Multidimensional interventions decreasing and preventing delirium in hospitalized adults

Evidence Based Research Project The University of Scranton Megan McCarthy

Practice Analysis
My mentor: Robin Silver of New York Presbyterian. New York-Presbyterian Hospital is the nation's largest not-for-profit, non-sectarian hospital, with approximately two million inpatient and outpatient visits per year. Being one of the top ten hospitals in the country, NY Presbyterian is committed to excellence in patient care, research, education, and community service.

Practice Analysis Continued

While implementing NY Presbyterians vision of excellence into practice,

Ms. Robin Silver works in a general medical acute care setting where she
is exposed to many diagnoses, disorders, and medical complications.

One challenge she finds in practice is the complications presented during treatment when a patient displays symptoms of delirium.

Another challenge that is faced is determining the most valid and reliable

standardized assessment tool that occupational therapists can use to

properly test for delirium.

PICO Question
For people at risk for developing or present symptoms of
delirium, does a multidimensional intervention approach, which includes early intervention by occupational therapists, decrease or prevent delirium deficits in hospitalized adults.

Search Strategy
Search Terms Used: Population: Older adults with delirium, patients with delirium, patients at risk for delirium. Intervention: Multidimensional interventions, early interventions, non-pharmacological interventions, occupational therapy. Comparison: prevention to treatment, delirium assessment tools and evaluations, interventions to treat delirium. Outcome: prevention of delirium, treatment of delirium.

Databases Searched: Although multiple databases were reviewed throughout the process of obtaining articles, most of the articles that were incorporated into the research are from CINHAL with Full Text Database, from the University of Scranton, and Google Scholar, which is a search engine that is devised to locate scholarly articles.

Journals Retrieved From: Arch Intern Med International Journal of Older People Nursing Journal of Advanced Nursing Journal of the American Geriatric Society Journal of Clinical Nursing Research and Theory for Nursing Practice: An International Journal

Literature Matrix
First Author, Year
Robinson, S. 2008

Level of Evidence
III

Design
Preintervention and postintervention study. The data was collected using retrospective record review.

Total N=
160 Preinterven t-ion group: 80. Postinterve n-tion group: 80.

Age, gender, diagnoses

65 and older with any combination of the risk factors of dementia, vision, hearing, and mobility. Both groups were composed of 37 men and 43 women.

Interventions
The hearing protocol, which helped to orient and facilitate communication. Providing visual aids. Mobility protocols. Planned care based on home regimen. Scheduled pain medication/ medication management. Stress reduction techniques.

Duration
Admission to discharge per subject.

Measurable Outcomes
Chart-based method for the Identification of delirium, Hospital Elder Life Program.

Major Findings
The Preintervention group 30(37.5%) demonstrated symptoms of delirium. In the postinterventio n group out of 80 at-risk patients, 11 (13.8%) demonstrated symptoms of delirium. The percentage of patients who developed delirium declined from 37.5% to 13.8% with the use of their protocol.

Vidan, M. 2009

II

Prospective controlled clinical trial.

542 Interventio n group: 170 participants . Unusual group: 372 participants .

Must be 70yrs or older with any risk for delirium.

Inouye, S. 2003

III

Preintervention and postintervention.

422

Patients must be 70 years or older, no delirium at admissions, and have an intermediate risk at baseline.

Educational measures and specic actions in seven risk areas: orientation, sensory impairment, sleep, mobilization, hydration, nutrition, drug use, and daily monitoring of adherence. Orientation, therapeutic activities, mobility, sleep, hearing or vision, and volume repletion.

Admissi on to discharg e per subject.

CAM, MMSE, APACHE II, and Snellen test.

A multicomponent, nonpharmacological intervention integrated into routine practice reduces delirium during hospitalization in older adults. It also improves quality care, and can be implemented without additional resources in a public healthcare system.

Duration was based off of the patients admissio n per subject.

Competency-based checklist, geriatric depression scale, Mini-Mental State Examination, digit span test, standard near-vision and hearing tests. The Confusion Assessment Method, Modified Blessed Dementia Rating Scale, Acute Physiological and Chronic Health Evaluation, Charles Comorbidity Index.

