Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial

Dynamic delirium - Nursing intervention to reduce delirium in patients critically Ill, a randomized control trial

OBJECTIVE

To determine the effectiveness of a nursing intervention based on the Dynamic Symptom Model (DSM) and scientific evidence versus daily care in reducing the incidence and duration of delirium in intensive care patients.

METHOD

We designed the intervention named "DyDel" (By Dynamic Delirium) based on the theoretical approach of the DSM and from scientific evidence. A double-masked clinical trial of parallel groups was developed to test DyDel, with 213 patients older than 18 admitted to the intensive care unit (ICU) randomized to the study groups. The intervention group received DyDel each shift from day 0 until discharged from the ICU, while the control group received daily care in the ICU. At the same time, all participants were followed to measure primary (incidence and duration of delirium) and secondary outcomes (level of sedation and pain, days of mechanical ventilation, stay in ICU, and physical restriction).

RESULTS

Overall, the study population were older than 60 years (60.3 ± 15.2 years), the male gender (59.6 %), and the diagnosis of acute myocardial infarction (73.7 %) were predominant. Comparing groups of study, the incidence of delirium was lower in the intervention group (5.6 %) than in the control group (14.8 %) (p = 0.037). The intervention group had lower days with delirium (0.07 ± 0.308) than the control group (0.34 ± 1.28) (p = 0.016), lower pain intensity (p = 0.002) and lower days of physical restraints (p = 0.06).

CONCLUSION

Non-pharmacological care, like the DyDel intervention, includes the family and focuses on the different patient's needs, which can help to reduce the incidence and duration of delirium in patients admitted to adult ICUs.

IMPLICATIONS FOR CLINICAL PRACTICE

DyDel was non-pharmacological and included the family. The DyDel's activities were focused on physiological, psychological, spiritual, and social needs and the experience and trajectory of delirium. The nurse can give humanized care in the ICU by applying DyDel.

The effect of nonpharmacological interventions applied by nurses to intensive care patients on the duration of delirium: a meta-analysis study

OBJECTIVE

It was aimed to determine the effect level of nonpharmacological methods applied by nurses to patients hospitalized in the intensive care unit on the duration of delirium.

MATERIALS AND METHODS

For this study, relevant studies were accessed by searching in July-October 2022. After the necessary exclusions were made, 14 studies were included in the study. The total sample size of the studies was 1123.

RESULTS

According to the results, nonpharmacological interventions applied by nurses to intensive care patients were found to reduce the duration of delirium (SMD: - 0.625, 95% CI: - 1.1040-0.210; Z =  - 2.950, p = 0.003, I2 = 93.119%). The country of the study (SMD: - 0.047, p = 0.001) and the types of nonpharmacological interventions used (SMD: - 0.062, p = 0.000) influenced the effect size of modulators on the duration of delirium in ICU patients.

CONCLUSION

Nonpharmacological interventions applied by nurses, who have significant responsibilities in the protection and promotion of health, were found to reduce the duration of delirium in intensive care patients. This study shows that nurses, one of the main components of the multidisciplinary team in intensive care, are successful when they apply nonpharmacological interventions well.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis

BACKGROUND

No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population.

OBJECTIVE

To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI.

METHODS

In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention.

RESULTS

Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%).

CONCLUSIONS

Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

Delirium education for family caregivers of patients in the intensive care unit: A pilot study

Objectives

Delirium, an acute change in mental state, seen in hospitalized older adults is a growing public health concern with implications for both patients and caregivers; however, there is minimal research on educating caregivers about delirium. Utilizing family caregivers to assist with delirium management in acute care settings demonstrates improved health outcomes supporting the need for patient and family centered care. The primary aims of the study were to determine feasibility of implementing a delirium education video for caregivers of patients in an adult oncology intensive care unit and compare delirium knowledge to caregivers in a control group.

Methods

A quasi-experimental design comprised of 31 family caregivers of adult patients in an oncology intensive care unit to determine feasibility of implementing a delirium education video.

Results

The results demonstrate feasibility of implementing a caregiver education video in-person and virtually. While total delirium knowledge scores were not statistically significant, knowledge gained within the delirium presentation subgroup was significant (p = .05).

Conclusion

This study demonstrates feasibility of implementing a caregiver education video and findings support further research in this area.

Innovation

Collaborating with caregivers to develop virtual video education for delirium allows for a versatile approach to connect with caregivers to support their caregiving role.

Non-pharmacological interventions to prevent and treat delirium in older people: An overview of systematic reviews

BACKGROUND

As advanced age is a major risk factor for confusion status, delirium has become prevalent in the older population, contributing to longer hospital stays, cognitive impairment, and higher risks of complications and mortality. Compared with pharmacological methods, non-pharmacological interventions are preferred and are recommended by the National Institute for Health and Care Excellence for the prevention of delirium. Numerous systematic reviews and meta-analyses have been carried out to investigate the effects of non-pharmacological interventions. However, the outcomes were diverse and the quality varied widely, making it challenging to draw firm conclusions from the evidence.

OBJECTIVE

To summarize the contents and evaluate the effects of non-pharmacological interventions to prevent and treat delirium among older people.

DESIGN

Overview of systematic reviews.

METHODS

A comprehensive literature search was conducted in Medline, Cochrane Library, EMBASE, CINAHL, PsycINFO, JBI EBP Database, China's SinoMed, CNKI, and Wangfang databases from inception to 2nd December 2022. Two reviewers performed the study selection, quality appraisal, and data extraction independently. The AMSTAR 2 tool was used to appraise the methodological quality of eligible reviews. The results were presented in narrative synthesis based on types of intervention, including multicomponent and single-component interventions.

RESULTS

Twenty-four systematic reviews were included in this overview, of which four reviews were of high quality. Multicomponent interventions were the most widely disseminated non-pharmacological strategy, which were effective in preventing delirium with 27 %-54 % reduction in delirium incidence. Additionally, the multicomponent strategy also reduced the incidence of falls and pressure ulcers, and showed trends toward shortening the length of stay and improving cognitive function. Among single-component interventions, physical training, geriatric risk assessment, and reorientation protocol revealed positive effects in delirium prevention. However, the effectiveness of non-pharmacological interventions for treating delirium was limited, and while multicomponent methods had inconsistent impacts on the duration and severity of delirium, single-component methods showed no significant impact.

