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Sist L, Ugenti NV, Donati G, Cedioli S, Mansutti I, Zanetti E, Macchiarulo M, Messina R, Rucci P, Palese A. Applicability of the interventions recommended for patients at risk or with delirium in medical and post-acute settings: a systematic review and a Nominal Group Technique study. Aging Clin Exp Res 2022. [PMID: 35451735 DOI: 10.1007/s40520-022-02127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is a common condition during hospitalisation that should be prevented and treated. Several recommendations have been established to date, whereas few studies have investigated their applicability in daily practice for medical and post-acute settings. AIM The aim of this research exercise was to emerge the applicability of the interventions recommended by studies in the daily care of patients at risk or with delirium cared in medical and post-acute settings. METHODS The study was organised in three phases. A systematic literature review according to Centre for Reviews and Dissemination was conducted (January-February 2021). Cochrane Library, Pubmed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Psychological Information Database, and the Joanna Briggs Institute databases were searched. Primary and secondary studies were evaluated in their methodological quality with the Standard Quality Assessment Criteria, the Critical Appraisal Skills Programme, and the Appraisal of Guidelines for Research & Evaluation. Then, the interventions identified were assessed in their applicability using the Nominal Group Technique who ranked their judgement on a four-point Likert scale from 1 (totally inapplicable) to 4 (totally applicable). Qualitative feedbacks were also considered, and a validation of the final list was performed by the Nominal Group. RESULTS A total of 12 studies were included producing a list of 96 interventions categorised into four macro-areas (prevention, non-pharmacological, communication and pharmacological management). The Nominal Group identified 51 interventions (average score > 3.5) as applicable in medical and post-acute settings. Then, through a process of re-reading, and revising according to the comments provided by the Nominal Group, a list of 35 interventions out of the initial 96 were judged as applicable. CONCLUSION Applicability should be assessed with experts in the field to understand the involved factors. One-third of interventions have been judged as applicable in the Italian context; the nurses' expertise, the work environment features, and the time required for each intervention in a high workload setting may prevent the full applicability of the interventions recommended by the literature.
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LaHue SC, Maselli J, Rogers S, Casatta J, Chao J, Croci R, Gonzales R, Holt B, Josephson SA, Lama S, Lau C, McCulloch C, Newman JC, Terrelonge M, Yeager J, Douglas VC. Outcomes Following Implementation of a Hospital-Wide, Multicomponent Delirium Care Pathway. J Hosp Med 2021; 16:397-403. [PMID: 34197303 PMCID: PMC9621338 DOI: 10.12788/jhm.3604] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delirium is associated with poor clinical outcomes that could be improved with targeted interventions. OBJECTIVE To determine whether a multicomponent delirium care pathway implemented across seven specialty nonintensive care units is associated with reduced hospital length of stay (LOS). Secondary objectives were reductions in total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. METHODS This retrospective cohort study included 22,708 hospitalized patients (11,018 preintervention) aged ≥50 years encompassing seven nonintensive care units: neurosciences, medicine, cardiology, general and specialty surgery, hematology-oncology, and transplant. The multicomponent delirium care pathway included a nurse-administered delirium risk assessment at admission, nurse-administered delirium screening scale every shift, and a multicomponent delirium intervention. The primary study outcome was LOS for all units combined and the medicine unit separately. Secondary outcomes included total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. RESULTS Adjusted mean LOS for all units combined decreased by 2% post intervention (proportional change, 0.98; 95% CI, 0.96-0.99; P = .0087). Medicine unit adjusted LOS decreased by 9% (proportional change, 0.91; 95% CI, 0.83-0.99; P = .028). For all units combined, adjusted odds of 30-day readmission decreased by 14% (odds ratio [OR], 0.86; 95% CI, 0.80-0.93; P = .0002). Medicine unit adjusted cost decreased by 7% (proportional change, 0.93; 95% CI, 0.89-0.96; P = .0002). CONCLUSION This multicomponent hospital-wide delirium care pathway intervention is associated with reduced hospital LOS, especially for patients on the medicine unit. Odds of 30-day readmission decreased throughout the entire cohort.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
- Corresponding Author: Sara C LaHue, MD;
| | - Judy Maselli
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Stephanie Rogers
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Julie Casatta
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jessica Chao
- Clinical Innovation Center, University of California, San Francisco, California
| | - Rhiannon Croci
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Ralph Gonzales