For patients with the highest adherence level had an 89% reduction risk of developing delirium. The highest adherence rate had a delirium rate of 2.9% compared to the lowest adherence group, which had a 38.1% delirium rate. The more interventions received by patients, the better response in the reduction of delirium. A multicomponent approached provided the best treatment outcomes.

Day, J. 2008

IV

Participatory action research (PAR).

The PAR group was comprised of research academics and 8 clinicians from the ward.

Wei, L. 2008

Systematic review.

239 articles were included in the systematic review; 11 validation studies, 16 adaptation studies of the CAM, 12 translation studies, 222 studies involving the application of the CAM into practice.

70yrs+, severe illness, dementia, physical frailty, infection, dehydration, visual impairment, hearing impairment, and polypharmacy were used as a central resource for this study. Original Englishlanguage articles using the Confusion Assessment Method (CAM) from 1/1/199112/31/2006.

Data was collected from past experience.

13 PAR sessions were held over five months.

N/A

The major constraints to delirium care, identified in this process, were: diagnosing and recognizing delirium, underreporting, environment constraints, communication amongst the interdisciplinary team, readmissions and repeat presentations, and a protracted admission process.

Examining the current usage of the CAM.

N/A

N/A

The CAM has gained widespread usage both nationally and internationally. Base on seven high quality studies, a combined sensitivity rate was calculated as 94% and combined specificity rate of 89%. The interrater reliability is moderate to high across studies. The CAM has improved identification of delirium in the clinical and research setting. The CAM should be scored based on observations made during standardized cognitive testing and training is highly suggested. Further action is needed to optimize the CAM and to improve the detection and management of delirium.

Milisen, K. 2005

Systematic review.

7 studies were included in the systematic review; 3 random control trials, 3 controlled studies, and 1 before-after study.

Hospitalized older adults 60 years or older.

Examining the impact of Multicompone nt intervention strategies on delirium.

N/A

N/A

Intervention strategies to prevent delirium proved to be the most efcacious in reducing its incidence, both with surgical and medical patients. Some additional positive effects of preventive strategies were found on the duration and severity of delirium, and functional status. Multicomponent interventions to prevent delirium are the most effective and should be implemented through the cooperation between healthcare disciplines.

Schweickert, W. 2009

II

Randomized controlled trial

104 Intervention group: 49 patients. Control group: 55 patients.

18 years or older, had been mechanically ventilated for less than 72 hours, but was expected to continue ventilation for another 24hrs.

P/ROM, physical therapy, occupational therapy, daily interruption of sedation, A/ROM, bed mobility, ADL activities, transfer training, pregait exercises, and walking.

N/A

All outcomes were directed towards finding and analyzing the efficienc y of various multicom ponent interventi on strategies to treat delirium.

Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group. Patients in the intervention group had a shorter duration of ventilation and delirium.

Espinoza, E. (in press)

Potential Level II

Randomized control trial .

Sample size was not indicated. 2 study groups were included: a standard nonpharmacological prevention group and intensive nonpharmacological prevention group.

60-95yrs old, admission to CCU for acute or chronic illness, expected admissions was for more than 24hours

Multi-sensory stimulation, positioning, cognitive stimulation, reorientation protocol, early mobilization, sleep protocol, environment management training, ADLs, upper limb motor stimulation, and family involvement.

Endpoint classification was presented as an efficiency study.

CAM, FIMS, MMSE, and grip strength test using the Jamar Dynamometer

Study was completed on 12/12 and has not been published yet.

Critically Appraised Topic (CAT)

QUESTION: For people at risk for developing or present symptoms of delirium, does a multidimensional intervention approach, which includes early intervention by occupational therapists, decrease or prevent delirium deficits in hospitalized adults. Bottom Line: A multicomponent, non-pharmacological intervention integrated into routine practice reduces delirium during hospitalization in older adults, improves quality care, and can be implemented without additional resources in a public healthcare system.

