Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards

Sustained delirium reduction in an inpatient neuroscience unit

BACKGROUND

Delirium is described as acute brain dysfunction that often fluctuates throughout the day and is highly prevalent in hospitalized adults. Delirium negatively affects patient outcomes with consequences including decreased cognitive functioning and increased mortality and healthcare costs. Furthermore, neurological patients are at increased risk for developing delirium due to their underlying diagnoses.

PURPOSE

The purpose of this evidence-based practice project was to evaluate the long-term impact of nursing education and use of trained volunteers to prevent the development of delirium in an inpatient neuroscience unit.

IMPLEMENTATION PLAN

This was a pre-post designed evidence-based practice project to educate and prioritize nursing care interventions for delirium prevention compared to a delirium management framework. The interventions included delirium education for nurses and nursing assistants along with the development of a specialized volunteer program to implement non-pharmacological, multi-component delirium prevention interventions. Long-term sustainment and enculturation occurred over the subsequent year.

OUTCOMES

The baseline data collection period included 2520 patients. The intervention period included 4515 patients, with both groups being similar in age, race, gender, and length of stay. The total number of patients with a discharge diagnosis of delirium decreased from 29.2% to 19.8% (p < .001). Fewer patients in the intervention group were discharged to a skilled nursing facility (p < .001) and other post-acute facility (p = .008), along with more patients being discharged to home care (p < .001).

LINKING EVIDENCE TO ACTION

This evidence-based practice project demonstrates long-term sustained reduction of delirium in the neuroscience population. Despite the challenges during the COVID-19 pandemic, delirium prevention strategies were found to be effective in decreasing the rate at which patients develop delirium.

The effects of environmental interventions for delirium in critically ill surgical patients

BACKGROUND

Delirium occurs at high rates among patients in intensive care units and increases the risk of morbidity and mortality. The purpose of this study was to investigate the effects of environmental interventions on delirium.

METHODS

This prospective cohort study enrolled 192 patients admitted to the surgical intensive care unit (SICU) during the pre-intervention (June 2013 to October 2013) and post-intervention (June 2014 to October 2014) periods. Environmental interventions involved a cognitive assessment, an orientation, and a comfortable environment including proper sleep conditions. The primary outcomes were the prevalence, duration, and onset of delirium.

RESULTS

There were no statistically significant differences in incidence rate, time of delirium onset, general characteristics, and mortality between the pre-intervention and post-intervention groups. The durations of delirium were 14.4±19.1 and 7.7±7.3 days in the pre-intervention and post-intervention groups, respectively, a significant reduction (P=0.027). The lengths of SICU stay were 20.0±22.9 and 12.6±8.7 days for the pre-intervention and post-intervention groups, respectively, also a significant reduction (P=0.030).

CONCLUSIONS

The implementation of an environmental intervention program reduced the duration of delirium and length of stay in the SICU for critically ill surgical patients.

Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment

Introduction

Postoperative delirium (POD) is a serious complication occurring in 4–53.3% of geriatric patients undergoing surgeries for hip fracture. Incidence of hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in 2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected to increase, POD is also anticipated to increase.

Signficance

Postoperative delirium remains the most common complication of emergency hip fracture surgery leading to high morbidity and mortality rates despite significant research conducted regarding this topic. This study reviews literature from 1990 to 2021 regarding POD in geriatric hip fracture management.

Results

Potentially modifiable and non-modifiable risk factors for developing POD include, but are not limited to, male gender, older age, multiple comorbidities, specific comorbidities (dementia, cognitive impairment, diabetes, vision impairment, and abnormal blood pressure), low BMI, preoperative malnutrition, low albumin, low hematocrit, blunted preoperative cytokines, emergency surgery, time to admission and surgery, preoperative medical treatment, polypharmacy, delirium-inducing medications, fever, anesthesia time, and sedation depth and type. Although the pathophysiology remains unclear, the leading theories suggest neurotransmitter imbalance, inflammation, and electrolyte or metabolic derangements as the underlying cause of POD. POD is associated with increased length of hospital stay, cost, morbidity, and mortality. Prevention and early recognition are key factors in managing POD. Methods to reduce POD include utilizing interdisciplinary teams, educational programs for healthcare professionals, reducing narcotic use, avoiding delirium-inducing medications, and multimodal pain control.

Conclusion

While POD is a known complication after hip fracture surgery, further exploration in prevention is needed. Early identification of risk factors is imperative to prevent POD in geriatric patients. Early prevention will enhance delivery of health care both pre- and post-operatively leading to the best possible surgical outcome and better quality of life after hip fracture treatment.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

The Modified Hospital Elder Life Program (HELP) in geriatric hospitalized patients in internal wards: A double-blind randomized control trial

Background

Hospital Elder Life Program (HELP) provides protocols based on factors for reducing delirium. Due to the lack of geriatric wards and aged care teams in Iran, it seems that some of the original HELP interventions need to be modified through a trial study. Hence, this study was conducted to determine whether the Iranian modified HELP could reduce delirium in geriatric hospitalized patients.

Methods

This double-blind randomized controlled trial was designed and conducted in a hospital at Kashan University of Medical Sciences in Iran. A total of 195 hospitalized patients aged ≥70 years, were 84 in the Intervention Group (IG) and 111 in the Control Group (CG). After assessing delirium risk factors, participants in the IG group received interventions based on the cognitive, vision/hearing, sleep, mobility, feeding, and hydration protocols by nursing students and the CG group received routine care.

Delirium incidence was assessed by the Confusion Assessment Method. Delirium incidence, cognitive and functional abilities, frailty, fall, and length of stay were outcomes.