- Department of Medicine, School of Medicine, University of California, San Francisco, California
- Clinical Innovation Center, University of California, San Francisco, California
| | - Brian Holt
- Continuous Improvement Department, University of California, San Francisco, California
| | - S Andrew Josephson
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
| | - Sudha Lama
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Catherine Lau
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Charles McCulloch
- Epidemiology & Biostatistics, University of California, San Francisco, California
| | - John C Newman
- Department of Medicine, School of Medicine, University of California, San Francisco, California
- Buck Institute for Research on Aging, Novato, California
| | - Mark Terrelonge
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
| | - Jan Yeager
- Clinical Innovation Center, University of California, San Francisco, California
| | - Vanja C Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
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Abstract
BACKGROUND Delirium is a common clinical syndrome defined as alterations in attention with an additional disturbance in cognition or perception, which develop over a short period of time and tend to fluctuate during the course of the episode. Delirium is commonly treated in hospitals or community settings and is often associated with multiple adverse outcomes such as increased cost, morbidity, and even mortality. The first-line intervention involves a multicomponent non-pharmacological approach that includes ensuring effective communication and reorientation in addition to providing reassurance or a suitable care environment. There are currently no drugs approved specifically for the treatment of delirium. Clinically, however, various medications are employed to provide symptomatic relief, such as antipsychotic medications and cholinesterase inhibitors, among others. OBJECTIVES To evaluate the effectiveness and safety of cholinesterase inhibitors for treating people with established delirium in a non-intensive care unit (ICU) setting. SEARCH METHODS We searched ALOIS, which is the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 26 October 2017. We also cross-checked the reference lists of included studies to identify any potentially eligible trials. SELECTION CRITERIA We included randomised controlled trials, published or unpublished, reported in English or Chinese, which compared cholinesterase inhibitors to placebo or other drugs intended to treat people with established delirium in a non-ICU setting. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. The primary outcomes were duration of delirium, severity of delirium, and adverse events. The secondary outcomes were use of rescue medications, persistent cognitive impairment, length of hospitalisation, institutionalisation, mortality, cost of intervention, leaving the study early, and quality of life. For dichotomous outcomes, we calculated the risk ratio (RR) with 95% confidence intervals (CIs); for continuous outcomes we calculated the mean difference (MD) with 95% CIs. We assessed the quality of evidence using GRADE to generate a 'Summary of findings' table. MAIN RESULTS We included one study involving 15 participants from the UK. The included participants were diagnosed with delirium based on the Confusion Assessment Method (CAM) criteria. Eight males and seven females were included, with a mean age of 82.5 years. Seven of the 15 participants had comorbid dementia at baseline. The risk of bias was low in all domains.The study compared rivastigmine with placebo. We did not find any clear differences between the two groups in terms of duration of delirium (MD -3.6, 95% CI -15.6 to 8.4), adverse events (nausea, RR 0.30, 95% CI 0.01 to 6.29), use of rescue medications (RR 0.13, 95% CI 0.01 to 2.1), mortality (RR 0.10, 95% CI 0.01 to 1.56), and leaving the study early (RR 0.88, 95% CI 0.07 to 11.54). Evidence was not available regarding the severity of delirium, persistent cognitive impairment, length of hospitalisation, cost of intervention, or other predefined secondary outcomes.The quality of evidence is low due to the very small sample size. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the use of cholinesterase inhibitors for the treatment of delirium in non-ICU settings. No clear benefits or harms associated with cholinesterase inhibitors were observed when compared with placebo due to the lack of data. More trials are required.
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Affiliation(s)
- Ailan Yu
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Shanshan Wu
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Zongwang Zhang
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Tom Dening
- The University of NottinghamDivision of Psychiatry & Applied PsychologyTriumph RoadNottinghamUKNG7 2TU
| | - Sai Zhao
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
| | - Gillian Pinner
- The University of NottinghamOld Age PsychiatryNottinghamUKNG7 2TU
| | - Jun Xia
- Institute of Mental Health, University of NottinghamCochrane Schizophrenia GroupTriumph RoadNottinghamUKNG7 2TU
| | - Daogui Yang
- Liaocheng People's HospitalDepartment of Gastrointestinal SurgeryNo.67 Dongchang West RoadLiaochengShandongChina252000
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