CONCLUSION

Non-pharmacological interventions are effective in reducing the incidence of delirium and improving other health outcomes among older patients. However, the effects on the duration and severity of delirium need more evidence to confirm.

REGISTRATION NUMBER

CRD42022376651 in PROSPERO.

Critical Care and Occupational Therapy Practice Across the Lifespan

This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.

Efficacy of Early Enhanced Occupational Therapy in an Intensive Care Unit (EFFORT-ICU): A Single-Site Feasibility Trial

IMPORTANCE

This research trial contributes to the evidence for occupational therapy service delivery in intensive care settings.

OBJECTIVE

To explore the feasibility of a trial to evaluate the impact of early enhanced occupational therapy on mechanically ventilated patients in intensive care.

DESIGN

Single-site assessor-blinded randomized controlled feasibility trial.

SETTING

Level 5 8-bed adult medical-surgical intensive care unit (ICU) at Logan Hospital, Brisbane, Australia.

PARTICIPANTS

Participants were 30 mechanically ventilated patients randomly allocated to two groups.

OUTCOMES AND MEASURES

We compared standard care with enhanced occupational therapy with outcomes measured at discharge from the ICU, hospital discharge, and 90 days post randomization. The primary outcome measure was the FIM®. Secondary outcomes included the Modified Barthel Index (MBI); Montreal Cognitive Assessment; grip strength, measured using a dynamometer; Hospital Anxiety and Depression Scale; and the 36-Item Short-Form Health Survey (Version 2). The intervention group received daily occupational therapy, including cognitive stimulation, upper limb retraining, and activities of daily living. Data were analyzed using independent groups t tests and effect sizes.

RESULTS

Measures and procedures were feasible. A significant difference was found between groups on FIM Motor score at 90 days with a large effect size (p = .05, d = 0.76), and MBI scores for the intervention group approached significance (p = .051) with a large effect size (d = 0.75) at 90 days. Further moderate to large effect sizes were obtained for the intervention group for cognitive status, functional ability, and quality of life.

CONCLUSIONS AND RELEVANCE

This trial demonstrated that occupational therapy is feasible and beneficial in the ICU. Criteria to progress to a full-scale randomized controlled trial were met. This study contributes to embedding ongoing consistency of practice and scope of service delivery for occupational therapy in this field. What This Article Adds: Occupational therapists should be considered core team members in the critical care-ICU, with funding to support ongoing service provision and optimization of patient outcomes based on effective and feasible service delivery.

Effect of using eye masks and earplugs in preventing delirium in intensive care patients: A single-blinded, randomized, controlled trial

BACKGROUND

Delirium, which is frequently encountered in intensive care patients, can be prevented with multicomponent nursing interventions, and thus the negative consequences can be reduced.

AIM

To examine the effect of using eye masks and earplugs in preventing delirium in intensive care units (ICUs).

STUDY DESIGN

A randomized, controlled, single-blind intervention study. This study was conducted in the medical and surgical ICUs of a tertiary hospital, and nurses were given pre-study training on delirium risks, diagnosis, prevention, and management. Data were collected using the patient information form, the Nursing Delirium Screening Scale, the Richard-Campbell Sleep Scale, and the daily follow-up form. Various environmental modifications were made in the ICUs for all patients, and evidence-based nonpharmacological nursing interventions were applied to the patients in both groups during the day and night shifts for 3 days. In addition, the patients in the intervention group were provided with eye masks and earplugs for three nights.

RESULTS

The study included a total of 60 patients (30 in the intervention group and 30 in the control group). There was a statistically significant difference in the development of delirium between the intervention and control groups (night of the 2nd day, p = .019; day of the 3rd day p < .001; night of the 3rd day p ≤ .001). The average total sleep quality score of the intervention group was found to be significantly higher than the control group (p ≤ .001 for three nights). Staying in the internal medicine ICU affected (odds ratio [OR], 11.84; 95% confidence interval [CI], 3.00-46.66; p = .017) more on the development of delirium than in coronary ICU, being in the age group of 65 and over, having a hearing impairment, coming to ICU from the operating room, and education level had an effect.

CONCLUSIONS

The earplugs and eye masks used by the intensive care patients overnight were found to be effective in increasing sleep quality and preventing delirium.

RELEVANCE TO CLINICAL PRACTICE

The use of eye masks and earplugs is recommended for ICUs in preventing delirium.

Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol

BACKGROUND

Delirium is a clinical condition characterised by acute and fluctuating deterioration of the cognitive state, generally secondary to an acute pathology. Delirium is associated with negative outcomes in older adults, such as longer hospitalisations, higher mortality, and short and medium-term institutionalisation. Randomised clinical trials have shown that delirium is preventable through non-pharmacological prevention measures, decreasing its incidence by 30-50%. These interventions include promoting physical activity, facilitating the use of glasses and hearing aids, cognitive stimulation, and providing frequent reorientation of time and space, among others. These measures are currently seldom applied in hospitals in Chile and around the world for reasons including the heavy workload of clinical staff, the lack of trained personnel, and in general the absence of a systematic implementation processes. We developed a software called PREVEDEL, which includes non-pharmacological strategies such as cognitive stimulation, early mobilisation, orientation, and pain assessment. We propose a randomised clinical trial to evaluate whether cognitive stimulation guided by PREVEDEL software prevents delirium status (full/subsyndromal delirium) in hospitalised older adults.

METHOD

A randomised controlled trial, with parallel, multicentre groups. We will recruite patients 65 years or older who have been hospitalised for less than 48 h in the general ward or the intermediate care units of four hospitals in Santiago, Chile. The participants in the intervention group will use a tablet with cognitive stimulation software for delirium prevention for five continuous days versus the control group who will use the tablet without the software. We will evaluate the incidence, duration, density of delirium, subsyndromal delirium with the Confusion Assessment Method, cognitive with the Montreal Cognitive Assessment, and functional status with the Functional Independence Measure at discharge. Moreover, we will evaluate the adherence to prevention measures, as well as demographic variables of interest.