Results

The mean age of the patients was 78.53(Standard Deviation = 5.87) years. Delirium incidence was higher in the CG comparing to IG (14.71% vs 3.66%).Significant reduction observed in risk incidence of delirium because of interventions [Odds Ratio:0.124, Confidence Interval: 0.03–0.48].

Conclusion

The modified HELP effectively reduced delirium rates in geriatric hospitalized patients.

Trial registration

This study was registered at the Iranian Registry of Clinical Trials IRCT20180910040995N1.

How We Prevent and Treat Delirium in the ICU

Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.

Preventing Delirium and Promoting Long-Term Brain Health: A Clinical Trial Design for the Perioperative Cognitive Enhancement (PROTECT) Trial

BACKGROUND

Perioperative neurocognitive disorders (PND), including postoperative delirium (POD), are common in older adults and, for many, precipitate functional decline and/or dementia.

OBJECTIVE

In this protocol, we describe a novel multidisciplinary, multicomponent perioperative intervention that seeks to prevent or reduce POD and associated cognitive decline.

METHODS

We will conduct a prospective, single-blind, pragmatic, randomized-controlled trial to compare our tailored multi-disciplinary perioperative pathway against current standard of care practices. We will recruit a total of 692 elective surgical patients aged 65 years or more and randomize them in a 1:1 design. Our perioperative intervention targets delirium risk reduction strategies by emphasizing the importance of early mobilization, nutrition, hydration, cognitive orientation, sensory aids, and avoiding polypharmacy. To promote healthy behavior change, we will provide a tailored psychoeducation program both pre- and postoperatively, focusing on cardiovascular and psychosocial risks for cognitive and functional decline.

RESULTS

Our primary outcome is the incidence of any PND (encapsulating POD and mild or major postoperative neurocognitive disorder) at three months postoperative. Secondary outcomes include any incidence of POD or neurocognitive disorder at 12 months. A specialized delirium screening instrument, the Confusion Assessment Method (3D-CAM), and a neuropsychological test battery, will inform our primary and secondary outcomes.

CONCLUSION

Delirium is a common and debilitating postoperative complication that contributes to the cognitive and functional decline of older adults. By adopting a multicomponent, multidisciplinary approach to perioperative delirium prevention, we seek to reduce the burden of delirium and subsequent dementia in older adults.

Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis

BACKGROUND

Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised.

OBJECTIVES

This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients.

METHODS

MEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO.

RESULTS

A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87).

CONCLUSIONS

Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.

Effectiveness of a Delirium Prevention Initiative on an Inpatient Neuroscience Unit

ABSTRACT

BACKGROUND: Delirium frequently develops in hospitalized patients and results in increased mortality, longer length of stay, and need for transitional care. Neurological patients are at an increased risk for developing delirium. There is a paucity of research on effective prevention strategies for this population. PURPOSE: The objectives of this project were to improve nurses' knowledge and confidence in delirium prevention, design a delirium volunteer program, and establish ongoing monitoring for continued improvement. METHODS: This study is a quality improvement project using a pretest-posttest design to examine the benefits of refocusing care from delirium management to delirium prevention. The sample included 304 patients pre and 332 post intervention. The interventions included delirium education for nurses and the recruitment of trained volunteers to implement nonpharmacological, multicomponent delirium prevention interventions. RESULTS: Forty-eight nurses completed delirium education, and 11 volunteers were recruited and trained. There was a significant increase in nursing knowledge (z = 3.967, P < .0005) and confidence (z = 3.989, P < .0005). Volunteers visited 54 patients and implemented 99 interventions post implementation. CONCLUSION: This pre-post improvement project provides beginning evidence that nursing education increased nurses' knowledge and confidence in preventing and treating delirium. Trained volunteers supported using nonpharmacological delirium prevention interventions, but ongoing evaluation is needed to determine the impact of volunteers on delirium rates.

The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT

Background

Delirium is a distressing, common and serious condition in older people in hospital. Evidence suggests that it could be prevented in about one-third of patients using multicomponent interventions targeting delirium risk factors, but these interventions are not yet routinely available in the NHS.

Objective

The objective was to improve delirium prevention for older people admitted to the NHS.

Design

Project 1 comprised case studies employing qualitative methods (observation, interviews, workshops) in three NHS hospitals to develop the Prevention of Delirium system of care. Project 2 comprised case studies using mixed methods in five NHS hospitals to test the Prevention of Delirium implementation, feasibility and acceptability, and to modify the Prevention of Delirium system of care. Project 3 comprised a multicentre, cluster randomised, controlled, pragmatic feasibility study in eight hospitals, with embedded economic evaluation, to investigate the potential clinical effectiveness and cost-effectiveness of the Prevention of Delirium system of care, compared with standard care, among older patients admitted to hospital for emergency care. The primary objectives related to gathering information to design a definitive trial. Criteria for progression to a definitive trial were as follows: a minimum of six wards (75%) completing the Prevention of Delirium manual milestone checklist and an overall recruitment rate of at least 10% of the potential recruitment pool.

Setting

This study was set in NHS general hospitals.

Participants

In project 1, participants were staff, volunteers, and patient and carer representatives. In project 2, participants were staff, volunteers, patients and carers. In project 3, participants were older patients admitted to elderly care and orthopaedic trauma wards.

Intervention

The developed intervention (i.e. the Prevention of Delirium system of care).

Main outcome measures

For the feasibility study (project 3), the primary outcome measure was the Confusion Assessment Method. The secondary outcome measures were the Nottingham Extended Activities of Daily Living scale, the Clinical Anxiety Scale and the Geriatric Depression Scale Short Form.

