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

Early identification and delirium recognition in acute care: A quality improvement initiative

Recognition of delirium continues to be a challenge in acute care despite the use of validated and reliable tools. This evidence-based quality improvement project aimed to increase delirium recognition by increasing daily screening using the Confusion Assessment Method (CAM) tool. Methods to increase usage and accuracy of the assessment included targeted education by specially trained geriatric nurse champions (GNCs). During rounds, GNCs performed bedside assessment, provided real-time feedback, and focused on non-pharmacological interventions on medical-surgical and telemetry units. All patients 65 years of age and older were included. Daily screening of CAM assessment increased by 7.6 % over three months, including an increase in CAM positive results from 7.1 % to 8.5 %-additional favorable outcomes observed with an increase in delirium diagnosis. This project increased knowledge retention and reinforcement of non-pharmacological interventions through peer coaching and focused rounds. Continued training efforts and education are needed to increase identification of patients experiencing delirium.

Delirium prevalence, interventions and barriers in intensive care units in German-speaking countries: A retrospective cross-sectional secondary analysis

BACKGROUND

The prevalence of delirium in intensive care units (ICUs) is high and has a major impact on patient outcomes.

AIM

To describe delirium assessment instruments, prevalence, interventions and barriers in delirium management in adult and paediatric ICUs; and to explore the association between delirium prevalence and reported interventions and barriers at unit level.

STUDY DESIGN

A secondary analysis of the cross-sectional World Delirium Awareness Day Delirium Survey on 15 March 2023. This was a prospective study to assess the one-day point delirium prevalence, practices and quality improvement efforts across healthcare systems. Data was analysed descriptively and using multiple linear regression.

RESULTS

Data of 1612 assessments in 123 ICUs from three German-speaking countries were analysed. The most frequently used delirium assessment instrument was the Intensive Care Delirium Screening Checklist (43.9%, n = 54). The prevalence of delirium at 8 AM was 18.6% and at 8 PM 20.4% from the 94 ICUs included in the regression analyses. Prevalence for adult and paediatric and mixed ICUs are comparable. Main reported over all unit-level interventions were 'pain management' (95.9%, n = 118), 'mobilization' (94.3%, n = 116) and 'verbal re-orientation' (84.6%, n = 104). Main reported over all unit-level barriers were 'shortage of staff' (53.7%, n = 66) and 'patients who are difficult to assess' (44.7%, n = 55). Interventions such as 'avoidance of bladder tubes/catheters' in all ICUs, 'use of ear plugs and/or sleep glasses' in adult ICUs and 'mobilization' in paediatric and mixed ICUs were associated with reduced delirium prevalence. Across all ICUs, as well as in both adult and paediatric ICUs, 'lack of appropriate scores for delirium assessment' was identified as a significant barrier.

CONCLUSIONS

One fifth of assessed ICU patients suffer from delirium. Several reported unit-level interventions and barriers may have an impact on delirium prevalence, suggesting an approach for future studies and clinical practice.

RELEVANCE TO CLINICAL PRACTICE

In clinical practice, unit-level 'avoidance of bladder tubes/catheters', 'use of ear plugs and/or sleep glasses' and 'mobilization' may be used as delirium prevention and treatment interventions.

Lipid dysregulation and delirium in older adults: A review of the current evidence and future directions

Delirium is a complex medical condition marked by acute episodes of cognitive dysfunction and behavioral disturbances, with a multifaceted etiology and challenging management across various clinical settings. Older adults, particularly in postoperative contexts, are at increased risk of developing delirium. Despite extensive research, a single underlying pathophysiological mechanism for delirium remains elusive. However, emerging evidence suggests a correlation between lipid dysregulation and delirium development in elderly patients, especially in postoperative settings. This connection has led to proposed treatments targeting dyslipidemia and associated neuroinflammatory effects in acute-phase delirium. This review aims to synthesize current literature on the relationship between lipid dysregulation and delirium in older adults, highlighting the need for further research into specific neurolipidome constituents and age-related lipid profile changes, potentially uncovering novel therapeutic strategies for delirium.

Prospective external validation of the automated PIPRA multivariable prediction model for postoperative delirium on real-world data from a consecutive cohort of non-cardiac surgery inpatients

OBJECTIVES

Postoperative delirium (POD) is a common complication in surgical patients over 60, increasing morbidity, mortality and hospital stays. While international guidelines recommend risk screening, resource constraints limit implementation. This study externally validated the Pre-Interventional Preventive Risk Assessment (PIPRA) algorithm, a CE-certified tool for identifying high-risk patients to enable targeted prevention.