Summary of Key Evidence

Level of Evidence: II

1)Study Design: Prospective Controlled Clinical Trial. 2)Sample: Total N=542; Intervention group: 170 participants; unusual group: 372 participants. 3) Procedure: Patients underwent a series of evaluations and data was obtained through interviews and medical record reviews. Once the assessments were completed, participants were divided into either a usual group and intervention group. The usual group received the standard care, provided by hospital staff, while the intervention group received a more invasive treatment specific to their diagnosis of delirium. Some interventions given to the intervention group were: education, environment management, sensorial perception, sleep preservation, early mobilization, hydration, nutrition, and medication management. 4) Outcome Measures: CAM, MMSE, APACHE II, Snellen Test. 5) Results: The rate of new delirium episodes, incidence of delirium and functional decline were lower in the intervention group than usual group. The study shows that an early multicomponent intervention strategy is the most effective to treating delirium.

CAT Continued
Appraisal and Application: Strengths: 1) Measurements were proven valid through extensive research of previous studies and assessment tools. 2) Intervention scores thoroughly represent a positive correlation in early multicomponent interventions and delirium.

Weaknesses: 1) Participants were lacking. Out of 1,027 patients screened, only 542 made into the study because of other preexisting diagnoses; 2) The study was not randomized.

Applicability to Practice Scenario: Affects of preventative measures and early intervention to treat delirium.

Citations: Vidan, M., Sanchez, E., Alonso, M., Montero, B., Ortiz, J., & Serra, J. (n.d.). An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients . (2009). Journal of the American Geriatric Society, 57(11), 20292036. doi: 10.1111/j.1532-5415.2009.0248.

Synthesis
Fourteen articles from these journals were selected as being relevant to the question presented. Of these fourteen articles, seven were selected based on the inclusion criteria of this analysis.
The inclusion criteria comprised of: (1) subjects must be eighteen years or older and have or are at risk for developing delirium. (2) studies must involve non-pharmacological interventions for delirium. (3) studies must focus on one or more of the following factors: adherence, orientation, sensory, mobilization, and cognitive stimulation.

The literature pertaining to delirium primarily focuses on the etiology and

evaluations used to detect the condition rather than specific factors and interventions that can assist in the treatment and intervention.

Among the studies that focus on the factors and intervention techniques, only one

was found to carry out a direct comparison of these factors to the occupational
therapy services that could potentially be provided to treat delirium.

Synthesis Continued
Several studies by Inouye, Milisen, Robinson, Schweickert, and Vidan concluded that a multidimensional intervention approach provided the most effective outcome in preventing and treating delirium. Specifically, these studies reported a decrease in the duration and severity of delirium. The additional component of facilitating early intervention within the first twenty-four hours of admissions proved critical in the equation since a delay in therapy can greatly influence a clients progress level.
One case-control study concluded that the higher adherence level one had, the lower the risk was for developing delirium. They also reported that the more multicomponent interventions received by patients, the better response in the treatment outcome and reduction of delirium (Inouye, et al 2003).

Another case-control study by Robinson et al (2008) demonstrated a positive correlation between delirium intervention and a decline in delirium diagnoses, which decreased from 37.5% to 13.8% with the use of their multidimensional protocol.

Further validating Inouye and Robinsons studies, Milisen, Lemiengre, Braes & Foreman (2005) conducted a systematic review on the management of delirium through multicomponent interventions and found these intervention strategies to be most efcacious in reducing its incidence, both with surgical and medical patients. Some additional benefits of preventive strategies were found on the duration, severity, and functional status.

Synthesis Continued
According to Vidan, et al (2009) incorporating multicomponent, nonpharmacological intervention into daily routine practice not only reduces delirium during hospitalization in older adults, but also improves quality care, and can be implemented without additional resources in a public healthcare system.

Researchers have concluded that the reasoning behind the paucity of services for delirium is due to the lack of knowledge and education in the field.
One pilot study showed that most nurses viewed delirium as an age related change or normal consequence of undergoing surgery. They also identified non-pharmacological therapies as a necessity to managing delirium, but stated they are not normally implemented because they are considered time-intensive measures (Day, Higgins, & Koch, 2008).