Results

Project 1: understanding of delirium prevention was poor. Drawing on evidence, and working with ward teams, we developed the Prevention of Delirium system of care, which targeted 10 delirium risk factors. This multicomponent intervention incorporated systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Project 2: five out of six wards implemented or partially implemented the Prevention of Delirium intervention. A prominent role for hospital volunteers was intended, but most wards were unable to recruit or sustain the numbers needed. We identified four conditions necessary to implement and deliver the Prevention of Delirium intervention: (1) commitment of senior nurse, (2) a named person to drive implementation forward, (3) dedicated time (1 day per week) of an experienced nurse to lead implementation and (4) adequate ward staffing levels. Overall, the intervention was acceptable to staff, volunteers, patients and carers, and did not increase nursing staff workload. In the light of these findings, the Prevention of Delirium system of care was modified for use in project 3. Project 3: 16 wards in eight hospitals (two wards per hospital) were recruited. Out of 4449 patients screened, 3274 (73.6%) were eligible and 713 were registered, resulting in a recruitment rate of 16.0%. Thirty-three (4.6%) participants withdrew. The screened and registered participants were similar, but some between-treatment group imbalances were noted among those registered to the trial. All eight wards allocated to the intervention group completed the Prevention of Delirium manual milestone checklist and delivered the Prevention of Delirium intervention (median time 18.6 weeks for implementation). Overall, fidelity to the intervention was assessed as being high in two wards, medium in five wards and low in one ward. Of the expected 5645 Confusion Assessment Method delirium assessments, 5065 (89.7%) were completed during the first 10 days of admission. The rates of return of the patient-reported questionnaire booklets were 98.0% at baseline, 81.8% at 30 days and 70.5% at 3 months. The return rate of the EuroQol-5 Dimensions questionnaire was 98.6% at baseline, 77.5% at 1 month and 65.3% at 3 months (94–98% fully completed). The completion rate of the resource use questionnaire was lower (48.7%). The number of people with new-onset delirium at 10 days was 24 (7.0%) in the Prevention of Delirium group and 33 (8.9%) in the control group. Multilevel logistic regression analysis showed that participants in the Prevention of Delirium group had non-significant lower odds of developing delirium (odds ratio 0.68, 95% confidence interval 0.37 to 1.26; p = 0.2225). The average cost of the Prevention of Delirium intervention was estimated as £10.98 per patient and the mean costs for the Prevention of Delirium and usual-care groups were £5332 and £4412, respectively, with negligible between-group differences in quality-adjusted life-years. There was conflicting evidence from the trial- and model-based analyses relating to the cost-effectiveness of the Prevention of Delirium intervention. Given this, and in view of issues with the data (e.g. high levels of missingness), the results from the economic evaluation are highly uncertain. The criteria for continuation to a future definitive randomised controlled trial were met. Such a trial would need to recruit 5200 patients in 26 hospital clusters (200 patients per cluster).

Conclusions

The Prevention of Delirium system of care was successfully developed, and a multicentre feasibility study showed that the intervention is capable of implementation and delivery in routine care, with acceptable intervention fidelity and preliminary estimate of effectiveness.

Limitations

A prominent role for volunteers was originally intended in the Prevention of Delirium system of care, but only three of the eight wards allocated to the trial intervention group involved volunteers.

Future work

The findings indicate that a definitive multicentre evaluation of the Prevention of Delirium system of care should be designed and conducted to obtain robust estimates of clinical effectiveness and cost-effectiveness.

Trial registration

Current Controlled Trials ISRCTN28213290 (project 1), ISRCTN65924234 (project 2) and ISRCTN01187372 (project 3).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Investigating how electroencephalogram measures associate with delirium: A systematic review

Delirium is a common neurocognitive disorder in hospital settings, characterised by fluctuating impairments in attention and arousal following an acute precipitant. Electroencephalography (EEG) is a useful method to understand delirium pathophysiology. We performed a systematic review to investigate associations between delirium and EEG measures recorded prior, during, and after delirium. A total of 1,655 articles were identified using PsycINFO, Embase and MEDLINE, 31 of which satisfied inclusion criteria. Methodological quality assessment was undertaken, resulting in a mean quality score of 4 out of a maximum of 5. Qualitative synthesis revealed EEG slowing and reduced functional connectivity discriminated between those with and without delirium (i.e. EEG during delirium); the opposite pattern was apparent in children, with cortical hyperexcitability. EEG appears to have utility in differentiating those with and without delirium, but delirium vulnerability and the long-term effects on brain function require further investigation. Findings provide empirical support for the theory that delirium is a disorder of reduced functional brain integration.

A Predictive Model of Intrinsic Factors Associated with Long-Stay Nursing Home Care After Hospitalization

We aimed to build a predictive model with intrinsic factors measured upon admission to skilled nursing facilities (SNFs) post-acute care (PAC) to identify older adults transferred from SNFs to long-term care (LTC) instead of home. We analyzed data from Massachusetts in 23,662 persons admitted to SNFs from PAC in 2013. Explanatory logistic regression analysis identified single "intrinsic predictors" related to LTC placement. To assess overfitting, the logistic regression predictive model was cross-validated and evaluated by its receiver operating characteristic (ROC) curve. A 12-variable predictive model with "intrinsic predictors" demonstrated both high in-sample and out-of-sample predictive accuracy in the receiver operating characteristic ROC and area under the ROC among patients at risk of LTC placement. This predictive model may be used for early identification of patients at risk for LTC after hospitalization in order to support targeted rehabilitative approaches and resource planning.