DISCUSSION

The use of cognitive PREVEDEL software could increase and improve the implementation of non-pharmacological prevention measures for delirium in hospitalised older adults, thus reducing its incidence and contributing to patients and health professionals.

TRIAL REGISTRATION

NCT05108207 ClinicalTrials.gov. Registered 4 November 2021.

ICU Delirium in Cardiac Patients

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Long-Term Prognosis Following Early Rehabilitation in the ICU: A Retrospective Cohort Study

OBJECTIVES

Critically ill patients often have residual functional disabilities. Studies have shown that early rehabilitation improves short-term physical function. However, it remains unknown whether early rehabilitation affects long-term prognosis and healthcare resource utilization.

DESIGN

Retrospective cohort study.

SETTING

This study used an administrative claims database in Kumamoto Prefecture, Japan, from April 2012 to February 2017.

PATIENTS

We identified patients who were admitted to the ICU and received rehabilitation. Eligible patients were divided into those who underwent rehabilitation within 3 days (early rehabilitation group) and after 4 or more days of ICU admission (delayed rehabilitation group). Propensity score matching analyses were conducted to compare the number of outpatient consultations within 1 year and 3 years after discharge from the index hospitalization, total duration of hospitalization after discharge, healthcare costs, and survival.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 6,679 patients were included in the study. Propensity score matching created 2,245 pairs. No difference was observed in the number of outpatient consultations 1 year after discharge, although there were differences between the groups 3 years after discharge. Long-term observation revealed a shorter overall duration of hospitalization (1.9 vs 2.6 mo; p < 0.001) and lower total costs ($28,159 vs $38,272; p < 0.001), as well as lower average costs per month ($1,690 vs $1,959; p = 0.001) in the early compared with the delayed rehabilitation group. No differences in survival were observed (log-rank test; p = 0.18).

CONCLUSIONS

Starting rehabilitation within 3 days of ICU admission was associated with shorter durations of future hospitalization and lower healthcare costs. Early rehabilitation for ICU patients might be associated with reduced healthcare resource utilization.

Investigating the effect of implementing a sensory stimulation program by family members on delirium status of brain injury patients hospitalized in the intensive care unit: A randomized clinical trial

BACKGROUND

Delirium is the most common psychological disorder in brain injury patients hospitalized in the intensive care unit (ICU), one of the leading causes of which can be sensory deprivation or sensory overload. This study aimed to determine the effect of implementing a sensory stimulation program by family members on the delirium status of ICU-hospitalized brain injury patients.

MATERIALS AND METHODS

In this randomized controlled clinical trial, 66 brain injury patients hospitalized in the ICUs were assigned to intervention and control groups using stratified random sampling. For the intervention group, a sensory stimulation program was implemented by family members for 1 h a day during the ICU stay. The control group received routine care. Patients' delirium status was assessed daily using the confusion assessment method for the intensive care unit (CAM-ICU). Data were analyzed by the SPSS software version 22, using Chi-square, independent t-test, and Binary logistic regression model tests, at a significance level of 0.05.

RESULTS

Odds of delirium Incidence in the intervention group was 94% lower than in the control group (OR = 0.057, 95% CI 0.017, 0.19, P = 0.001). There is a significant difference between the two groups in terms of length of delirium (P = 0.001), stay in ICU (P = 0.001) and mechanical ventilation (P = 0.001). The mean of all three variables in the intervention group was lower than the control group.

CONCLUSIONS

Implementing of sensory stimulation program by the family members, as a non-pharmacological method, can reduce the incidence of delirium in brain injury patients admitted to ICU.

Innovative Non-Pharmacological Management of Delirium in Persons with Dementia: New Frontiers for Physiotherapy and Occupational Therapy?

BACKGROUND

Delirium and dementia are two of the most common geriatric syndromes, which requires innovative rehabilitation approaches.

AIM

We aimed at determining which occupational therapy and physiotherapy interventions are applied with older people with delirium and dementia in different care settings. We also identified the assessment tools that were used.

MATERIALS AND METHODS

We conducted a literature search for scientific articles published from 2012 to 2022 (PubMed, MEDLINE, AMED and CINAHL) with adults aged >65 years including experimental study designs with randomized or non-randomized intervention, exploratory studies, pilot studies, quasi-experimental studies, case series and/or clinical cases. Studies that did not use interventions that could be classified as occupational therapy or physiotherapy were excluded.

RESULTS

After applying the exclusion criteria, 9 articles were selected. The most widely used assessment to define dementia was the MMSE (N = 5; 55.5%), whereas the CAM (N = 2; 22.2%), CAM-ICU (N = 2; 22.2%) and RASS (N = 3; 33.3%) were the most widely used to define delirium. The rehabilitation interventions that were most frequently performed were early mobilization, inclusion of the caregiver during treatment, modification of the environment to encourage orientation and autonomy, the interprofessional systemic approach and engaging persons in meaningful activities.

CONCLUSIONS

Despite the growing evidence on its effectiveness, the role of physiotherapy and occupational therapy interventions in the prevention and treatment of people with dementia and delirium is still emerging. More research is needed to investigate if effective occupational therapy programs known to reduce the behavioral and psychological symptoms in people with dementia are also useful for treating delirium and specifically delirium superimposed on dementia. Regarding physiotherapy, it is crucial to know about the amount and timing of intervention required. Further studies are needed including older adults with delirium superimposed on dementia to define the role of the interprofessional geriatric rehabilitation team.

Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized

Objective

Delirium in older emergency department (ED) adults is associated with poorer long-term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration).

Methods

This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged ≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI).

Results

The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR, 0.39; 95% CI, 0.21-0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82-1.27).

Conclusion

In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.

Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial

Background

Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures.

Methods

A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium.

Results

In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery.

Discussion

Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT03704090.

Occupational therapist-guided cognitive interventions in critically ill patients: a feasibility randomized controlled trial

PURPOSE

Intensive care unit (ICU) delirium is a common complication of critical illness requiring a multimodal approach to management. We assessed the feasibility of a novel occupational therapist (OT)-guided cognitive intervention protocol, titrated according to sedation level, in critically ill patients.

