quality and quantity in adult intensive care patients.

REVIEW METHOD USED

Systematic review.

DATA SOURCES

Five databases were searched in August 2018 and updated in February 2019 and 2020.

REVIEW METHODS

Searches were limited to peer reviewed randomised controlled trials, published in English involving adult populations in intensive care units. Interventions were related to the complementary and alternative medicine domains of mind and body practices and natural products. Included studies were assessed using Cochrane's risk of bias tool.

RESULTS

Seventeen studies were included. The interventions used varied: 4 investigated melatonin; 4 music +/- another therapy; 3 acupressure; 2 aromatherapy and 1 each for relaxation and imagery, reflexology, bright light exposure and inspiratory muscle training. Measurement of sleep quantity and quality was also varied: 5 studies used objective measures such as Polysomnography and Bispectral index with the remaining using subjective patient or clinician assessment (for example, Richards-Campbell Sleep Questionnaire, Pittsburgh Sleep Quality Index, observation). Given the different interventions, outcomes and measures used in the studies a meta-analysis was not possible. Generally, the results support the use of complementary and alternative medicine for assisting with sleep with 11 out of 17 trials reporting significant results for the interventions examined.

CONCLUSIONS

Complementary and alternative medicine interventions, in particular, melatonin and music, have shown promise for improving sleep in adults with critical conditions; however, further research that addresses the limitations of small sample sizes and improved techniques for measuring sleep is needed.

Risk factors for delirium after esophagectomy

INTRODUCTION

Postoperative delirium is a common complication after major surgical procedures and affects outcomes and long-term survival. We identified factors associated with postoperative delirium in patients undergoing esophagectomy.

METHODS

Retrospective cohort analysis of 378 patients undergoing esophagectomy. We examined the association between postoperative delirium (DSM-V) criteria with respect to baseline variables and postoperative complications.

RESULTS

Postoperative delirium was diagnosed in 64 (16.93%) patients and associated with increasing age (P < .05), chronic obstructive pulmonary disease (P = .07), pneumonia (P = .01), transfusion intraoperatively or within 72 hours of surgery (P < .001), and sepsis (P = .001). Unplanned intubation and increased length of stay (median, 14 days) were significant in patients with delirium (P = .001 and P < .001, respectively). In a secondary analysis, surgical technique and operative approach were associated with delirium. Modified McKeown (three-hole) esophagectomy was twice more likely to develop delirium compared with Ivor Lewis (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.03-4.23). The strongest association was found between delirium and open techniques (thoracotomy and laparotomy) as compared with minimally invasive techniques (thoracoscopy and laparoscopy) (OR, 2.66; 95% CI, 1.22-5.76). Survival was similar between both groups.

CONCLUSIONS

Postoperative delirium is common and associated with complications following esophagectomy. Identification of predisposing factors such as age and pre-existing pulmonary diseases and proper selection of surgical treatment may reduce delirium and improve surgical outcomes.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Actigraphy to Measure Physical Activity in the Intensive Care Unit: A Systematic Review

OBJECTIVE

In the intensive care unit (ICU), prolonged inactivity is common, increasing patients' risk for adverse outcomes, including ICU-acquired weakness. Hence, interventions to minimize inactivity are gaining popularity, highlighting actigraphy, a measure of activity involving a wristwatch-like accelerometer, as a method to inform these efforts. Therefore, we performed a systematic review of studies that used actigraphy to measure patient activity in the ICU setting.

DATA SOURCES

We searched PubMed, EMBASE, CINAHL, Cochrane Library, and ProQuest from inception until December 2016.

STUDY SELECTION

Two reviewers independently screened studies for inclusion. A study was eligible for inclusion if it was published in a peer-reviewed journal and used actigraphy to measure activity in ≥5 ICU patients.

DATA EXTRACTION

Two reviewers independently performed data abstraction and risk of bias assessment. Abstracted actigraphy-based activity data included total activity time and activity counts.

RESULTS

Of 16 studies (607 ICU patients) identified, 14 (88%) were observational, 2 (12%) were randomized control trials, and 5 (31%) were published after 2009. Mean patient activity levels per 15 to 60 second epoch ranged from 25 to 37 daytime and 2 to 19 nighttime movements. Actigraphy was evaluated in the context of ICU and post-ICU outcomes in 11 (69%) and 5 (31%) studies, respectively, and demonstrated potential associations between actigraphy-based activity levels and delirium, sedation, pain, anxiety, time to extubation, and length of stay.