METHODS

A prospective validation study was conducted at a 335-bed Swiss hospital as part of a quality improvement initiative. Data from 866 patients aged ≥60 undergoing non-cardiac, non-intracranial surgery (May-June 2023) were analysed. The PIPRA model's performance was assessed on discrimination (Area Under the Receiver Operating Characteristic Curve (AUROC)) and calibration.

RESULTS

POD occurred in 11.5% (n=100) of patients. The PIPRA model showed good discrimination (AUROC=0.77, 95% CI: 0.72 to 0.82) and generally accurate calibration, though slightly overpredicting risk in high-risk patients. POD was associated with higher mortality, prolonged intensive care unit (ICU)/hospital stays and increased nursing care needs. The model effectively stratified patients for targeted interventions.

DISCUSSION

The PIPRA algorithm demonstrated robust performance in a real-world setting, affirming its utility for POD risk prediction. The study highlighted the model's applicability across diverse clinical environments, despite differences in patient populations and screening protocols.

CONCLUSIONS

The PIPRA algorithm is a reliable tool for identifying surgical patients at risk of POD, supporting early intervention strategies to improve patient outcomes. Its integration into clinical workflows may enhance POD prevention efforts and optimise resource allocation in perioperative care.

Prioritization Patterns of Nurses in the Management of a Patient With Delirium: Results of a Q-Methodology Study

Nurses are required to decide on priorities; however, how they prioritize the interventions toward patients with delirium is still unclear. Therefore, expanding the knowledge on (a) how nurses prioritize interventions to manage episodes of delirium and (b) the underlying prioritization patterns were the aims of this study. The Q-methodology was applied in 2021. A systematic review to identify the recommended interventions for patients with delirium was performed, and a nominal group technique was used to select those interventions that are applicable in daily practice (35 out of 96 identified). Then, using a specific scenario, 56 clinical nurses working in hospital medical (n = 31), geriatric (n = 15), and postacute (n = 10) units were asked to order the 35 interventions (from -4 the lowest to +4 the highest priority) using a Q-sort table. Averages (confidence interval at 95%) were calculated at the group level, and a by-person factor analysis was applied to discover underlying patterns of prioritization at the overall and at the individual levels. At the group level, "Ensuring a safe environment (e.g., reducing bed height)" was ranked as the highest priority (2.29 out of four); at the individual level, three prioritization patterns accounting for a total variance of 50.21% have emerged: "Individual needs-oriented" (33.82% variance explained; 41 nurses); "Prevention-oriented" (8.47%; five nurses); and "Cognitive-oriented" (7.92%; six nurses). At the group level, nurses prioritize safety while caring for patients with delirium; however, at the individual level, they follow three different patterns of prioritization oriented toward diverse aspects, suggesting uncertainty in the actions to be taken-with potential implications for patients.

The global research trends in perioperative cognitive function protection for preventing postoperative delirium: A bibliometric analysis

BACKGROUND AND OBJECTIVES

This study aims to analyze the global trends and current status of perioperative cognitive function protection for preventing postoperative delirium(PCFP-POD), as well as to predict research hotspots.

METHODS

We conducted a literature search on the Web of Science Core Collection (WoSCC) and selected articles published between January 1, 2014, and December 31, 2023, related to PCFP-POD. The retrieved data were subjected to bibliometric analysis and visualization using CiteSpace 6.2.R4, VOSviewer 1.6.20 software, and the Bibliometrics website.

RESULTS

A total of 355 articles published between 2014 and 2023 were retrieved from the online databases. The number of publications on perioperative cognitive function protection for preventing postoperative delirium sharply increased from 2018 onwards. Key themes included drug and non-drug interventions, postoperative cognitive dysfunction in cardiac and hip surgery, and the effects of anesthetic drugs. High-frequency keywords included postoperative delirium, intervention, postoperative cognitive impairment, and cognitive training.

CONCLUSION

The number of research articles on PCFP-POD increased significantly from 2014 to 2023. Future research trends may focus on cognitive function protection related to surgical categories, anesthesia methods, electroencephalogram monitoring, and nursing care.

Frailty as an independent risk factor for sepsis-associated delirium: a cohort study of 11,740 older adult ICU patients

BACKGROUND

Sepsis-associated delirium (SAD) is a common complication in intensive care unit (ICU) patients and is associated with increased mortality. Frailty, characterized by diminished physiological reserves, may influence the development of SAD, but this relationship remains poorly understood.

AIMS

To comprehensively analyze the assessment of frailty as a predictive factor for sepsis-associated delirium in older adults.

