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

Therapeutic use of music in neurological disorders: A concise narrative review

Background

Music elicits multifactorial benefits in emotional, social, cognitive, and academic aspects of human life. Music is clinically proven to reduce stress and anxiety, and improve mood and self-expression, particularly after traumatic events. Studies have also demonstrated that music promotes parasympathetic autonomic systems, suppresses hyperactivation of stress responses, and boosts immune functions. However, its ability to promote brain plasticity and signalling are only beginning to be realized. Moreover, its employment as a therapy for the treatment of specific aspects of other neurological disorders, including neurodevelopmental and neurodegenerative conditions and their comorbidities, is fast becoming an interesting field of research.

Objective

The aim of this review is to summarize some of the recent studies focused on evaluating the applications of music therapy. For this purpose, we have focused on disorders encompassing both temporal extremities of brain developmental stages, from developmental conditions of autism and attention deficit hyperactivity disorder (ADHD), to ageing-related pathologies of Parkinson's disease and dementias.

Results

The findings of the reviewed studies indicate potent utilities of music-based interventions in beneficially affecting multiple spheres of brain functions, such as sensorimotor, auditory, communication/language, psychological/emotional, behavioural, sleep and memory and cognitive attributes of patients diagnosed with diverse neuropathologies. Nevertheless, lack of standardized protocols for music provision as well as absence of information regarding key aspects, such as cultural and musical orientations of subjects and therapists'/caregivers' attitudes, have hindered the complete realization of music's therapeutic potential for neurological conditions. Further, while some studies have undertaken assessments of core neurophysiological mechanisms underlying music therapy, this information is largely lacking for most clinical studies.

Conclusion

While this is not an exhaustive review of literature, we do hope that it serves as a platform to promote future research for establishing music therapy as a relevant neurotherapeutic strategy.

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

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

Association between nonpharmacological strategies and delirium in intensive care unit

BACKGROUND

Several nonpharmacological strategies for the prevention and treatment of delirium have been increasingly used because the aetiology of delirium is multifactorial.

AIMS

To verify the association between nonpharmacological strategies (presence of companion, mobilization, absence of physical restraint and natural light) and the occurrence of delirium, and to identify risk factors for delirium in intensive care unit (ICU) patients.

STUDY DESIGN

The study was conducted in a Brazilian medical and surgical ICU. The sample included patients older than 18 years with length of ICU stay greater than 24 h and without delirium on admission. Delirium was identified by applying the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The association between the variables and delirium was analysed using Mann-Whitney and chi-square tests, and multivariate logistic regression to identify the predictive factors.

RESULTS

Of the 356 patients, 64 (18%) had delirium. The presence of a companion, mobilization, and physical restraint were associated with delirium, and the first two were identified as protective factors. That is, the odds of delirium decreased by 88% when a companion was present and by 95% when the patient was mobilized. The risk factors of delirium were length of ICU stay and age.

CONCLUSIONS

The presence of a companion and patient mobilization were identified as protective factors against delirium, highlighting their importance as preventive actions, especially in patients with a higher risk of developing this disorder. The findings regarding physical restraint can also be considered evidence indicating the need for careful use of this measure in clinical practice until evidence of its relationship with delirium is confirmed.

RELEVANCE TO CLINICAL PRACTICE

The implementation of strategies such as early mobilization, presence of a companion and careful assessment for the use of physical restraint by the multidisciplinary team can help control the occurrence of delirium in the ICU.

Circadian Synchrony: Sleep, Nutrition, and Physical Activity

The circadian clock in mammals regulates the sleep/wake cycle and many associated behavioral and physiological processes. The cellular clock mechanism involves a transcriptional negative feedback loop that gives rise to circadian rhythms in gene expression with an approximately 24-h periodicity. To maintain system robustness, clocks throughout the body must be synchronized and their functions coordinated. In mammals, the master clock is located in the suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN is entrained to the light/dark cycle through photic signal transduction and subsequent induction of core clock gene expression. The SCN in turn relays the time-of-day information to clocks in peripheral tissues. While the SCN is highly responsive to photic cues, peripheral clocks are more sensitive to non-photic resetting cues such as nutrients, body temperature, and neuroendocrine hormones. For example, feeding/fasting and physical activity can entrain peripheral clocks through signaling pathways and subsequent regulation of core clock genes and proteins. As such, timing of food intake and physical activity matters. In an ideal world, the sleep/wake and feeding/fasting cycles are synchronized to the light/dark cycle. However, asynchronous environmental cues, such as those experienced by shift workers and frequent travelers, often lead to misalignment between the master and peripheral clocks. Emerging evidence suggests that the resulting circadian disruption is associated with various diseases and chronic conditions that cause further circadian desynchrony and accelerate disease progression. In this review, we discuss how sleep, nutrition, and physical activity synchronize circadian clocks and how chronomedicine may offer novel strategies for disease intervention.

Study protocol for a prospective randomised double-blind placebo-controlled clinical trial investigating a Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium: the Basel BOMP-AID study

INTRODUCTION

Delirium is frequently observed in the intensive care unit (ICU) population, in particular. Until today, there is no evidence for any reliable pharmacological intervention to treat delirium. The Basel BOMP-AID (Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium) randomised trial targets improvement of hypoactive delirium therapy in critically ill patients and will be conducted as a counterpart to the Basel ProDex Study (Study Protocol, BMJ Open, July 2017) on hyperactive and mixed delirium. The aim of the BOMP-AID trial is to assess the superiority of melatonin to placebo for the treatment of hypoactive delirium in the ICU. The study hypothesis is based on the assumption that melatonin administered at night restores a normal circadian rhythm, and that restoration of a normal circadian rhythm will cure delirium.

METHODS AND ANALYSIS

The Basel BOMP-AID study is an investigator-initiated, single-centre, randomised controlled clinical trial for the treatment of hypoactive delirium with the once daily oral administration of melatonin 4 mg versus placebo in 190 critically ill patients. The primary outcome measure is delirium duration in 8-hour shifts. Secondary outcome measures include delirium-free days and death at 28 days after study inclusion, number of ventilator days, length of ICU and hospital stay, and sleep quality. Patients will be followed after 3 and 12 months for activities of daily living and mortality assessment. Sample size was calculated to demonstrate superiority of melatonin compared with placebo regarding the duration of delirium. Results will be presented using an intention-to-treat approach.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Northwestern and Central Switzerland and will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonisation (ICH) of technical requirements for registration of pharmaceuticals for human use; Good Clinical Practice (GCP) or ISO EN 14155 (as far as applicable), as well as all national legal and regulatory requirements. Study results will be presented in international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03438526.

PROTOCOL VERSION

Clinical Study Protocol Version 3, 10.03.2019.

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

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