CONCLUSION

Actigraphy has demonstrated that patients are profoundly inactive in the ICU with actigraphy-based activity levels potentially associated with important measures, such as delirium, sedation, and length of stay. Larger and more rigorous studies are needed to further evaluate these associations and the overall utility of actigraphy in the ICU setting.

Increasing Light Exposure for the Prevention of Delirium: A Systematic Review

BACKGROUND

Delirium is a neurological disorder with correlations to increased hospital length of stays and higher morbidity and mortality rates, particularly in the growing elderly population, making prevention strategies key in improving patient outcomes and health care systems.

OBJECTIVES

Does increased exposure to light, by artificial or natural means, decrease the incidence of delirium?

METHODS

A systematic review was conducted of 4 revered databases, CINAHL, PubMed, PsycINFO, and Scopus, for articles related to key words "delirium" and "lighting" or "daylight" or "natural light" or "bright light" or "sunlight." Results were narrowed to adult inpatients, defined as age older than 18 years. After limiting for quality of the study and content that addressed the objective, 7 articles were selected for review: 4 related to artificial means of light therapy and 3 consistent with increased exposure to natural light.

RESULTS

Two studies examined the effects of bright light therapy and reported a decreased incidence of delirium. Two studies researched whether increased lighting via a lighting system with varying degrees of intensity throughout the day would prevent delirium, and neither reported a decrease in delirium. The remaining 3 studies focused on whether increased natural light via windows decreased the occurrence of delirium and uncovered no correlation.

DISCUSSION

It is recommended that the study by Potharajaroen et al, which demonstrated significant findings for bright light therapy preventing delirium, be replicated as well as new pilot studies to enrich the growing body of research. Bright light therapy is a low-cost and easy-to-institute intervention that should be utilized on a case-to-case basis.

The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis

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.

Effect of dynamic light at the coronary care unit on the length of hospital stay and development of delirium: a retrospective cohort study

Background

Disturbed circadian rhythm is a potential cause of delirium and is linked to disorganisation of the circadian rhythmicity. Dynamic light (DL) could reset the circadian rhythm by activation of the suprachiasmatic nucleus to prevent delirium. Evidence regarding the effects of light therapy is predominantly focused on psychiatric disorders and circadian rhythm sleep disorders. In this study, we investigated the effect of DL on the total hospital length of stay (LOS) and occurrence of delirium in patients admitted to the Coronary Care Unit (CCU).

Methods

This was a retrospective cohort study. Patients older than 18 years, who were hospitalized longer than 12 h at the CCU and had a total hospital LOS for at least 24 h, were included. Patients were assigned to a room with DL (n = 369) or regular lighting conditions (n = 379). DL was administered at the CCU by two ceiling-mounted light panels delivering light with a colour temperature between 2700 and 6500 degrees Kelvin. Reported outcome data were: total hospital LOS, delirium incidence, consultation of a geriatrician and the amount of prescripted antipsychotics.

Results

Between May 2015 and May 2016, data from 748 patients were collected. Baseline characteristics, including risk factors provoking delirium, were equal in both groups. Median total hospital LOS in the DL group was 100.5 (70.8–186.0) and 101.0 (73.0–176.4) h in the control group (P = 0.935). The incidence of delirium in the DL and control group was 5.4% (20/369) and 5.0% (19/379), respectively (P = 0.802). No significant differences between the DL and control group were observed in secondary endpoints. Subgroup analysis based on age and CCU LOS also showed no differences.

Conclusion

Our study suggests exposure to DL as an early single approach does not result in a reduction of total hospital LOS or reduced incidence of delirium. When delirium was diagnosed, it was associated with poor hospital outcome.

Perceptions of Family Members, Nurses, and Physicians on Involving Patients' Families in Delirium Prevention

BACKGROUND

Delirium occurs in up to 80% of patients admitted to an intensive care unit. Nonpharmacologic delirium-prevention strategies, which are commonly used by the bedside nurse, have reduced the incidence and duration of delirium in patients in the intensive care unit. With increasing demands on the nurse, strategies such as including the patient's family in delirium prevention activities should be investigated. OBJECTIVE To determine opinions and willingness of health care providers to involve patients' families in nonpharmacologic delirium-prevention activities in the intensive care unit, and of patients' families to be involved.