A multicentre, pragmatic, cluster randomised, controlled feasibility trial of the POD system of care

OBJECTIVE

to provide a preliminary estimate of the effectiveness of the prevention of delirium (POD) system of care in reducing incident delirium in acute hospital wards and gather data for a future definitive randomised controlled trial.

DESIGN

cluster randomised and controlled feasibility trial.

SETTING

sixteen acute care of older people and orthopaedic trauma wards in eight hospitals in England and Wales.

PARTICIPANTS

patients 65 years and over admitted to participating wards during the trial period.

INTERVENTIONS

participating wards were randomly assigned to either the POD programme or usual care, determined by existing local policies and practices. The POD programme is a manualised multicomponent delirium prevention intervention that targets 10 risk factors for delirium. The intervention wards underwent a 6-month implementation period before trial recruitment commenced. Main outcome measure incidence of new-onset delirium measured using the Confusion Assessment Method (CAM) measured daily for up to 10 days post consent.

RESULTS

out of 4449, 3274 patients admitted to the wards were eligible. In total, 714 patients consented (713 registered) to the trial, thirty-three participants (4.6%) withdrew. Adherence to the intervention was classified as at least medium for seven wards. Rates of new-onset delirium were lower than expected and did not differ between groups (24 (7.0%) of participants in the intervention group versus 33 (8.9%) in the control group; odds ratio (95% confidence interval) 0.68 (0.37-1.26); P = 0.2225).

CONCLUSIONS

based on these findings, a definitive trial is achievable and would need to recruit 5220 patients in 26 two-ward hospital clusters. Trial registration: ISRCTN01187372. Registered 13 March 2014.

Investigation of ward fidelity to a multicomponent delirium prevention intervention during a multicentre, pragmatic, cluster randomised, controlled feasibility trial

BACKGROUND

delirium is a frequent complication of hospital admission for older people and can be reduced by multicomponent interventions, but implementation and delivery of such interventions is challenging.

OBJECTIVE

to investigate fidelity to the prevention of delirium system of care within a multicentre, pragmatic, cluster randomised, controlled feasibility trial.

SETTING

five care of older people and three orthopaedic trauma wards in eight hospitals in England and Wales.

DATA COLLECTION

research nurse observations of ward practice; case note reviews and examination of documentation.

ASSESSMENT

10 health care professionals with experience in older people's care assessed the fidelity to 21 essential implementation components within four domains: intervention installation (five items; maximum score = 5); intervention delivery (12 items; maximum score = 48); intervention coverage (three items; maximum score = 16); and duration of delivery (one item; maximum score = 1).

RESULTS

the mean score (range) for each domain was: installation 4.5 (3.5-5); delivery 32.6 (range 27.3-38.3); coverage 7.9 (range 4.2-10.1); and duration 0.38 (0-1). Of the 10 delirium risk factors, infection, nutrition, hypoxia and pain were the most and cognitive impairment, sensory impairment and multiple medications the least consistently addressed. Overall fidelity to the intervention was assessed as high (≥80%) in two wards, medium (51-79%) in five wards and low (≤50%) in one ward.

CONCLUSION

the trial was designed as a pragmatic evaluation, and the findings of medium intervention fidelity are likely to be generalisable to delirium prevention in routine care and provide an important context to interpret the trial outcomes.

Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials

Background

The choice of anesthesia technique remains debatable in patients undergoing surgical repair of hip fracture. This meta-analysis was performed to compare the effect of neuraxial (epidural/spinal) versus general anesthesia on perioperative outcomes in patients undergoing hip fracture surgery.

Methods

Medline, Cochrane Library, Science-Direct, and EMBASE databases were searched to identify eligible studies focused on the comparison between neuraxial and general anesthesia in hip fracture patients between January 2000 and May 2019. Perioperative outcomes were extracted for systemic analysis. Sensitivity analyses were conducted using a Bonferroni correction and the leave-one-out method. The evidence quality for each outcome was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Nine randomized controlled trials (RCTs) including 1084 patients fulfilled our selection criteria. The outcomes for the meta-analysis showed that there were no significant differences in the 30-day mortality (OR = 1.34, 95% CI 0.56, 3.21; P = 0.51), length of stay (MD = − 0.65, 95% CI -0.32, 0.02; P = 0.06), and the prevalence of delirium (OR = 1.05, 95% CI 0.27, 4.00; P = 0.95), acute myocardial infarction (OR = 0.88, 95% CI 0.17, 4.65; P = 0.88), deep venous thrombosis (OR = 0.48, 95% CI 0.09, 2.72; P = 0.41), and pneumonia (OR = 1.04, 95% CI 0.23, 4.61; P = 0.96) for neuraxial anesthesia compared to general anesthesia, and there was a significant difference in blood loss between the two groups (MD = − 137.8, 95% CI -241.49, − 34.12; p = 0.009). However, after applying the Bonferroni correction for multiple testing, all the adjusted p-values were above the significant threshold of 0.05. The evidence quality for each outcome evaluated by the GRADE system was low.

Conclusions

In summary, our present study demonstrated that there might be a difference in blood loss between patients receiving neuraxial and general anaesthesia, however, this analysis was not robust to adjustment for multiple testing and therefore at high risk for a type I error. Due to small sample size and enormous inconsistency in the choice of outcome measures, more high-quality studies with large sample size are needed to clarify this issue.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

Effectiveness of non-pharmacological strategies for managing delirium in hospitalized postoperative adults: an umbrella review protocol

REVIEW QUESTION/OBJECTIVE

The question of this review: What is the effectiveness of non-pharmacological strategies for the management of delirium in hospitalized adult postoperative patients?The objective of this umbrella review is to determine the effectiveness of non-pharmacological strategies for the management of delirium in adult postoperative patients, 18 years and over, in an acute care hospitalized setting.More specifically, the review aims to identify which non-pharmacological strategy/strategies, provided as a single strategy or combined as two or more strategies, is the most effective for management of delirium in hospitalized postoperative adult patients?

Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

BACKGROUND

Older people represent a risk group for acquiring or further development of delirium during hospitalization, therefore requiring suitable nonpharmacological delirium interventions.

OBJECTIVE

This scoping review analyzed nonpharmacological intervention programs for older inpatients with or without cognitive decline on regular or acute geriatric wards to present the range of interventions.

METHODS

A systematic literature search was conducted using scientific databases. A total of 4652 records were screened by two independent reviewers, leaving 81 eligible articles for full-text screening and 25 studies were finally included. Inclusion criteria were older patients ≥65 years in regular or acute geriatric wards and nonpharmacological multicomponent interventions.

RESULTS

More than a half of the included studies (14, 56%) recruited patients with pre-existing cognitive decline as part of the study population and 12% focused exclusively on patients with cognitive decline. On average 11 intervention components were integrated in the programs and two programs included full coverage of all 18 identified components.

CONCLUSION

Only few programs were described for older inpatients and even fewer regarding pre-existing cognitive decline. The low numbers of interventions and data heterogeneity restricted the assessment of outcomes; however, delirium incidence, as reported by two thirds of the studies was reduced by nonpharmacological multicomponent interventions.

Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review

BACKGROUND

Delirium is common, distressing, serious and under-researched in specialist palliative care settings.

OBJECTIVES

To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were.

DESIGN

Systematic review (PROSPERO 2017 CRD42017062178).

DATA SOURCES

Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment.

RESULTS

The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall.

CONCLUSION

Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.

Preventing Delirium Takes a Village: Systematic Review and Meta-analysis of Delirium Preventive Models of Care

BACKGROUND

Each hospital day of delirium incurs greater healthcare costs, higher levels of care, greater staff burden, and higher complication rates. Accordingly, administrators are incentivized to identify models of care that reduce delirium rates and associated costs.

PURPOSE

We present a systematic review and meta-analysis of delirium prevention models of care.

DATA SOURCES

Ovid MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, and PsycINFO.

STUDY SELECTION

Eligible models of care were defined as provider-oriented interventions involving revision of professional roles, multidisciplinary teams, and service integration. Included studies implemented multidomain, multicomponent interventions, used a validated delirium instrument, and enrolled a control group to evaluate efficacy or effectiveness.

DATA EXTRACTION

We extracted data on study design; Population, model of care, outcomes, and results.

DATA SYNTHESIS

A total of 15 studies were included. All but two studies reported reduction in delirium or its duration, and 11 studies reported statistically significant improvements. Using random effects models, the pooled odds ratios of delirium incidence were 0.56 (95% CI: 0.37-0.85) from three randomized controlled trials, 0.63 (95% CI 0.37-1.07) from four pre-post intervention studies, and 0.79 (95% CI: 0.46-1.37) from three additional nonrandomized studies.

CONCLUSIONS

Several models of care can prevent delirium. In general, higher quality studies were more likely to demonstrate statistical significance of an effect. The diverse models of care included here explored interventions adapted to specific care settings, especially by addressing setting-specific delirium risk factors. These care models illustrate a range of promising strategies that deserve growing recognition, refinement, and implementation.

Differentiating between dementia, delirium and depression in older people

Older people can find hospital stays challenging and distressing. When their presenting symptoms make it challenging for healthcare professionals to differentiate between dementia, delirium and depression, their experience may be increasingly distressing, and can result in delays in diagnosis and treatment, as well as an increased risk of morbidity. This article considers each of the conditions of dementia, delirium and depression, their presenting features and how nurses can differentiate between them to enable comprehensive assessment, diagnosis and treatment in older people.

State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018

Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Where next for delirium research?

Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.

Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness

BACKGROUND

Delirium, defined as an acute disorder of attention and cognition with high morbidity and mortality, can be prevented by multicomponent nonpharmacological interventions. The Hospital Elder Life Program (HELP) is the original evidence-based approach targeted to delirium risk factors, which has been widely disseminated.

OBJECTIVE

To summarize the current state of the evidence regarding HELP and to highlight its effectiveness and cost savings.

METHODS

Systematic review of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1999 to 2017, using a combination of controlled vocabulary and keyword terms.

RESULTS

Of the 44 final articles included, 14 were included in the meta-analysis for effectiveness and 30 were included for examining cost savings, adherence and adaptations, role of volunteers, successes and barriers, and issues in sustainability. The results for delirium incidence, falls, length of stay, and institutionalization were pooled for meta-analyses. Overall, 14 studies demonstrated significant reductions in delirium incidence (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.37-0.59). The rate of falls was reduced by 42% among intervention patients in three comparative studies (OR 0.58, 95% CI 0.35-0.95). In nine studies on cost savings, the program saved $1600-$3800 (2018 U.S. dollars) per patient in hospital costs and over $16,000 (2018 U.S. dollars) per person-year in long-term care costs in the year following delirium. The systematic review revealed that programs were generally successful in adhering to or appropriately adapting HELP (n = 13 studies) and in finding the volunteer role to be valuable (n = 6 studies). Successes and barriers to implementation were examined in 6 studies, including ensuring effective clinician leadership, finding senior administrative champions, and shifting organizational culture. Sustainability factors were examined in 10 studies, including adapting to local circumstances, documenting positive impact and outcomes, and securing long-term funding.