Synthesis Continued
Most of the literature that explored multidimensional intervention as a key factor in the recovery of delirium suggested that immediate implementation of therapy, within twenty-four hours of admission, had the best outcome regarding patient progress. Also the research displays the importance of how detecting early signs can act as a preventative measure to the full onset of delirium.

According to Vidan (2009), who conducted a prospective control clinical trial study on immediate therapy vs. usual therapy, discovered correspondence between immediate therapy and a decrease in duration and prevalence of the disease.

Another aspect to make note of, so immediate therapy can proceed, is properly educating clinicians
in sign, symptoms, and the use of proper assessments to evaluate for delirium.

Inouye (2006) states that delirium increases hospital costs by $2,500 per patient, which calculates to more than $6.9 billion in hospital cost per year due to the poor recognition of delirium. Also suggested by

McCDonnell and Timmins (2012), the incidence of delirium can be reduced by 30% through early detection
of symptoms and use of preventative measures .

Synthesis Continued
One valid and reliable evaluation tool that is widely researched and can assist in detecting delirium is the Confusion Assessment Method (CAM).

The CAM provides health care clinicians a standardized method to asses delirium and is designed to
be scored based on observations made during formal cognitive testing such as the MMSE (Wasznski, 2007).

In most practice settings, occupational therapists are the ones who administer formal cognitive testing, which makes this an assessment tool that can be easily implemented into OT practice. A systematic review on the application of the CAM by Wei, et al (2008) displays an overall sensitivity rate of 94% and specify of 89%. Additional findings state that the CAM has been adapted for use in the ICU, emergency setting, institutional setting, and for scoring severity, sub-syndromal delirium, has a short and long version

and is offered in ten different languages, making this an exemplary tool to utilize within multiple
settings.

Synthesis Continued

Among the literature that examines whether a multidimensional intervention is the best approach to preventing or treating delirium, very few mention occupational therapists having a role in delirium treatment. Most of the studies mention and refer to services that represent relevant to OT such as ADL, PROM, AROM, orientation and sensory stimulation.
One randomized-control trial particularly tests the effects of early occupational and physical therapy intervention during periods of daily interruption of sedation in mechanically ventilated patient. After therapy was performed, researchers found that patients who receive immediate OT and PT had decreased the duration of delirium, ventilation, length of stay, mortality, and showed a higher return to independent functional status at discharge (Schweickert et al, 2009).

Synthesis Continued
The literature examining non-pharmacological interventions to treat delirium is not plentiful, but
existing studies do reveal that a significantly increased positive outcome toward treatment occurs when early intervention, multidimensional treatments are provided. All of the foregoing results that attribute importance to the presence of a multidimensional intervention to treat delirium support the incorporation of many therapeutic activities OTs provide.

For instance, reorientation tasks, sensory input activates, performing structural ADLs task, cognition stimulation, and engaging the patient in P/ROM or A/ROM exercise are only some of the many activities that branch under the profession of occupational therapy.

After thoroughly examining the literature to determine if a multidimensional intervention approach, which includes early intervention by occupational therapists, decrease or prevent delirium deficits in hospitalized adults, it must be concluded that the results are inconclusive.

There is a definite potential for OT to service this population, but due to the lack of literature directly comparing OT services to delirium prevention, there is not enough evidence to coincide with the question at hand. Further research is necessary in order to determine whether the implementation of occupational therapy into a multidimensional approach stands beneficial in preventing and treating adult patients with delirium.

Implications for OT
Analysis of the literature on delirium suggests that further research must be conducted in order to examine occupational therapys role in the prevention and treatment of delirium. It can be stated with a fair degree of certainty that OTs have th e necessary skills to become involved in the treatment and prevention of delirium.

Many of the evaluations used to detect delirium, after being educated and trained to administer, can easily be incorporated into an occupational therapists screening and assessment process.

For example the Confusion Assessment Method (CAM) is an evaluation used to detect delirium during a formal cognitive test such as the Mini-Mental State Examination. Training is suggested in order to properly administer the test and some of the areas examined include: inattention, disorganized thinking, memory, which OTs already have experience in evaluating through other various assessments. This can also be a very useful tool for measuring improvements throughout the course of treatment in the case of a client being diagnosed with delirium. Properly assessing for delirium will help the therapist meet the clients nee ds and incorporate validated non-pharmacological interventions shown to be effective the treatment of delirium.

By rectitude of the profession, occupational therapists have the skills to perform many of the interventions incorporated into a multidimensional component approach to treat and prevent delirium. Some interventions that correlate with occupational therapy practice are: early mobilization, orienting, sensory input, adherence, visual aids, self-care, sleep preservation, pain and medication management. Occupational therapists can provide valuable assistance to the clients in these areas all through the use of occupations and the individual needs of the client.

Implications Continued
A review of the existing literature reveals that there is one study that is in process of examining how OT can be incorporated in delirium treatment.

The random control trial by Espinoza (2013) researches the efficacy of non-pharmacological prevention and intensive nonpharmacological prevention, which contains standard non-pharmacological prevention plus early and intensive occupational therapy, of delirium in critically non-ventilated older patients. Even though the findings of the study have not been published yet, it is important to note and mention that this is a question at stake and others are investigating how OT can be effective in the treatment and prevention of delirium, which will ultimately assist in the expansion of the field.

It is imperative that occupational therapists continue the AOTA centennial vision and stay current on emerging methods, assessments, and new developments in the field. It is essential that OTs embrace their role as life-long learners and implement evidence based research to ensure that all interventions being used provide the best treatment outcome for the client. As therapeutic advancements are made, there is hope that occupational therapists will continue review the literature and conduct research to display all the benefits occupational therapy can serve in working with patients whom are at risk or diagnosed with delirium. As healthcare services continue to reform, there are many emerging opportunities within practice that OTs must take advantage of and further investigate in order to strengthen and protect the integrity of occupational therapy.

References
Aguirre, E. (n.d.). Delirium and hospitalized older adults: A review of nonpharmacologic treatment. (2010). The Journal of Continuing Education in Nursing, 41(4), 151-152. Day, J., Higgins, I., & Koch, T. (n.d.). Delirium and older people: what are the constraints to best practice in acute care?. (2008). International Journal of Older People Nursing, 3, 170-177. Espinoza, E. (in press). Early occupational therapy for delirium prevention in older patients admitted to critical care unit. Inouye, S., Bogardus, S., Williams, C., Leo-Summers, L., & Agostini, J. (2003). The role of adherence on the effectiveness of nonpharmacologic interventions. Arch Intern Med, 163, 958-964. McDonnell, S., & Timmins, F. (2012). A quantitative exploration of the subjective burden experience by nurses when caring for patient with delirium. Journal of Clinical Nurses, 21(17-18), 2488-2498. Robinson, S., Rich, C., Weitze, T., Vollmer, C., & Eden, B. (2008). delirium prevention for cognitive, sensory, and mobility impairments. Research and Theory for Nursing Practice: An International Journal, 22(2), 103-113. doi: 10.1891/0889-7182.22.2.103. Schweickert, W., Pohlman, M., Pohlman, A., Nigos, C., Pawlik, A., Esbrook, C., Spears, L., & Miller, M. (n.d.). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. (2009). Lancet, 373, 1874-1882. doi: 10.1016/S0140-6736(09)60658-9. Vidan, M., Sanchez, E., Alonso, M., Montero, B., Ortiz, J., & Serra, J. (n.d.). An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients . (2009). Journal of the American Geriatric Society, 57(11),

20292036. doi: 10.1111/j.1532-5415.2009.02485.x.

Waszynski, C. (n.d.). Detecting delirium . (2007). AJN, 107(12), 50-58. Wei, L., Fearing, M., Sternberg, E., & Inouye, S. (n.d.). The confusion assessment method: a systematic review of current usage. (2008). Journal of the American Geriatric Society, 56, 823-830. Yevchak, A., Steis, M., Diehl, T., Hill, N., Kolanowski, A., & Fick, D. (n.d.). Managing delirium in the acute setting: a pilot focus group study. (2012). International Journal of Older People Nursing, 7, 152-162.