METHODS

A retrospective cohort analysis was performed on sepsis patients aged ≥ 65 years admitted to the ICU. Frailty was assessed using the Modified Frailty Index based on 11 items including comorbidities and functional status. Patients were categorized into non-frail (MFI: 0-2) and frail (MFI ≥ 3) groups. Delirium was assessed using the ICU Confusion Assessment Method (CAM-ICU) and retrospective nursing notes. Logistic regression analysis was used to examine the relationship between frailty in older patients and the risk of delirium, and odds ratios (OR) and their 95% confidence intervals (CI) were calculated.

RESULTS

Among 11,740 patients (median age approximately 76 years [interquartile range: 70.47-83.14], 44.3% female), frail patients tended to have longer ICU stays, higher severity scores, and potentially worse clinical outcomes. The study found a significant positive association between MFI and the risk of developing SAD (OR: 1.13, 95% CI: 1.09-1.17, p < 0.001). Additionally, frail patients had a higher risk of developing SAD compared to non-frail patients (OR: 1.31, 95% CI: 1.20-1.43, p < 0.001).

CONCLUSIONS

Frailty independently predicts SAD development in older adults with sepsis in the ICU, emphasizing the importance of early recognition and prevention.

Comparative effectiveness of delirium recognition with and without a clinical decision assessment system on outcomes of hospitalized older adults: Cluster randomized controlled trial

BACKGROUND

Early recognition of delirium is essential for effective management, but it often goes unrecognized, resulting in adverse outcomes. Clinical decision support systems can enhance adherence to guidelines and improve patient outcomes. We developed a mobile-based clinical decision assessment tool (3D-DST) based on the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM). Implementing the 3D-DST may enhance delirium recognition and adherence to interventions among healthcare professionals, potentially improving outcomes in older adults.

OBJECTIVE

To test whether improved recognition of delirium could lead to better clinical outcomes in older adults.

DESIGN

A cluster randomized controlled trial with pair-matching.

SETTING

A tertiary geriatric hospital.

PARTICIPANTS

Patients aged ≥65 years.

METHODS

Four general wards were paired and randomly assigned to the intervention group (two wards) or the control group (two wards). The intervention included routine delirium assessments by nurses using either the 3D-DST or the 3D-CAM, along with delirium prevention and intervention measures carried out by a multidisciplinary team. Outcomes measured included delirium incidence, duration, severity, length of stay, and adherence to the delirium assessment, prevention, and treatment protocol. A trained nursing researcher collected data on demographics, clinical characteristics, and primary and secondary outcomes.

RESULTS

211 eligible patients participated (106 in the intervention group and 105 in the control group), with 21 identified as delirium-positive using the 3D-DST. The median Charlson comorbidity index score among older adults in the intervention group was 1 (1-2), compared to 2 (1-3) in the control group (P = 0.032). Nurses' adherence to delirium assessment was significantly higher in the intervention group than in the control group (73 % vs. 31 %). The recognition rate of delirium among nurses was 89 % in the intervention group and 42 % in the control group. There were no statistically significant differences in delirium duration (6 [3-9] vs. 7 [2-14], P = 0.967), incidence (8.5 % vs. 11.4 %, P = 0.500), severity (2 [1-3] vs. 2 [1-4], P = 0.891) or length of hospital stay (15 [14-18] vs. 18 [13-22], P = 0.568) between the intervention and control groups.

CONCLUSIONS

The 3D-DST enhanced adherence to routine delirium recognition by nurses. However, effective strategies are urgently needed to strengthen multidisciplinary collaboration and enhance adherence to delirium management among healthcare professionals.

REGISTRATION

Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402.

Cognitive and functional change in skilled nursing facilities: Differences by delirium and Alzheimer's disease and related dementias

BACKGROUND

Whether cognitive and functional recovery in skilled nursing facilities (SNF) following hospitalization differs by delirium and Alzheimer's disease related dementias (ADRD) has not been examined.

OBJECTIVE

To compare change in cognition and function among short-stay SNF patients with delirium, ADRD, or both.

DESIGN

Retrospective cohort study using claims data from 2011 to 2013.

SETTING

Centers for Medicare and Medicaid certified SNFs.

PARTICIPANTS

A total of 740,838 older adults newly admitted to a short-stay SNF without prevalent ADRD who had at least two assessments of cognition and function.

MEASUREMENTS

Incident delirium was measured by the Minimum Data Set (MDS) Confusion Assessment Method and ICD-9 codes, and incident ADRD by ICD-9 codes and MDS diagnoses. Cognitive improvement was a better or maximum score on the MDS Brief Interview for Mental Status, and functional recovery was a better or maximum score on the MDS Activities of Daily Living Scale.