CONCLUSION

The Hospital Elder Life Program is effective in reducing incidence of delirium and rate of falls, with a trend toward decreasing length of stay and preventing institutionalization. With ongoing efforts in continuous program improvement, implementation, adaptations, and sustainability, HELP has emerged as a reference standard model for improving the quality and effectiveness of hospital care for older persons worldwide.

The Effects of Delirium Prevention Guidelines on Elderly Stroke Patients

This study aimed to evaluate the effectiveness of the delirium prevention interventions recommended by the Delirium Prevention Guidelines for Elderly Stroke Patients (DPGESP). The DPGESP comprises nine dimensions with 28 interventions, including risk factor assessment, orientation disorder prevention, sleeping pattern maintenance, sensory interventions, constipation, dehydration, hypoxia and infection prevention, pain management, and appropriate nutrition maintenance. This quasi-experimental study used a nonequivalent control group and a pretest–posttest design. The experimental and control groups each included 54 patients, and the participants were elderly patients who were admitted to the stroke unit. The study outcomes were the delirium incidence and severity, stroke impact, and length of hospitalization. Posttest values for delirium incidence, severity, stroke impact, and length of hospitalization were significantly improved in the experimental group. Implementation of the DPGESP had beneficial effects on the delirium incidence and severity, stroke impact, and length of hospitalization among elderly patients admitted to a stroke unit.

Preventing postoperative delirium

BACKGROUND

Delirium is a common complication in elderly hospitalized patients. It prolongs the length of hospital stay, raises costs, increases the workload of the nursing staff, and may necessitate transfer of the patient to a nursing home. The risk of postoperative delirium is particularly high in elderly patients with pre-existing cognitive deficits.

METHODS

In an open study, we systematically assessed the frequency of postoperative delirium in patients over age 70 on two surgical wards of a general hospital. In a six-month "prevalence phase," from March to August 2011, we counted the number of patients with postoperative delirium, but did not initiate any intervention. Thereafter, in a ten-month "intervention phase" from September 2011 to June 2012, a nurse with special training in the management of delirium carried out an intervention involving component measures of the Hospital Elder Life Program (HELP) on one of the two wards, with the aim of preventing postoperative delirium. The patients on the other ward served as a control group.

RESULTS

In the prevalence phase, 20.2% of all patients developed postoperative delirium (95% confidence interval [CI], 14.6-26.4). In the intervention phase, postoperative delirium arose in 20.8% (95% CI, 11.3-32.1) of the patients on the ward with no specific interventions, but in only 4.9% (95% CI, 0.0-11.5) of those on the ward where the intervention was carried out. The difference was presumably due to the measures initiated by the specially trained nurse, including validation, improvement of sleep, cognitive activation, early mobilization, improved sensory stimulation, and improved nutritional and fluid intake. Important predictors of postoperative delirium included a low score on the Mini-Mental State Examination, advanced age, and preoperative infection.

CONCLUSION

The frequency of postoperative delirium in elderly patients with cognitive deficits can be lowered with nursing measures carried out by a specially trained nurse, close postoperative supervision, and cognitive activation.

Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review

Advances have been made in our understanding of the neuropathogenesis, recognition, and strategies for reducing the incidence of delirium in acute-care settings. However, relatively little attention has been given to delirium in elderly patients in the postacute care (PAC) and long-term care (LTC) settings. The present article reviews the most relevant current research pertaining to this population. Hospital patients with delirium are often discharged to PAC settings. Delirium that develops in the LTC setting is often more insidious and subtle in presentation. Despite incorporating systematic screening tools for delirium in PAC and LTC settings, delirium prevention strategies have not yet been shown to be beneficial beyond the acute-care setting. The management of delirium combined with dementia and guidance on when it is appropriate to use antipsychotic medications is also discussed.

Triggers and nursing influences on delirium in intensive care units

Among care providers, nurses have the most influence on the occurrence of delirium in patients. To identify and investigate the risk factors associated with delirium and analyse the nurse's influence on delirium, a secondary data analysis approach was used with clinical data from the electronic medical record and health care provider data from the management information systems of a university hospital. Data of 3284 patients (delirium = 688, non-delirium = 2596) hospitalized in the medical and surgical intensive care units containing 2178 variables were analysed. Donabedian's structure-process-outcome model was applied to categorize the factors for multilevel hierarchical logistic regression analysis. Sixteen factors (10 patient factors, 1 provider factor, 1 environmental factor, 2 nursing intervention factors and 2 medical intervention factors) were identified as significant in the final model. Longer intensive care unit experience of nurses did not decrease the risk of delirium. Greater number of nursing intervention needs and greater use of restraints were associated with an increased risk of delirium. The duration of nursing career did not affect the reduction of the risk of delirium. Nurses should therefore endeavour to acquire nursing experience specific for delirium care and attend training courses for delirium management.

Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

Delirium in the geriatric unit: proton-pump inhibitors and other risk factors

Background

Delirium remains a major nosocomial complication of hospitalized elderly. Predictive models for delirium may be useful for identification of high-risk patients for implementation of preventive strategies.

Objective

Evaluate specific factors for development of delirium in a geriatric ward setting.

Methods

Prospective cross-sectional study comprised 675 consecutive patients aged 79.2±7.7 years (66% women and 34% men), admitted to the subacute geriatric ward of a multiprofile university hospital after exclusion of 113 patients treated with antipsychotic medication because of behavioral disorders before admission. Comprehensive geriatric assessments including a structured interview, physical examination, geriatric functional assessment, blood sampling, ECG, abdominal ultrasound, chest X-ray, Confusion Assessment Method for diagnosis of delirium, Delirium-O-Meter to assess delirium severity, Richmond Agitation-Sedation Scale to assess sedation or agitation, visual analog scale and Doloplus-2 scale to assess pain level were performed.