METHODS

Patients aged ≥ 18 yr admitted to a medical/surgical ICU were randomized to the standard delirium prevention protocol or to the OT-guided cognitive intervention protocol in addition to standard of care. The target enrolment number was N = 112. Due to the COVID-19 pandemic, the study enrolment period was truncated. The primary outcome was feasibility of the intervention as measured by the proportion of eligible cognitive interventions delivered by the OT. Secondary outcomes included feasibility of goal session length (20 min), participant clinical outcomes (delirium prevalence and duration, cognitive status, functional status, quality of life, and ICU length of stay), and a description of methodological challenges and solutions for future research.

RESULTS

Seventy patients were enrolled and 69 patients were included in the final analysis. The majority of OT-guided sessions (110/137; 80%) were completed. The mean (standard deviation [SD]) number of sessions per patient was 4.1 (3.8). The goal session length was achieved (mean [SD], 19.8 [3.1] min), with few sessions (8/110; 7%) terminated early per patient request.

CONCLUSION

This novel OT-guided cognitive intervention protocol is feasible in medical/surgical ICU patients. A larger randomized controlled trial is required to determine the impact of such a protocol on delirium prevalence or duration.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT03604809); registered 18 June 2018.

Advancing the Care of Delirium and Comorbid Dementia

Delirium is defined as an acute neuropsychiatric disorder characterized by a disturbance in attention and awareness, which develops over a short period of time, with additional disturbances in cognition which are not explained by a pre-existing cognitive impairment [...].

Impact of Pain, Agitation, and Delirium Bundle on Delirium and Cognitive Function

BACKGROUND

Differences in short-term cognitive function between mechanically ventilated patients treated with multicomponent interventions and those receiving routine nursing care have not been established because of the lack of follow-up in previous studies.

PURPOSE

This study was designed to evaluate the effects of the pain, agitation, and delirium (PAD) care bundle on delirium occurrence and clinical outcomes, specifically in terms of short-term cognitive function, in mechanically ventilated patients.

METHODS

Data on 243 patients with mechanical ventilation were analyzed from January 2017 to February 2019. The eligible patients were divided randomly into two groups. The control group ( n = 120) received usual care, whereas the intervention group ( n = 123) received the PAD bundle, including pain monitoring and management, light sedation and daily awakening, early mobility, sleep promotion, and delirium monitoring. The incidence and duration of delirium, ventilator time, and intensive care unit (ICU) length of stay were compared between the two groups. Upon discharge from the ICU and at 3 and 6 months after discharge, cognitive function was assessed using the Montreal Cognitive Assessment scale and compared between the two groups.

RESULTS

The incidence of delirium was reduced significantly in the intervention group, and significant decreases in the duration of delirium, ventilator time, and ICU length of stay were found. Cognitive impairment in the intervention group was significantly lower at the 3-month follow-up assessment.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The PAD bundle was shown to be associated with a lower incidence of delirium and improved clinical outcomes. Short-term cognitive impairment occurred in fewer patients who were managed with the PAD bundle after ICU discharge. Our findings indicate that the PAD bundle has the potential to improve clinical outcomes. The administrative staff of ICUs should use strategies, such as interdisciplinary teamwork, to facilitate the buy-in and implementation of interventions.

The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review

Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit.

Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report.

Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium.

Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.

Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis

OBJECTIVE

Sleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes.

REVIEW METHODS

This study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I).

RESULTS

The systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = -0.68, 95% CI = -0.93 to -0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention.

CONCLUSIONS

Our results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person-environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium.

PROSPERO REFERENCE NUMBER

CRD42021230815.

Effects of social influence and implementation climate and leadership on nurse-led early mobility behaviours in critical care

Introduction

Early mobility (EM), initiating and advancing physical activity in the earliest days of critical illness, has been described as the most difficult component of the ABCDEF bundle to implement and coordinate. Successful implementation of EM in clinical practice requires multiple targeted implementation strategies.

Objective

Describe the associations of nurses’ EM attitudes, subjective norms, perceived behavioural control, intention, and implementation climate and leadership with self-reported and documented EM behaviour in the intensive care unit (ICU).

Design

This was a two-site, descriptive, cross-sectional study to explore nurses’ perception of the factors influencing EM adherence.

Setting

Three ICUs (medical, surgical and cardiovascular) in an academic medical centre and two ICUs (medical/surgical and cardiovascular) in a regional medical centre in middle Tennessee.

Patients

Critically ill adults.

Interventions

None.

Main outcome measures

A 34-item investigator-developed survey, Implementation Leadership Scale, and Implementation Climate Scale were administered to ICU nurses. Survey development was informed by a Theory of Planned Behavior based elicitation study and implementation science frameworks.

Results

The academic medical centre had markedly lower EM documentation. We found no difference in nurses’ EM attitudinal beliefs, social influence, facilitators, and barriers at both sites. Nurses perceived moderate social influence to perform EM similarly across sites and considerable control over their ability to perform EM. We did note site differences for implementation climate and leadership and objective EM adherence with the regional community medical centre demonstrating statistically significant relationships of implementation climate and leadership with self-report and documented EM behaviours.

Conclusions

We identified contextual differences in implementation climate and leadership influence when comparing nurse EM behaviours. Streamlined documentation, leadership advocacy for interprofessional coordination and manpower support, and multicomponent context-based implementation strategies could contribute to better EM adherence.

Occupational therapy service provision in adult intensive care units in Australia: A survey of workload practices, interventions and barriers

INTRODUCTION

Occupational therapy practice within intensive care units (ICUs) is limited with respect to published research evidence and guidelines regarding scope of practice. An understanding of the current level of service provision, feasibility of services in ICUs and training and development needs of occupational therapists is required to enable consistent best practice and promote the occupational therapy profile. This study aimed to explore occupational therapy practice within ICUs in Australia including the barriers and enablers to practice perceived by occupational therapists.

METHODS

In this cross-sectional study, a national customised online survey was completed by registered occupational therapists who provide services in intensive care settings in Australia. Recruitment was from July to September 2019 through Occupational Therapy Australia and other professional networks and interest groups.

RESULTS

The survey was completed by 43 respondents. The majority were experienced therapists from Queensland with greater than 10-years post-qualification and working in a tertiary hospital setting. The most common length of time spent working in the ICU was 0-2 h per week. Formal and informal self-care measures, cognitive screens and physical outcome measures were commonly used. Bed-based grooming retraining, pressure care management, functional upper limb retraining and passive ranging were the most frequent interventions provided on a daily basis. Perceived barriers to occupational therapy service provision in ICU included lack of funding for staffing, competing workload demands, lack of occupational therapy role delineation and scope of practice and lack of published evidence and training.

CONCLUSION

Occupational therapy services in intensive care settings in Australia are limited. Published practice guidelines, further research, applications for service funding and ongoing education of the ICU multidisciplinary team regarding the scope of occupational therapy practice are recommended to promote the development of occupational therapy services in ICU.

Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial

PURPOSE

Delirium is a common dysfunction in the intensive care unit (ICU) and it is associated with negative short- and long-term outcomes. This study evaluated the effectiveness of combined non-pharmacological interventions in preventing delirium in critically ill patients.

MATERIALS AND METHODS

This is a single-center randomized controlled trial conducted in three Brazilian ICUs from February to September 2019. Patients assigned to the control group received standard care (n = 72) and those assigned to the experimental group (n = 72) received a bundle of non-pharmacological interventions (periodic reorientation, cognitive stimulation, correction of sensory deficits [visual or hearing impairment], environmental management and sleep promotion) throughout the ICU stay. Delirium was monitored twice a day with the Confusion Assessment Method for the Intensive Care Unit Flowsheet. The primary outcome was the incidence density of delirium.

RESULTS

The incidence density of delirium was lower in the intervention group (1.3 × 10^-2 person-days) than in the control group (2.3 × 10^-2 person-days), with a hazard ratio of 0.40 (95% confidence intervals, 0.17-0.95; p = 0.04) after adjustment for Simplified Acute Physiology Score III, surgical admission and alcoholism.

CONCLUSIONS

Combined non-pharmacological interventions reduced delirium in critically ill patients, compared to standard care.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC), Identifier RBR-6xq95s, October 03, 2018.

Impacto de la pandemia COVID-19 en la práctica clínica profesional de la terapia ocupacional

Resumen Introducción Una serie de medidas restrictivas para el cuidado de la salud emergieron limitando acciones que incluyen el quehacer de terapeutas ocupacionales y proponiendo adaptaciones para brindar atención a las personas que así lo requieran. Objetivo Identificar el impacto y las adaptaciones en la atención de los profesionales clínicos de terapia ocupacional a causa de la pandemia por COVID-19 en Colombia. Método Estudio de corte transversal que aplica cuestionario online en enero-febrero de 2021 a terapeutas ocupacionales colombianos en ambientes clínicos/hospitalarios. Se analizaron variables sociodemográficas, ejercicio profesional clínico y el impacto del COVID-19 en cuanto a la pérdida del empleo, modificaciones y adaptaciones para la intervención. Se realizan análisis descriptivos por variable y se aplica prueba Chi-cuadrado de independencia para asociaciones entre variables. Resultados 382 terapeutas ocupacionales colombianos participaron. El tiempo promedio de ejercicio profesional fue de 10.8 años. Del total, el 89% trabajaba antes de la pandemia y continuó sus labores, al menos el 64% adujo que perdió su trabajo por el COVID-19. De los que continuaron trabajando el 20.5% lo hizo de manera virtual y el 79.5% en clínica presencial. A nivel virtual, el 89% lo hizo debido a exigencia laboral y al menos el 53% lo realizó sin formación en telesalud. Presencialmente, el 68% reportó restricciones en las acciones practicadas y disminución de remisiones a terapia. Conclusiones La pandemia ha redimensionado el actuar del terapeuta ocupacional, modificando los medios y formas de intervención y permitiendo la reinvención de su quehacer.

Impact of the COVID-19 pandemic on the professional clinical practice of occupational therapy

Abstract Introduction A series of restrictive health care measures emerged limiting actions that include the work of occupational therapists and proposing adaptations to provide care to people who require it. Objective To identify the impact and adaptations in the care of Occupational Therapy clinical professionals due to the COVID-19 pandemic in Colombia. Methods Cross-sectional study that applies an online questionnaire in January-February 2021 to Colombian occupational therapists in clinical/hospital settings. Sociodemographic variables, clinical professional practice, and the impact of COVID-19 in terms of job loss, modifications, and adaptations for the intervention were analyzed. Descriptive analyzes are performed by variable and a Chi-square test of independence is applied for associations between variables. Results 382 Colombian occupational therapists participated. The average time of professional practice was 10.8 years. Of the total, 89% worked before the pandemic and continued their work, and at least 64% claimed that they lost their job due to COVID-19. Of those who continued to work, 20.5% did so virtually and 79.5% in a face-to-face clinic. On a virtual level, 89% did it due to a job requirement and at least 53% did it without training in telehealth. In face-to-face, 68% reported restrictions in the actions practiced and decreased referrals to therapy. Conclusions The pandemic has resized the actions of the occupational therapist, has modified the means and forms of intervention, allowing the reinvention of their work.

Predicting Delayed Neurocognitive Recovery After Non-cardiac Surgery Using Resting-State Brain Network Patterns Combined With Machine Learning

Delayed neurocognitive recovery (DNR) is a common subtype of postoperative neurocognitive disorders. An objective approach for identifying subjects at high risk of DNR is yet lacking. The present study aimed to predict DNR using the machine learning method based on multiple cognitive-related brain network features. A total of 74 elderly patients (≥ 60-years-old) undergoing non-cardiac surgery were subjected to resting-state functional magnetic resonance imaging (rs-fMRI) before the surgery. Seed-based whole-brain functional connectivity (FC) was analyzed with 18 regions of interest (ROIs) located in the default mode network (DMN), limbic network, salience network (SN), and central executive network (CEN). Multiple machine learning models (support vector machine, decision tree, and random forest) were constructed to recognize the DNR based on FC network features. The experiment has three parts, including performance comparison, feature screening, and parameter adjustment. Then, the model with the best predictive efficacy for DNR was identified. Finally, independent testing was conducted to validate the established predictive model. Compared to the non-DNR group, the DNR group exhibited aberrant whole-brain FC in seven ROIs, including the right posterior cingulate cortex, right medial prefrontal cortex, and left lateral parietal cortex in the DMN, the right insula in the SN, the left anterior prefrontal cortex in the CEN, and the left ventral hippocampus and left amygdala in the limbic network. The machine learning experimental results identified a random forest model combined with FC features of DMN and CEN as the best prediction model. The area under the curve was 0.958 (accuracy = 0.935, precision = 0.899, recall = 0.900, F1 = 0.890) on the test set. Thus, the current study indicated that the random forest machine learning model based on rs-FC features of DMN and CEN predicts the DNR following non-cardiac surgery, which could be beneficial to the early prevention of DNR. Clinical Trial Registration: The study was registered at the Chinese Clinical Trial Registry (Identification number: ChiCTR-DCD-15006096).

The Impact of Nursing Delirium Preventive Interventions in the Intensive Care Unit: A Multicenter Cluster Randomized Controlled Trial

Rationale Delirium is common in critically ill patients and associated with deleterious outcomes. Non-pharmacologic interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objective To determine the effects of a multicomponent nursing intervention program on delirium in the Intensive Care Unit. Methods Stepped wedge cluster randomized controlled trial, conducted in Intensive care units of 10 centers. Adult critically ill surgical, medical or trauma patients at high risk to develop delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. Primary outcome was the number of delirium-free and coma-free days alive in 28 days after Intensive Care Unit admission. Measurements and main results A total of 1749 patients were included. Time spent per 8 hours shift on interventions was median [IQR] 38 [14-116] in the intervention period and median 32 [13-73] minutes in the control period (p=0.44). Patients in the intervention period had median 23 [4-27] delirium-free and coma-free days alive, compared to median 23 [5-27] days for patients in the control group (mean difference -1.21 days, 95%CI -2.84 to 0.42 days; p=0.15). Also, the number of delirium days was similar: median 2 [1-4] days (ratio of medians 0.90, 95%CI 0.75 to 1.09; p=0.27). Conclusion In this large randomized controlled trial in adult ICU patients, a limited increase was achieved of the use of nursing interventions, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT03002701.

Heterogeneity in design and analysis of ICU delirium randomized trials: a systematic review

BACKGROUND

There is a growing number of randomized controlled trials (RCTs) evaluating interventions to prevent or treat delirium in the intensive care unit (ICU). Efforts to improve the conduct of delirium RCTs are underway, but none address issues related to statistical analysis. The purpose of this review is to evaluate heterogeneity in the design and analysis of delirium outcomes and advance methodological recommendations for delirium RCTs in the ICU.

METHODS

Relevant databases, including PubMed and Embase, were searched with no restrictions on language or publication date; the search was conducted on July 8, 2019. RCTs conducted on adult ICU patients with delirium as the primary outcome were included where trial results were available. Data on frequency and duration of delirium assessments, delirium outcome definitions, and statistical methods were independently extracted in duplicate. The review was registered with PROSPERO (CRD42020141204).

RESULTS

Among 65 eligible RCTs, 44 (68%) targeted the prevention of delirium. The duration of follow-up varied, with 31 (48%) RCTs having ≤7 days of follow-up, and only 24 (37%) conducting delirium assessments after ICU discharge. The incidence of delirium was the most common outcome (50 RCTs, 77%) for which 8 unique statistical methods were applied. The most common method, applied to 51 of 56 (91%) delirium incidence outcomes, was the two-sample test comparing the proportion of patients who ever experienced delirium. In the presence of censoring of patients at ICU discharge or death, this test may be misleading. The impact of censoring was also not considered in most analyses of the duration of delirium, as evaluated in 24 RCTs, with 21 (88%) delirium duration outcomes analyzed using a non-parametric test or two-sample t test. Composite outcomes (e.g., rank-based delirium- and coma-free days), used in 11 (17%) RCTs, seldom explicitly defined how ICU discharge, and death were incorporated into the definition and were analyzed using non-parametric tests (11 of 13 (85%) composite outcomes).

CONCLUSIONS

To improve delirium RCTs, outcomes should be explicitly defined. To account for censoring due to ICU discharge or death, survival analysis methods should be considered for delirium incidence and duration outcomes; non-parametric tests are recommended for rank-based delirium composite outcomes.

TRIAL REGISTRATION

PROSPERO CRD42020141204 . Registration date: 7/3/2019.

Delirium REduction after administration of melatonin in acute ischemic stroke (DREAMS): A propensity score-matched analysis

BACKGROUND AND PURPOSE

Poststroke delirium (PSD) comprises a common and severe complication after stroke. However, treatment options for PSD remain insufficient. We investigated whether prophylactic melatonin supplementation may be associated with reduced risk for PSD.

METHODS

Consecutive patients admitted to the Tübingen University Stroke Unit, Tübingen, Germany, with acute ischemic stroke (AIS), who underwent standard care between August 2017 and December 2017, and patients who additionally received prophylactic melatonin (2 mg per day at night) within 24 h of symptom onset between August 2018 and December 2018 were included. Primary outcomes were (i) PSD prevalence in AIS patients and (ii) PSD risk and PSD-free survival in patients with cerebral infarction who underwent melatonin supplementation compared to propensity score-matched (PSM) controls. Secondary outcomes included time of PSD onset and PSD duration.

RESULTS

Out of 465 (81.2%) patients with cerebral infarction and 108 (18.8%) transient ischemic attack (TIA) patients, 152 (26.5%) developed PSD (median time to onset [IQR]: 16 [8-32] h; duration 24 [8-40] h). Higher age, cerebral infarction rather than TIA, and higher National Institutes of Health Stroke Scale score and aphasia on admission were significant predictors of PSD. After PSM (164 melatonin-treated patients with cerebral infarction versus 164 matched controls), 42 (25.6%) melatonin-treated patients developed PSD versus 60 (36.6%) controls (odds ratio, 0.597; 95% confidence interval, 0.372-0.958; p = 0.032). PSD-free survival differed significantly between groups (p = 0.027), favoring melatonin-treated patients. In patients with PSD, no between-group differences in the time of PSD onset and PSD duration were noted.

CONCLUSIONS

Patients prophylactically treated with melatonin within 24 h of AIS onset had lower risk for PSD than patients undergoing standard care. Prospective randomized trials are warranted to corroborate these findings.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

Diagnosis, prevention, and management of delirium in the intensive cardiac care unit

Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program

OBJECTIVE

To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium.

METHODS

A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method.

RESULTS

Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99).

CONCLUSIONS

Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Intervenção não farmacológica no manejo de delirium: uma revisão bibliográfica integrativa

Resumo Introdução O delirium é um quadro clínico complexo caracterizado por uma expressão neuropsiquiátrica de doença orgânica, em que o indivíduo apresenta súbita alteração da capacidade cognitiva, possíveis flutuações do sono, consciência e atenção. O tratamento do delirium deve ser realizado por meio de uma abordagem multicomponente e interdisciplinar. Objetivo Conhecer as intervenções não farmacológicas para o manejo de delirium por equipe multiprofissional e aquelas conduzidas especificamente pelo terapeuta ocupacional. Método Revisão bibliográfica integrativa da literatura indexada nas bases Lilacs, Pubmed, Scopus e Web of Science e SciELO sem recorte temporal. Resultados As intervenções visavam o empoderamento e a participação de todos os agentes envolvidos no tratamento do paciente com delirium. Destacaram-se estratégias voltadas para: o aumento da autonomia e da independência do paciente; adequação das condições ambientais, de modo a promover segurança, conforto, familiaridade e orientação temporal-espacial; adaptação da rotina para favorecer o ciclo sono-vigília; estimulação física, cognitiva e sensorial; melhora do desempenho ocupacional e estímulo à realização de atividades significativas; prescrição de recursos de tecnologia assistiva e terapias complementares, quando indicado; avaliação e monitoramento constante do paciente; controle da dor, de sintomas emocionais e de condições clínicas que predispõem ao delirium; melhora da comunicação do paciente e sua vinculação com a equipe e com a rede de apoio; e educação em saúde. Conclusão As intervenções visam à integralidade do cuidado e devem, portanto, ser realizadas pelos diferentes profissionais que componham a equipe, destacando-se o papel que os terapeutas ocupacionais exercem no gerenciamento do delirium.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

Perceptions of current occupational therapy practice with older adults experiencing delirium

OBJECTIVES

To describe the perceptions of Australian occupational therapists of their role, knowledge and skills in enabling older adults with delirium to participate in meaningful occupations.

METHODS

This is a mixed-methods cross-sectional study. Participants (n = 91) completed an online survey, with quantitative data analysed descriptively and qualitative data subjected to content analysis.

RESULTS

Occupational therapists had good general delirium knowledge, but less understanding of specific risk factors. Participants asserted the importance of occupational therapy assessment and treatment for older people experiencing delirium and generally felt confident or somewhat confident in their skills. While all participants provided collaborative care with multidisciplinary team members, only a minority thought colleagues had a satisfactory knowledge of the occupational therapy role with delirium.

CONCLUSION

Currently, the role of occupational therapy with older people experiencing delirium remains emerging rather than established, and there are many opportunities for further research and development in this practice area.

The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review

Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.

The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review

Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.

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.

Risk factors associated with postoperative intensive care unit delirium in patients undergoing invasive mechanical ventilation following acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

This study was performed to determine the risk factors associated with intensive care unit delirium (ICUD) in patients undergoing invasive mechanical ventilation (IMV) secondary to acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Data involving 620 patients undergoing IMV secondary to acute exacerbation of COPD from 2009 to 2019 at the First Hospital of Hebei Medical University were retrospectively analysed. The primary endpoint was the risk factors associated with developing ICUD. Univariable and multivariable logistic regression analyses were used to identify these risk factors.

RESULTS

Of 620 patients, 93 (15.0%) developed ICUD. In the multivariable analysis, risk factors that were significantly associated with ICUD were increased age, male sex, alcoholism with active abstinence, current smoking, stage 3 acute kidney injury (AKI), and an American Society of Anesthesiologists (ASA) physical status of III.

CONCLUSION

This study showed that increasing age, male sex, alcoholism with active abstinence, current smoking, stage 3 AKI, and an ASA physical status of III might be associated with a risk of developing ICUD. Even if these risk factors are unaltered, they provide a target population for quality improvement initiatives.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review

PURPOSE

A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients.

SOURCE

Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology.

PRINCIPAL FINDINGS

Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies.

CONCLUSION

The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.

Hintergrundtext zu Empfehlungen der DGPRM zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in Intensivmedizin und Intermediate Care

Wissenschaftlicher Hintergrund, Erläuterungen, Definitionen von Begriffen, Literaturangaben und Empfehlungen zur Empfehlungen der Deutschen Gesellschaft für Physikalische und Rehabilitative Medizin (DGPRM) zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in der Intensivmedizin und Intermediate Care. Konkrete Problemfelder und mögliche Maßnahmen werden erläutert. Sowohl für personelle Schlüssel als auch Therapiefrequenz und Dauer jeweils werden konkrete Empfehlungen benannt.

Effects of early mobilization on the prognosis of critically ill patients: A systematic review and meta-analysis

BACKGROUND

Early mobilization is considered a safe and effective therapeutic strategy for accelerating the rehabilitation of patients admitted to the intensive care unit, with a proven benefit for critically ill patients.

OBJECTIVES

To evaluate the effects of early mobilization on the prognosis of critically ill patients through a meta-analysis of data pooled from studies meeting the inclusion criteria.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Electronic databases including PubMed, EMBASE, the Cochrane Library, CINAHL, ProQuest, Web of Science, ProQuest Dissertations and Theses, Chinese BioMedical Literature Service System, WANFANG database, CNKI database, and Clinical Trial Register Platform were systematically searched from inception up to December 31, 2019.

REVIEW METHODS

Study eligibility was independently evaluated by two researchers. The title and abstract of the studies were first screened, and full-text articles of the remaining studies were screened for verification. Methodologic quality and risk of bias of the included studies were evaluated, and data were extracted from eligible studies. The meta-analysis was conducted using Review Manager v5.3 software. Key outcomes are presented as pooled risk ratio, weighted mean difference, and the corresponding 95% confidential interval .

RESULTS

A total of 39 articles were included in the meta-analysis. The results showed that early mobilization improved ventilator-associated pneumonia patients' Medical Research Council score; reduced the incidence of intensive care unit-acquired weakness and intensive care unit-related complications such as ventilator-associated pneumonia, deep vein thrombosis, and pressure sores; and shortened the duration of mechanical ventilation, length of intensive care unit stay and hospital stay. However, there were no statistically significant differences in handgrip strength, delirium rate, intensive care unit mortality, hospital mortality, and physical function- and mental health-related quality of life at 2-3 months and 6 months post-hospital discharge.

CONCLUSIONS

Early mobilization was effective in enhancing the recovery of critically ill patients, but more large-scale, multicenter randomized controlled trials are required to further confirm these findings.

Non-Pharmacologic Multicomponent Interventions Preventing Delirium in Hospitalized People

BACKGROUND/OBJECTIVES

Delirium is a common neurobehavioral complication in hospitalized patients with a high prevalence in various clinical settings. Prevention of delirium is critical due to its common occurrence and associated poor outcomes. Our objective was to evaluate the efficacy of multicomponent interventions in preventing incident delirium in hospitalized patients at risk.

DESIGN

Systematic review and meta-analysis.

SETTING

Hospital.

PARTICIPANTS

We included a study if it was a randomized controlled trial and was evaluating effects of coordinated non-pharmacologic multicomponent interventions in the prevention of delirium.

MEASUREMENTS

We performed a systematic literature search in PubMed and CENTRAL (PROSPERO: CRD42019138981; last update May 24, 2019). We assessed the quality of included studies by using the criteria established by the Cochrane Collaboration. We extracted the measured outcomes for delirium incidence, duration of delirium, length of hospital stay, falls during hospital stay, discharge to institutional care, and inpatient mortality.

RESULTS

In total, we screened 1,027 eligible records and included eight studies with 2,105 patients in the review. We found evidence of an effect (ie, reduction) of multicomponent interventions on the incidence of delirium (risk ratio = .53; 95% confidence interval = .41-.69; I² = 0). We detected no clear evidence of an effect for delirium duration, length of hospital stay, accidental falls, and mortality. Subgroup analyses did not result in findings of substantial effect modifiers, which can be explained by the high homogeneity within studies.

CONCLUSION

Our findings confirm the current guidelines that multicomponent interventions are effective in preventing delirium. Data are still lacking to reach evidence-based conclusions concerning potential benefits for hard outcomes such as length of hospital stay, return to independent living, and mortality. J Am Geriatr Soc 68:1864-1871, 2020.

Occupational Therapy in the ICU: A Scoping Review of 221 Documents

OBJECTIVES

Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients.

DATA SOURCES

Eight electronic databases from inception to 05/2018.

STUDY SELECTION

We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions.

DATA EXTRACTION

Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus.

DATA SYNTHESIS

Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%).

CONCLUSIONS

The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.

Activity-based occupational therapy intervention for delirium superimposed on dementia in nursing home setting: a feasibility study

OBJECTIVE

Multi-component interventions can reduce delirium incidence. Occupational therapy (OT) has been effective in the management of dementia. We designed a real-world feasibility study of an OT intervention in the management of delirium superimposed on dementia (DSD).

METHODS

We included a convenient sample of 22 patients older than 65 years of age with delirium and moderate dementia admitted to a nursing home (NH). The OT procedures were standardized according to the level of agitation or sedation of the patient and based on a structured OT evaluation. The Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution.

RESULTS

The mean age was 86.45 ± 6.46 years. The first daily treatment was delivered in the entire sample, while the second was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6. The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min. The mean time of the first treatment varied day 1 through day 6 from 14.8 ± 8.5 to 20 ± 0 min, while the second treatment from 3.9 ± 6.7 to 20.1 ± 0 min. The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution.

CONCLUSIONS

This is the first study to report the feasibility of an OT intervention for the management of DSD in a NH setting. The results are important to support future trials on delirium management in a setting often understudied and underrepresented.

"Please mind the gap": A secondary analysis of discomfort and comfort in intensive care

AIMS AND OBJECTIVES

To explore in depth discomfort in intensive care as experienced by patients and attended to by critical care nurses.

BACKGROUND

Discomfort in illness is complex and persistent, and its alleviation is a challenge for nurses working in intensive care units (ICU). In previous studies, we showed that ICU patients described little actual pain but suffer from much discomfort. Critical care nurses had a systematic approach to the treatment of pain, but were more haphazard in dealing with other types of discomfort.

DESIGN

Secondary qualitative analysis of data from two previous exploratory studies.

METHODS

Content analysis was used on existing data from 28 interviews with ICU patients, and 16 field notes and interviews with critical care nurses. Kolcaba's Comfort Theory was applied for further analysis. The COREQ checklist was used.

RESULTS

Three themes, "Being deprived of a functioning body", "Being deprived of a functioning mind" and "Being deprived of integrity" characterised the discomfort experienced by ICU patients. The nurses appeared to attend to all areas of discomfort expressed by patients. In need of, and providing acknowledgment and alleviation became a common overarching theme. We identified a comfort gap caused by the discrepancy between the patients' needs and the nurses' achievements in fulfilling these needs.

CONCLUSIONS

A gap exists between ICU patients' comfort needs and nurses' achievements in fulfilling these, indicating that discomfort currently is an inevitable part of the critical illness trajectory. Increased knowledge about how the brain is affected in ICU patients and more systematic approaches to assessing comfort needs and enhancing comfort may support nurses in fulfilling patient needs and possibly diminish the existing comfort gap.

RELEVANCE FOR CLINICAL PRACTICE

An increased understanding of the complex experience of discomfort in ICU patients may bring about more systematic approaches to enhance comfort and direct for education and further research.