METHODS

Two surveys, one for intensive care unit nurses and physicians and one for patients' families, were developed and administered. The provider survey focused on current delirium-prevention practices and opinions about family involvement. The family survey concentrated on barriers and willingness to participate in prevention activities.

RESULTS

Sixty nurses and 58 physicians completed the survey. Most physicians (93%) and all nurses believed families could assist with delirium prevention. Only 50% reported speaking with family members about delirium and delirium prevention. The family survey was completed by 60 family members; 38% reported a provider spoke with them about delirium. Family members reported high levels of comfort in participating in delirium-prevention activities.

CONCLUSIONS

Health care providers and family members are supportive of the latter performing delirium-prevention activities. Family of patients in the intensive care unit may work collaboratively with nurses to reduce the incidence and duration of delirium in these patients.

Actigraphy to Evaluate Sleep in the Intensive Care Unit. A Systematic Review

RATIONALE

Poor sleep quality is common in the intensive care unit (ICU) and may be associated with adverse outcomes. Hence, ICU-based efforts to promote sleep are gaining attention, motivating interest in methods to measure sleep in critically ill patients. Actigraphy evaluates rest and activity by algorithmically processing gross motor activity data, usually collected by a noninvasive wristwatch-like accelerometer device. In critically ill patients, actigraphy has been used as a surrogate measure of sleep; however, its use has not been systematically reviewed.

OBJECTIVES

To conduct a systematic review of ICU-based studies that used actigraphy as a surrogate measure of sleep, including its feasibility, validity, and reliability as a measure of sleep in critically ill patients.

METHODS

We searched PubMed, EMBASE, CINAHL, Proquest, and Web of Science for studies that used actigraphy to evaluate sleep in five or more patients in an ICU setting.

RESULTS

Our search yielded 4,869 citations, with 13 studies meeting eligibility criteria. These 13 studies were conducted in 10 countries, and eight (62%) were published since 2008. Across the 13 studies, the mean total sleep time of patients in the ICU, as estimated using actigraphy, ranged from 4.4 to 7.8 hours at nighttime and from 7.1 to 12.1 hours over a 24-hour period, with 1.4 to 49.0 mean nocturnal awakenings and a sleep efficiency of 61 to 75%. When compared side-by-side with other measures of sleep (polysomnography, nurse assessments, and patient questionnaires), actigraphy consistently yielded higher total sleep time and sleep efficiency, fewer nighttime awakenings (vs. polysomnography), and more overall awakenings (vs. nurse assessment and patient questionnaires). None of the studies evaluated the association between actigraphy-based measures of sleep and outcomes of patients in the ICU.

CONCLUSIONS

In critically ill patients, actigraphy is being used more frequently as a surrogate measure of sleep; however, because actigraphy only measures gross motor activity, its ability to estimate sleep is limited by the processing algorithm used. Prior ICU-based studies involving actigraphy were heterogeneous and lacked data regarding actigraphy-based measures of sleep and patient outcomes. Larger, more rigorous and standardized studies are needed to better understand the role of actigraphy in evaluating sleep and sleep-related outcomes in critically ill patients.

Recent progress in perioperative management of patients undergoing esophagectomy for esophageal cancer

Esophagectomy remains the mainstay of curative intent treatment for esophageal cancer. Oncologic esophagectomy is a highly invasive surgery and both morbidity and mortality rates still remain high. Recently, it has been revealed that multidisciplinary perioperative management can decrease the postoperative complications after esophagectomy. In this review, we summarized the recent progress in each component of multidisciplinary perioperative care bundle, including oral hygiene, cessation of smoking and alcohol, respiratory training, measurement of physical fitness, swallowing evaluation and rehabilitation, nutritional support, pain control and management of delirium. The accumulation of evidence and the popularization of knowledge will increase safety of esophagectomy and thus improve the outcome of patients with esophageal cancer.

Bright light and oxygen therapies decrease delirium risk in critically ill surgical patients by targeting sleep and acid-base disturbances

This study examined the effects of bright light therapy (BLT) on the incidence of delirium in post-operative patients admitted to a surgical intensive care unit (SICU) and delineates risk and protective factors. We included 62 patients in a single-blind, randomized controlled study. The intervention group was treated with care as usual plus BLT for three consecutive days. Delirium was diagnosed by DSM-5 criteria with the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). Risk factors for delirium were measured, including the APACHE II score, Insomnia Severity Index (ISI), as well as hematocrit and bicarbonate levels. Results were adjusted for treatment with nasal cannula oxygen and medications. Thirteen patients developed delirium within the three days following surgery. Generalized estimating equations analysis showed a significant preventive effect of BLT on delirium, which was independent of risk or treatment factors. Higher APACHE-II and ISI scores, lower hematocrit and lower bicarbonate levels increased the risk of developing delirium. BLT plus nasal cannula oxygen significantly reduced the likelihood of delirium. BLT significantly lowered ISI scores, while nasal cannula oxygen significantly enhanced bicarbonate levels. The results indicate that BLT and supplementary oxygen therapy may protect against delirium by targeting sleep-wake and deficits in the bicarbonate buffer system.

Perceptions of Families of Intensive Care Unit Patients Regarding Involvement in Delirium-Prevention Activities: A Qualitative Study

BACKGROUND

Nonpharmacologic delirium-prevention strategies are commonly used in the intensive care unit by bedside nurses. With up to 80% of intensive care unit patients becoming delirious, and lacking treatment options, prevention is key. However, with increasing nurse workloads, innovative delirium-prevention strategies such as involving the patient’s family are needed.

OBJECTIVE

To gain insight into opinions of patients’ families regarding active participation in delirium-prevention activities to inform specific recommendations for involving patients’ families in such activities.

METHODS

Purposeful sampling was used. Patients’ families were contacted to be interviewed about their opinions and attitudes on participation in nonpharmacologic delirium prevention activities while visiting the intensive care unit. An interview guide was created and used to facilitate discussion. Interviews were conducted, transcribed verbatim, and coded by 2 independent coders. Themes were identified, defined, and compared between independent coders; disagreements were resolved by the study team.

RESULTS

After 10 interviews were conducted, thematic saturation occurred. Three major themes emerged: (1) consistent family presence and participation in care, (2) improving ease of interactions between family and patient, and (3) delirium education for families.

CONCLUSION

Family members want to be involved with care and delirium prevention; however, many times they do not know what to do without the direction of a health care provider. Family members would benefit from open dialogue with the bedside nurse to increase family comfort and involvement in care.

The effect of chronotherapy on delirium in critical care - a systematic review

BACKGROUND

Delirium is highly prevalent within critical care and is linked to adverse clinical outcomes, increased mortality and impaired quality of life. Development of delirium is thought to be caused by multiple risk factors, including disruption of the circadian rhythm. Chronotherapeutic interventions, such as light therapy, music and use of eye shades, have been suggested as an option to improve circadian rhythm within intensive care units.

AIM

This review aims to answer the question: Can chronotherapy reduce the prevalence of delirium in adult patients in critical care?

DESIGN

This study is a systematic review of quantitative studies.

RESEARCH METHOD

Six major electronic databases were searched, and a hand search was undertaken using selected key search terms. Research quality was assessed using the critical appraisal skills programme tools. The studies were critically appraised by both authors independently, and data were extracted. Four themes addressing the research question were identified and critically evaluated.

FINDINGS

Six primary research articles that investigated different methods of chronotherapy were identified, and the results suggest that multi-component non-pharmacological interventions are the most effective for reducing the prevalence of delirium in critical care. The melatonergic agonist Ramelteon demonstrated statistically significant reductions in delirium; however, the reliability of the results in answering the review question was limited by the research design. The use of bright light therapy (BLT) and dynamic light application had mixed results, with issues with the research design and outcomes measured limiting the validity of the findings.

CONCLUSION

Multi-component non-pharmacological interventions, such as noise and light control, can reduce delirium in critical care, whereas other interventions, such as BLT, have mixed outcomes. Melatonin, as a drug, may be a useful alternative to sedative-hypnotics.

RELEVANCE TO CLINICAL PRACTICE

Chronotherapy can reduce the incidence of delirium within critical care, although further research is warranted. Staff education is essential in the implementation of chronotherapy.

Nonpharmacological interventions to prevent delirium: an evidence-based systematic review

Development of delirium in critical care patients is associated with increased length of stay, hospital costs, and mortality. Delirium occurs across all inpatient settings, although critically ill patients who require mechanical ventilation are at the highest risk. Overall, evidence to support the use of antipsychotics to either prevent or treat delirium is lacking, and these medications can have adverse effects. The pain, agitation, and delirium guidelines of the American College of Critical Care Medicine provide the strongest level of recommendation for the use of nonpharmacological approaches to prevent delirium, but questions remain about which nonpharmacological interventions are beneficial.

Circadian Rhythm Disruption in the Critically Ill: An Opportunity for Improving Outcomes

OBJECTIVES

Circadian rhythms are severely disrupted among the critically ill. These circadian arrhythmias impair mentation, immunity, autonomic function, endocrine activity, hormonal signaling, and ultimately healing. In this review, we present a modern model of circadian disruption among the critically ill, discuss causes of these circadian arrhythmias, review observational and intervention studies of the effects of circadian-rhythm-restoring factors on medical outcomes, and identify needed key trials of circadian interventions in the critically ill.

DATA SOURCES

MEDLINE, EMBASE, PsychINFO, Google Scholar through December 2014.

STUDY SELECTION

Articles relevant to circadian rhythms, melatonin, and light in the critically ill were selected.

DATA EXTRACTION AND DATA SYNTHESIS

Articles were synthesized for this review of circadian arrhythmia and the use of circadian-rhythm-restoring interventions among the critically ill.

CONCLUSIONS

Circadian disruption often demonstrates serial degradation: initially, the amplitude attenuates along with delayed circadian phase. With increasing acuity of illness, circadian rhythmicity may be lost entirely. Causes of chronodisruption may be environmental or internal to the patient. In particular, inadequate daytime illumination and nocturnal light pollution disrupt healthy circadian periodicity. Internal causes of circadian arrhythmia include critical illness itself and subjective experience of distress and pain. Observational studies of windowed rooms and real-time ambient lighting have found that physiologic light-dark patterns may support recovery from critical illness. Studies of early morning bright light or evening melatonin agonists have found improved rates of delirium, enhanced sleep, and lower arrhythmia prevalence. The current evidence base emphasizes that lighting and melatoninergic interventions deserve to be tested in full-scale trials.

Dynamic light application therapy to reduce the incidence and duration of delirium in intensive-care patients: a randomised controlled trial

BACKGROUND

Disturbed circadian rhythm is a potentially modifiable cause of delirium among patients in intensive-care units (ICUs). Bright-light therapy in the daytime can realign circadian rhythm and reduce the incidence of delirium. We investigated whether a high-intensity dynamic light application (DLA) would reduce ICU-acquired delirium.

METHODS

This was a randomised, controlled, single-centre trial of medical and surgical patients admitted to the ICU of a teaching hospital in the Netherlands. Patients older than 18 years, expected to stay in the ICU longer than 24 h and who could be assessed for delirium were randomised to DLA or normal lighting (control), according to a computer-generated schedule. The DLA was administered through ceiling-mounted fluorescent tubes that delivered bluish-white light up to 1700 lux between 0900 h and 1600 h, except for 1130-1330 h, when the light was dimmed to 300 lux. The light could only be turned off centrally by investigators. Control light levels were 300 lux and lights could be turned on and off from inside the room. The primary endpoint was the cumulative incidence of ICU-acquired delirium. Analyses were by intention to treat and per protocol. The study was terminated prematurely after an interim analysis for futility. This study is registered with Clinicaltrials.gov, number NCT01274819.

FINDINGS

Between July 1, 2011, and Sept 9, 2013, 734 patients were enrolled, 361 in the DLA group and 373 in the control group. Delirium occurred in 137 (38%) of 361 DLA patients and 123 (33%) of 373 control patients (odds ratio 1·24, 95% CI 0·92-1·68, p=0·16). No adverse events were noted in patients or staff.

INTERPRETATION

DLA as a single intervention does not reduce the cumulative incidence of delirium. Bright-light therapy should be assessed as part of a multicomponent strategy.

FUNDING

None.

Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series

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.

Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series

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.

Bright light therapy for depression: a review of its effects on chronobiology and the autonomic nervous system

Bright light therapy (BLT) is considered among the first-line treatments for seasonal affective disorder (SAD), yet a growing body of literature supports its use in other neuropsychiatric conditions including non-seasonal depression. Despite evidence of its antidepressant efficacy, clinical use of BLT remains highly variable internationally. In this article, we explore the autonomic effects of BLT and suggest that such effects may play a role in its antidepressant and chronotherapeutic properties. After providing a brief introduction on the clinical application of BLT, we review the chronobiological effects of BLT on depression and on the autonomic nervous system in depressed and non-depressed individuals with an emphasis on non-seasonal depression. Such a theory of autonomic modulation via BLT could serve to integrate aspects of recent work centered on alleviating allostatic load, the polyvagal theory, the neurovisceral integration model and emerging evidence on the roles of glutamate and gamma-hydroxybutyric acid (GABA).

Update on clinical impact, documentation, and management of complications associated with esophagectomy

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.

The clinical and economic costs of delirium after surgical resection for esophageal malignancy

OBJECTIVE

The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy.

BACKGROUND

Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population.

METHODS

All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival.

RESULTS

Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival.

CONCLUSIONS

This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.

Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults

Objective

Delirium is associated with poor outcomes following acute hospitalization. A specialized delirium management unit, the Geriatric Monitoring Unit (GMU), was established. Evening bright light therapy (2000–3000 lux; 6–10 pm daily) was added as adjunctive treatment, to consolidate circadian activity rhythms and improve sleep. This study examined whether the GMU program improved sleep, cognitive, and functional outcomes in delirious patients.

Method

A total of 228 patients (mean age = 84.2 years) were studied. The clinical characteristics, delirium duration, delirium subtype, Delirium Rating Score (DRS), cognitive status (Chinese Mini–Mental State Examination), functional status (modified Barthel Index [MBI]), and chemical restraint use during the initial and predischarge phase of the patient’s GMU admission were obtained. Nurses completed hourly 24-hour patient sleep logs, and from these, the mean total sleep time, number of awakenings, and sleep bouts (SB) were computed.

Results

The mean delirium duration was 6.7 ± 4.6 days. Analysis of the delirium subtypes showed that 18.4% had hypoactive delirium, 30.2% mixed delirium, and 51.3% had hyperactive delirium. There were significant improvements in MBI scores, especially for the hyperactive and mixed delirium subtypes (P < 0.05). Significant improvements were noted on the DRS sleep–wake disturbance subscore, for all delirium-subtypes. The mean total sleep time (7.7 from 6.4 hours) (P < 0.05) and length of first SB (6.0 compared with 5.3 hours) (P < 0.05) improved, with decreased mean number of SBs and awakenings. The sleep improvements were mainly seen in the hyperactive delirium subtype.

Conclusion

This study shows initial evidence for the clinical benefits (longer total sleep time, increased first SB length, and functional gains) of incorporating bright light therapy as part of a multicomponent delirium management program. The benefits appear to have occurred mainly in patients with hyperactive delirium, which merits further in-depth, randomized controlled studies.

Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials

INTRODUCTION

The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions.

METHODS

The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay.

RESULTS

We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04).

CONCLUSIONS

The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

Bright light therapy as an adjunctive treatment with risperidone in patients with delirium: a randomized, open, parallel group study

OBJECTIVE

The purpose of this study was to determine the effect of adjuvant light therapy with antipsychotic treatment in patients with delirium.

METHODS

Thirty-six patients were referred to the consulting psychiatry division of our hospital for a disturbance in consciousness. The patients were randomized to risperidone (n=16) or risperidone with light therapy (n=20). They were evaluated on Day 0 (baseline) and on Days 1 to 5 with the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS). Sleep parameters were measured using a sleep log.

RESULTS

Mean DRS and MDAS scores decreased significantly over time in both treatment groups. Risperidone with light therapy group showed a significantly greater decrease in the DRS score than the risperidone-only group (F=2.87, P=.025), but the MDAS score was not significantly different between the two groups. There was a significant improvement in total sleep time (F=2.07, P=.037) and sleep efficiency (F=2.79, P=.029) in the risperidone with light therapy group than in the risperidone-only group.

CONCLUSIONS

Our results indicate that risperidone with light therapy may be a helpful adjuvant treatment for patients with delirium. Adequately powered studies with a head-to-head comparison design are mandatory to confirm our findings.