Results

Multivariate logistic regression analysis revealed five independent factors associated with development of delirium in geriatric inpatients: transfer between hospital wards (odds ratio [OR] =2.78; confidence interval [CI] =1.54–5.01; P=0.001), preexisting dementia (OR =2.29; CI =1.44–3.65; P<0.001), previous delirium incidents (OR =2.23; CI =1.47–3.38; P<0.001), previous fall incidents (OR =1.76; CI =1.17–2.64; P=0.006), and use of proton-pump inhibitors (OR =1.67; CI =1.11–2.53; P=0.014).

Conclusion

Transfer between hospital wards, preexisting dementia, previous delirium incidents, previous fall incidents, and use of proton-pump inhibitors are predictive of development of delirium in the geriatric inpatient setting.

Pilot study of a preventive multicomponent nurse intervention to reduce the incidence and severity of delirium in hospitalized older adults: MID-Nurse-P

BACKGROUND

Although multicomponent interventions are the gold standard for delirium management, few nurse-led interventions in Acute Geriatric Units (AGU) are described.

OBJECTIVES

To analyze if a preventive multicomponent non-pharmacologic nurse-led intervention randomized clinical trial (MID-Nurse Study) is feasible (pilot study), and can reduce the incidence, duration, and severity of delirium in hospitalized older adults in an AGU.

DESIGN

Parallel-group double-blind randomized clinical trial (pilot Study).

SETTING

AGU Complejo Hospitalario Universitario, Albacete (Spain).

PARTICIPANTS

50 patients ≥65 years hospitalized in the AGU. Intervention group (IG) 21, control group (CG) 29.

INTERVENTION

After risk factor analysis, all participants in the IG received a daily multicomponent non-pharmacologic intervention (orientation, sensorial deficit, sleep, mobilization, hydration, nutrition, drug chart review, elimination, oxygenation, pain) by the intervention nurses. The CG received usual care.

MEASUREMENTS

Daily delirium presence with the Confusion Assessment Method (CAM), and severity with the Delirium Rating Scale-Revised-98 (DRS). Outcome measures were delirium incidence, prevalence, severity, and number of days with delirium, mortality, length of stay, use of physical restraint measures, and use of drugs for delirium control.

RESULTS

Mean age 86.5 (48% women). 21 participants presented delirium during hospitalization (14CG and 7 IG). Process, resources, management, and scientific objectives were considered positive, making the study feasible. Delirium prevalence (33.3% vs 48.3%) and incidence (14.3% vs 41.4%; p=0.039) were reduced in the IG compared to CG. Total delirium severity was lower in the IG compared to the CG (35.0 vs 65.0; p=0.040). Mortality was not different between groups (CG 17.2% vs IG 19.0%).

CONCLUSION

The MID-Nurse Study is feasible, and a multicomponent nurse-led intervention on patients with delirium in an AGU can reduce delirium prevalence, incidence, and severity. The clinical trial registration number ClinicalTrials.gov ID: NCT02558777.

Association between frailty and delirium in older adult patients discharged from hospital

Background

Delirium and frailty – both potentially reversible geriatric syndromes – are seldom studied together, although they often occur jointly in older patients discharged from hospitals. This study aimed to explore the relationship between delirium and frailty in older adults discharged from hospitals.

Methods

Of the 221 patients aged >65 years, who were invited to participate, only 114 gave their consent to participate in this study. Delirium was assessed using the confusion assessment method, in which patients were classified dichotomously as delirious or nondelirious according to its algorithm. Frailty was assessed using the Edmonton Frailty Scale, which classifies patients dichotomously as frail or nonfrail. In addition to the sociodemographic characteristics, covariates such as scores from the Mini-Mental State Examination, Instrumental Activities of Daily Living scale, and Cumulative Illness Rating Scale for Geriatrics and details regarding polymedication were collected. A multidimensional linear regression model was used for analysis.

Results

Almost 20% of participants had delirium (n=22), and 76.3% were classified as frail (n=87); 31.5% of the variance in the delirium score was explained by frailty (R²=0.315). Age; polymedication; scores of the Confusion Assessment Method (CAM), instrumental activities of daily living, and Cumulative Illness Rating Scale for Geriatrics; and frailty increased the predictability of the variance of delirium by 32% to 64% (R²=0.64).

Conclusion

Frailty is strongly related to delirium in older patients after discharge from the hospital.

Risk of Pre-and Post-Operative Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients

BACKGROUND AND PURPOSE

Delirium is common after hip fracture. Previous work has shown that a simple delirium risk factor tool, the Delirium Elderly At Risk instrument (DEAR), has a high inter-rater reliability in this population. Little research has looked at the ability of risk factor screening tools to identify patients at high risk of pre-operative delirium. This study investigates the ability of the DEAR to identify patients at high risk of pre-operative delirium, as well as reporting its performance in a post-operative validation sample. Associations between delirium risk factors and pre-operative delirium are explored.

METHODS

This prospective cohort study took place on an orthopedic in-patient service at a University-affiliated tertiary care hospital. Patients aged 65 and older who were admitted for surgical repair of hip fracture (N = 283) were assessed pre-operatively for 5 delirium risk factors (cognitive impairment, sensory impairment, functional dependence, substance use, age) using the DEAR. Patients were assessed for delirium using the Mini-Mental State Examination and the Confusion Assessment Method pre-operatively and on post-operative days 1, 3 and 5. Characteristics of patients who developed delirium were compared with the characteristics of those who did not.