RESULTS

Within 30 days of SNF admission, the rate of cognitive improvement in patients with both delirium/ADRD was half that of patients with neither delirium/ADRD (HR = 0.45, 95% CI:0.43, 0.46). The ADRD-only and delirium-only groups also were 43% less likely to have improved cognition or function compared to those with neither delirium/ADRD (HR = 0.57, 95% CI:0.56, 0.58 and HR = 0.57, 95% CI:0.55, 0.60, respectively). Functional improvement was less likely in patients with both delirium/ADRD, as well (HR = 0.85, 95% CI:0.83, 0.87). The ADRD only and delirium only groups were also less likely to improve in function (HR = 0.93, 95% CI:0.92, 0.94 and HR = 0.92, 95% CI:0.90, 0.93, respectively) compared to those with neither delirium/ADRD.

CONCLUSIONS

Among older adults without dementia admitted to SNF for post-acute care following hospitalization, a positive screen for delirium and a new diagnosis of ADRD, within 7 days of SNF admission, were both significantly associated with worse cognitive and functional recovery. Patients with both delirium and new ADRD had the worst cognitive and functional recovery.

Benefits of an automated postoperative delirium risk prediction tool combined with non-pharmacological delirium prevention on delirium incidence and length of stay: a before-after analysis based on a quality improvement project

BACKGROUND

Postoperative delirium (POD) significantly impacts older surgical patients, necessitating effective prevention strategies.

OBJECTIVE

To assess the effectiveness of the Pre-Interventional Preventive Risk Assessment (PIPRA) automated delirium risk prediction tool alongside non-pharmacological prevention strategies on POD incidence, hospital length of stay (LOS) and nursing time.

METHODS

This quality improvement project, set in a 335-bed Swiss private hospital, employed a before-after design to evaluate the impact of PIPRA and preventive measures on POD, LOS and nursing time in non-cardiac and non-intracranial surgery inpatients aged 60 or older. The control phase focused on enhancing POD screening, whilst the intervention phase incorporated PIPRA for risk assessment and staff training to enable targeted non-pharmacological prevention in patients at risk.

RESULTS

A total of 866 patients were included; 299 control and 567 intervention. The odds ratio of POD, comparing the intervention group to the control, was 0.71 [95% confidence interval (CI) 0.44-1.16] when adjusting for baseline patient characteristics. The intervention was associated with an LOS 0.94 (95% CI 0.85-1.05) and nursing time 0.96 (95% CI 0.86-1.07) times that of the control, adjusted for baseline patient characteristics. Medium risk patients (21.6% of patients) had an LOS 0.74 (95% CI 0.59-0.92) and required nursing time 0.79 (95% CI from 0.62-1.00) times the control, adjusted for baseline patient characteristics, equivalent to an LOS reduction of 1.36 days and nursing time saving of 19.3 hours per patient.

CONCLUSIONS

Medium risk patients in the intervention group had shorter LOS and nursing time compared to the control group, underscoring the importance of targeted prevention.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

LINKING EVIDENCE TO ACTION

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

Exploring academic and clinical nurses' perspectives on evidence-based nursing course for undergraduates from perspectives of academic-practice partnerships: a qualitative study

AIM

To explore nurses' perceptions of evidence-based nursing courses for undergraduates through academic-practice partnerships.

DESIGN

A deductive thematic analysis based on the practice-academic logic model.

METHODS

Fifteen academic and clinical nurses were interviewed between November and December 2023, either online or through face-to-face meetings. Each interview lasted 20-30 min. The interview outline was constructed based on the practice-academic partnership logic model, which was followed during the process of recorded, analyzed, and checked.

RESULTS

Themes identified include inputs (e.g., stakeholder commitment), activities (e.g., communication), outputs (e.g., nursing projects), and outcomes (e.g., improved competence). These themes highlight the various aspects and outcomes of academic-practice partnerships in evidence-based nursing courses.

CONCLUSION

Effective academic-practice partnerships are crucial for developing evidence-based nursing courses, leading to positive educational and professional outcomes.

IMPACT

Nurses' perceptions provide valuable guidelines for developing effective evidence-based nursing courses.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public users participated in this study.

Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study

BACKGROUND

Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay.

OBJECTIVE

We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions.

DESIGN AND METHODS

A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model.

RESULTS

A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals.

CONCLUSIONS

This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation.

TWEETABLE ABSTRACT

Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures.

STUDY REGISTRATION

DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.