RESULTS

Delirium was present in 58% (95% CI = 52-63%) of patients pre-operatively and 42% (95% CI = 36-48%) post-operatively. Individually, sensory impairment (χ(2) = 21.7, p = .0001), functional dependence (χ(2) = 24.1, p = .0001), cognitive impairment (χ(2) = 55.5, p = .0001) and substance use (χ(2) = 7.5, p = .007) were significantly associated with pre-operative delirium, as was wait-time for surgery (t = 3.1, p = .003) and length of stay (t = 2.8, p =.03). In multivariate modeling, the strongest association with pre-operative delirium was cognitive impairment.

CONCLUSIONS

The DEAR, a simple, delirium risk factor screening tool, can be used to identify hip fracture patients at risk of both pre-operative and post-operative delirium, which may allow targeted implementation of delirium prevention strategies.

Multicomponent delirium prevention: not as effective as NICE suggest?

Multicomponent delirium prevention strategies have been shown in intervention studies consistently to reduce the occurrence of delirium. Based on this convincing evidence base, the National Institute for Health and Care Excellence has advocated the widespread adoption of multicomponent delirium prevention interventions into the routine inpatient care of older people. However, despite successful reductions in incident delirium of about a third, anticipated reductions in mortality or admissions to long-term care--both clinically important endpoints statistically correlated with the occurrence of delirium--have not been conclusively observed. We hypothesise that the reasons for this disconnection are partly methodological, due to difficulties in delirium detection and blinding of study personnel to the intervention, but predominantly due to the underlying relationship between delirium and the abnormal health state of frailty; the interaction between these two geriatric syndromes is currently poorly understood.

Prevention of delirium (POD) for older people in hospital: study protocol for a randomised controlled feasibility trial

Background

Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme.

Methods/Design

The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; in-hospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience.

Discussion

This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial.

Trial registration

ISRCTN01187372. Registered 13 March 2014.

Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis

IMPORTANCE

Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these strategies for preventing subsequent adverse outcomes has been limited to small studies to date.

OBJECTIVE

To evaluate available evidence on multicomponent nonpharmacological delirium interventions in reducing incident delirium and preventing poor outcomes associated with delirium.

DATA SOURCES

PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews from January 1, 1999, to December 31, 2013.

STUDY SELECTION

Studies examining the following outcomes were included: delirium incidence, falls, length of stay, rate of discharge to a long-term care institution (institutionalization), and change in functional or cognitive status.

DATA EXTRACTION AND SYNTHESIS

Two experienced physician reviewers independently and blindly abstracted data on outcome measures using a standardized approach. The reviewers conducted quality ratings based on the Cochrane risk-of-bias criteria for each study.

MAIN OUTCOMES AND MEASURES

We identified 14 interventional studies. The results for outcomes of delirium incidence, falls, length of stay, and institutionalization were pooled for the meta-analysis, but heterogeneity limited our meta-analysis of the results for change in functional or cognitive status. Overall, 11 studies demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58). Four randomized or matched trials reduced delirium incidence by 44% (OR, 0.56; 95% CI, 0.42-0.76). The rate of falls decreased significantly among intervention patients in 4 studies (OR, 0.38; 95% CI, 0.25-0.60); in 2 randomized or matched trials, the rate of falls was reduced by 64% (OR, 0.36; 95% CI, 0.22-0.61). Length of stay and institutionalization also trended toward decreases in the intervention groups, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) day shorter and the odds of institutionalization 5% lower (OR, 0.95; 95% CI, 0.71-1.26). Among higher-quality randomized or matched trials, length of stay trended -0.33 (95% CI, -1.38 to 0.72) day shorter, and the odds of institutionalization trended 6% lower (OR, 0.94; 95% CI, 0.69-1.30).

CONCLUSIONS AND RELEVANCE

Multicomponent nonpharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization. Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.

A prospective observational study to investigate the association between abnormal hand movements and delirium in hospitalised older people

OBJECTIVE

to examine the relationship between carphology (aimlessly picking at bedclothes), floccillation (plucking at the air) and delirium in older patients admitted to specialist elderly care wards.

DESIGN

daily observation for behaviours of carphology and floccillation embedded within a 'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted to hospital as emergencies.

METHODS

patients recruited into a delirium prevention study were observed daily for delirium using the confusion assessment method (CAM). Occurrences of carphology and/or floccillation were also recorded. Sensitivity, specificity and positive and negative predictive values for carphology/floccillation for the diagnosis of delirium were calculated. Inpatient mortality rates were compared for patients who did, and did not exhibit features of carphology and/or floccillation.

RESULTS

four hundred and thirty-seven patients were recruited into the study. One hundred and ten participants experienced an episode of delirium, 21 exhibited behaviours of carphology and/or floccillation. The sensitivity and specificity of carphology and/or floccillation for the diagnosis of delirium were 14 and 98%, respectively; positive likelihood ratio 6.8. Carphology and floccillation were associated with both hyper- and hypo-active delirium subtypes, and occurred early during incident delirium (67% within 2 days of delirium onset). The inpatient mortality rate in patients with carphology/floccillation was double the rate in patients without the behaviours (23.8 versus 11.2%, Fisher's exact test P = 0.16).

CONCLUSIONS

carphology and floccillation are uncommon physical signs, but their presence is highly suggestive of delirium. The behaviours are unrelated to delirium subtype making their presence particularly useful in the diagnosis of hypo-active delirium.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

An analytical framework for delirium research in palliative care settings: integrated epidemiologic, clinician-researcher, and knowledge user perspectives

CONTEXT

Delirium often presents difficult management challenges in the context of goals of care in palliative care settings.

OBJECTIVES

The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions.

RESULTS

Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very" or "extremely" important confirmed their priority.

CONCLUSION

Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings.