Geriatric Nursing xx (2016) 1e6

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

The effect of range of motion exercises on delirium prevention

among patients aged 65 and over in intensive care units
Canan Karadas, MSc *, Leyla Ozdemir, RN, PhD
Hacettepe University Faculty of Nursing, Ankara, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to determine the effect of range of motion exercises on preventing
Received 27 June 2015 delirium and shortening the duration of delirium among patients in the intensive care unit who are aged
Received in revised form 65 and over. The study was conducted in the intensive care unit on patients with non-invasive me-
7 December 2015
chanical ventilation. The sample size included 47 patients from the intervention group and 47 from the
Accepted 14 December 2015
control group. The incidence of delirium was 8.5% in the intervention group and 21.3% in the control
Available online xxx
group. The duration of delirium was 15 h for patients in the intervention group and 38 h for those in the
control group. Although delirium incidence and duration decreased by 2.5-fold in the intervention group
Keywords:
Intensive care
compared to the control group; there was no signicant relationship between the intervention and
Mobility control groups. In conclusion, as the decreases in delirium occurrence and duration were not statistically
Range of motion signicant, the effect of range of motion exercises was limited.
Delirium 2015 Elsevier Inc. All rights reserved.
Geriatrics

Introduction improved nutrition levels by oral feeding, and a decreased risk of

Delirium, as an acute state of confusion, is a severe geriatric
syndrome common among older patients in the intensive care unit
(ICU) that is caused by a decrease in functional, metabolic and
cognitive activities.1,2 Delirium is a complicated clinical syndrome
affected by patients physiological parameters and their health
conditions. These parameters are utilized to develop a model to
predict delirium. Inouye et al.s model to predict delirium includes
four risk factors for delirium: the presence of cognitive and vision
impairment, an Acute Physiology and Chronic Health Assessment II
(APACHE II) score of 16 or above, and a bloodeurea nitrogen (BUN)/
serum creatinine ratio of 18 or above.3 Delirium occurs at a high
incidence in patients with ventilation support. In invasive me-
chanic ventilation (IMV), the patient is supported via an endotra-
cheal tube that provides positive pressure from a ventilator.4 In
non-invasive mechanic ventilation (NIMV), the patient is supported
by a face mask that provides positive pressure from a ventilator.
NIMV has certain advantages, such as a decreased need for seda-
tion, a reduced use of physical restraints, a decreased number of
tubes, low anxiety levels due to the patients speaking ability,
Conict of interest: The authors have no nancial disclosures to declare and no
conicts of interest to report.
* Corresponding author. Adnan Saygun Cad., D-Bloklar -1, Kat 06100
Samanpazar, Ankara, Turkey. Tel.: 90 534 348 40 34.
E-mail address: karadas.canan@gmail.com (C. Karadas).
respiratory infections.5,6 Delirium incidence differs as to the type of
ventilation support. Although its incidence in patients with NIMV is
20%e50%, in patients with IMV this ratio is 60%e80%.7 Among
elderly populations, the incidence is also high. More than 20% of
people aged 65 and over suffer from delirium at the time of
admission to the emergency room.8 This number varies from 20% to
79% in the ICU.9e11
Although delirium screening is important,10,12,13 it does not
ensure an improvement in health outcomes. Therefore, the clinical
guidelines of the National Institute for Health and Care Excellence
(NICE) and the ABCDE bundle recommend early mobility to prevent
delirium.12,13 The ABCDE bundle is a set of evidence-based practices
designated by an acronym that represents ABC: awakening and
breathing coordination, D: delirium monitoring and management,
and E: early mobility.12 The ABC component contains sedation
awakening and spontaneous breathing trials. The D component
includes delirium screening by a validated tool such as the Intensive
Care Delirium Screening Checklist or the Confusion Assessment
Method for the Intensive Care Unit (CAM-ICU). The E component
contains early mobility encouragement and safety screening for
vital and hemodynamic signs.7,14 Early mobility refers to the
mobilization of patients in the rst 48 h after ICU admission, and it
includes movements varying from passive range of motion (ROM)
exercises to ambulation in the unit.15 The ABCD components are
implemented in many ICUs as part of routine care, but the E
component has certain implementation decits.7 Although exercise

0197-4572/$ e see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2015.12.003
2 C. Karadas, L. Ozdemir / Geriatric Nursing xx (2016) 1e6
is benecial and highly recommended for patients with delirium, it
is time consuming. Therefore, its feasibility is considered to be low
by health care professionals.16 Indeed, early mobility prevents
complications of immobility by encouraging the patient to move
and improve vital functions.17 Mobility has positive effects such as
improving the venous return and stroke volume, increasing the
amount of oxygen distributed to tissues, reducing ventilation time
and enhancing cognitive abilities.17,18
The research regarding the effect of exercise on delirium mostly
centers on patients with IMV.19,20 Schweickert et al found that
patients who underwent physical therapy, including the passive
ROM exercises, sitting balance and tolerance, pre-ambulation ex-
ercises and ambulation have shorter durations of delirium and
more ventilator-free days compared to patients who did not receive
this therapy.20 Another study emphasized that the patients with
acute respiratory failure who receive physical therapy benet from
improved delirium status and a decreased length of hospital stay.19
Although patients with NIMV suffer from delirium at a high
incidence, this patient group has not been sufciently investigated.
The literature does not include any studies concerning the effect of
exercises on decreasing delirium incidence or preventing delirium
among older adults with NIMV.7 Therefore, we aimed to determine
the effect of ROM exercises on preventing delirium and shortening
the delirium duration among patients in the ICU aged 65 years and
over with non-invasive mechanical ventilation. The hypotheses of
the study were generated as follows:
H1. ROM exercises would prevent the development of delirium in
the intervention group compared to the control group.
H2. ROM exercises would shorten the duration of delirium in the
intervention group compared to the control group.
Patients admitted to the ICU
(n = 199)
State of meeting the sample
criteria
Patients excluded from the
sample
(n = 105)
<65 years of age <65 years of age and
(n = 58) on IMV* support
(n = 17)
Being on IMV Having delirium
(n = 13) (n = 5)
Amputated Active GIS**
extremity bleeding
(n = 1) (n = 2)
Refused to participate in
Having a cognitive the study
disorder (n = 6)
(n = 3)
*IMV: Invasive mechanical ventilation
** GIS: Gastrointestinal system
Fig. 1. Procedure ow chart.
Materials and methods
Study setting and design
This study was performed in the adult medical ICUs of a uni-
versity hospital in Turkey. Our study was a randomized, controlled
clinical trial. A stratied randomization was used in this study.
Patients were stratied and matched based on their BUN/serum
creatinine ratios (>18 and 17.9), their APACHE II scores (>16 and
15) and the existence of visual impairments (present or absent)
via the delirium predict model.3 All patients meeting the inclusion
criteria were matched according to their BUN/serum creatinine
ratios, their APACHE II scores and the existence of visual impair-
ments. The rst patient was assigned to the intervention group, and
a subsequent similar patient was matched in the control group. The
groups were homogeneous according to the BUN/creatinine ratio
(t 0.271, p 0.787), the APACHE II score (t 1.449, p 0.151)
and visual impairments (X2 1.138, p 0.286).
Population and sample
A power analysis was utilized to determine the sample size for
this study. Accordingly, the analysis revealed that the intervention
and control groups should each include 47 patients, resulting in a
test power of 0.80 (a 0.05). Within the scope of the study, 199
patients were approached between January 2015 and April 2015
(Fig. 1). A total of 102 patients were excluded from the study based
on their ineligibility. Three patients refused to participate because
they declined the exercise intervention. Therefore, the study was
conducted with 94 patients who were consented.
Patients included in
the sample
(n = 94)
Randomization of patients
included in the sample
Control (n:47)
- Daily CAM-ICU assessment
-RASS assessment
-Routine clinical procedures
Intervention (n:47)
- Daily CAM-ICU assessment
-RASS assessment
-Routine clinical procedures
- Performing ROMs
 C. Karadas, L. Ozdemir / Geriatric Nursing xx (2016) 1e6
The inclusion criteria of the study were as follows: no previous
delirium before the procedure, an ICU stay of at least 24 h, aged 65
years and over and voluntary participation. The exclusion criteria
were dened as follows: not meeting the age requirement, having
an amputated extremity, undergoing invasive mechanical ventila-
tion and procedures limiting mobility (intracranial monitoring,
femoral artery catheter, extracorporeal circulation devise, and un-
stable fracture), a Richmond AgitationeSedation Scale (RASS) score
of 4 and 5 (deep sedation and coma), advanced osteoporosis,
terminal illness, known cognitive disorders (dementia and psy-
chosis), increased intracranial pressure, active gastrointestinal
system bleeding, arrhythmia and active myocardial ischemia.12,18,20
Data collection tools
To collect data, a patient data form with the CAM-ICU Scale and
the RASS was used. Researchers evaluated the CAM-ICU and the
RASS Scales for each patient. Patient charts completed by doctors
and nurses provided data on the APACHE II scores and BUN/creat-
inine ratio values. Besides APACHE II scores, BUN/creatinine ratio
values, and the data about existence of visual impairments were
taken from the patient charts.
The Patient Data Form was developed by researchers based on
previous literature and consists of four sections.12,13,19,20 The rst
section includes questions regarding the descriptive traits of the
patient (age, gender, length of stay in the ICU), the second includes
questions regarding the patients medical status (number of
chronic diseases, type and number of medications), and the third
section includes questions regarding the characteristics of delirium
(type, duration, occurrence time and potential causes of delirium,
and treatment procedures) in patients who experienced it during
the study. The last section includes the type and duration of ROM
exercise. Age, length of stay in the ICU, number of chronic diseases,
type and number of medications, potential causes of delirium, and
treatment procedures were collected from the patients charts. The
data included gender, delirium type, duration and occurrence time,
ROM exercise type and duration, which were evaluated by the
researchers.
The CAM-ICU Scale was developed by Ely et al21 A Turkish
reliabilityevalidity study was performed by Aknc et al, resulting in
an acceptable level of sensitivity (65%e69%), perfect specicity
(97%) and reliability (k 0.96).22 The scale consists of four sub-
categories: change in patients mental status, inattention, disorga-
nized thinking and an altered level of consciousness. Based on the
responses provided to the questions in the scale, the result in-
dicates if the patient is delirium positive or negative. Prior to
assessing delirium, the state of consciousness (awakening) should
be assessed using the RASS.
The RASS Scale was developed by Sessler et al to assess the
sedation levels of adult patients in the ICU.23 The RASS Scale in-
cludes 10 different scores between 4 and 5 that represent 4
combative, 3 very agitated, 2 agitated, 1 restless, 0 alert and
calm, 1 drowsy, 2 light sedation, 3 moderate sedation, 4 deep
sedation and 5 unarousable. For the delirium assessment, the
RASS score of a patient should be 3 or higher.23 RASS scores
between 1 and 4 indicate hyperactive delirium, while those
between 0 and 3 display hypoactive delirium, and scores that
change between the positive and negative ranges are dened as
mixed-type delirium.24
Intervention
Patients in the intervention and control groups were monitored
during the day shifts until they were discharged from the ICU. The
researcher also assessed patients in the control group every day
3
using the RASS and the CAM-ICU Scales. The control group received
no intervention apart from routine clinical practice. In the inter-
vention group, after the daily RASS and CAM-ICU assessments, ROM
exercises were performed once a day until the patients were dis-
charged. Passive, assisted-active or active ROM exercises were
performed based on the patients ability to respond to verbal
commands. ROM exercises were performed for the four extremities
in the supine position with 10 repetitions for approximately 30 min.
If the patient was unable to tolerate the intervention, the exercise
ceased and the intervention continued the next day. The parame-
ters indicating that the exercise was not tolerated were as follows:
average arterial pressure 65 mm Hg, systolic blood pressure
200 mm Hg and above, pulse rate 40 or 130, saturation 88%,
breathing rate 5 or 40 per minute, and arrhythmia.
Data analysis
The data were analyzed using the IBM SPSS Statistics 22 pro-
gram. Percentages, means and medians were used for the
descriptive and medical patient characteristics, and the character-
istics of patients experiencing delirium and ROM intervention
traits. The Chi-square test was used to assess the delirium incidence
and vision impairment homogeneity, the ManneWhitney U test
was used to assess the delirium duration, the independent sample t
test was used to assess the BUN/creatinine ratio, and the APACHE II
score was used to assess homogeneity.
Ethical consideration
This study was approved by the Ethical Committee of the Turgut
Ozal University Faculty of Medicine (Reference no.99950699/340).
The researcher explained the study to the patients and their proxy
decision maker prior to the study. Informed consent was obtained
from the patient or the proxy decision maker. If patients were
unable to provide informed consent, due to their level of con-
sciousness, including confusion or lethargy, informed consent was
obtained from their proxy decision maker, and the patients were
later informed when they re-gained consciousness. Three patients
had a 2 score (light sedation) from the RASS Scale at the
beginning of the study, so their informed consent was given by
their proxy decision maker, and the other 91 patients provided
consent.
Results
Descriptive, medical, and ROM exercises characteristics of patients
The mean age of patients from the intervention group was
75  7.5 years, and 48.9% of them were female. The mean age of the
patients in the control group was 72.6  6.8 years, and 57.4% of
them were female. In both groups, 51.1% of the patients stayed in
the ICU for less than 9 days. All of the patients in the intervention
group had chronic diseases, and the average number of chronic
diseases was 4.04  1.2. The current number of medications was
11.44  1.4, and H2 receptor antagonists were frequently used
(46.8%) in the intervention group. In the control group, 95.7% of the
patients had chronic diseases, and the average number of chronic
diseases was 4.0  3.9. The current number of medications was
11.14  3.7, and H2 receptor antagonist group medication was
frequently used in the control group.
The median duration of the ROM exercises in the intervention
group was 5 days (range: 1e16 days). Active ROM exercises were
administered to 63.8% of the patients, followed by assisted-active
ROM exercises (34.1%) and passive ROM exercises (2.1%).
4 C. Karadas, L. Ozdemir / Geriatric Nursing xx (2016) 1e6

Delirium development, duration, and the characteristics of patients Table 1

experiencing delirium The relationship between the CAM-ICU items by group.

Characteristics Intervention Control Chi-square p

During the study, four patients (8.5%) from the intervention n % n %
group and 10 (21.3%) from the control group experienced delirium
Change in mental status from the baseline
(Fig. 2). However, this difference was not statistically signicant Absent 40 85.1 36 76.6 1.099 0.294
(p > 0.05, X2 3.02). Upon assessment, the delirium duration in Present 7 14.9 11 23.4
patients in the intervention group was shorter. Accordingly, the Fluctuation in mental status during the past 24 h
Absent 42 89.4 37 78.7 1.983 0.159
median delirium duration among patients from the intervention
Present 5 10.6 10 21.3
group was 15 h (range: 3e144 h), and was 38 h (range: 9e120 h) in Change in sedation or coma scale value during the past 24 h
patients from the control group. However, there was a non- Absent 38 80.9 32 68.1 2.014 0.156
signicant difference between the groups in terms of the Present 9 19.1 15 31.9
delirium duration (p > 0.05; Z 0.997). There was a decrease in Having difculty in focusing attention
Absent 40 85.1 34 72.3 2.286 0.131
the incidence of the delirium scale sub-items in the intervention
Present 7 14.9 13 27.7
group; however, this difference was not signicant between the Difculty in maintaining or shifting attention
groups (p > 0.05) (Table 1). All of the patients from the inter- Absent 40 85.1 33 70.2 3.005 0.083
vention group experienced delirium at night, and half of them had Present 7 14.9 14 29.8
a mixed-type delirium. All patients with delirium received active Success status in attention examination
Successful 40 85.1 34 72.3 2.286 0.131
ROM in the intervention group. Although the patients with Unsuccessful 7 14.9 13 27.7
delirium in the intervention group stayed in the ICU for 4.5 (range: Item 3 or 4 incidencea
1e9 days) days, the median duration of active ROM exercise was 2 Absent 42 89.4 36 76.6 2.712 0.100
(range: 1e4 days) days. Of these patients, one had respiratory Present 5 10.6 11 23.4
instability and one had an intracranial arterial condition that was a
Item 3: Disorganized thinking, Item 4: Altered level of consciousness. If the
a barrier to the ROM exercises. The other two patients with other items meet the delirium criteria, the existence of one of these two items is
enough for diagnosis; therefore, they are indicated together in the table.
delirium completed their ROM exercise sessions without any
interruptions.
In the control group, 70% of the patients experienced delirium intensive care patients.26 On the other hand, other relevant studies
at night and 60% had a hypoactive delirium. In the intervention have determined that delirium incidence rates can be reduced by
group, the causes of delirium were infection (50%), an acid-base mobility interventions.19,27 In a study by Needham et al, the ratio of
imbalance (25%) and renal function disorder (25%). In the con- delirium decreased from 53% to 21% after a physical therapy
trol group, the causes of delirium were a uideelectrolyte intervention.19 In a study by Balas et al, early mobility reduced the
imbalance (50%), renal function disorder (20%), an acid-base incidence of delirium by almost half.27 The content of the exercise
imbalance (10%), infection (10%) and anemia or bleeding (10%). intervention may be cause of these contradictory results. Exercise
In both groups, half of the patients did not receive delirium interventions only focused on ROM exercises in the current study. A
management treatment (Table 2). wide range of mobility interventions, including sitting upright in
bed, sitestand activities, pre-gait exercises and walking, according
to the patients tolerance, might be more efcient to prevent the
Discussion development of delirium. The characteristics of the sample may
have also inuenced on the insignicant results in this study. At this
When we examined the effect of ROM exercises on delirium point, looking closely at the delirious patients in the intervention
occurrence, the difference between the two groups was not sta- group could be benecial to understand the insufcient responses
tistically signicant (p > 0.05); however, the delirium incidence
was 8.5% in the intervention group and 21.3% in the control group. Table 2
There is no consensus regarding the responses to ROM exercises in The distribution of delirium characteristics in the intervention and control groups
ICU patients with delirium. Accordingly, there are different results (n 14).

in the literature related to the effect of ROM exercises on the Delirium characteristic Intervention Control (n 10)
development of delirium. A study using a delirium prevention (n 4)
protocol including early mobility in the ICU, showed no signicant n % n %
effect on the incidence of delirium.25 Nydahl et al also asserted that Duration (h) 15 (3e144) 38 (9e120)
there is a consensus decit regarding early mobilization of (med  minemax)
28 3 75 5 50
>28 1 25 5 50
100% Occurrence time
90%
Night 4 100 7 70
Morning 0 0 3 30
80%
Type
70% Hyperactive 1 25 4 40
60% 37 Hypoactive 1 25 6 60
43 Mixed 2 50 0 0
50%
Treatment procedure
40%
Pharmacologica 0 0 1 10
30%
Non-pharmacologicb 1 25 1 10
20% Pharmacologic 1 25 3 30
10% 10 non-pharmacologic
4 No procedure 2 50 5 50
0%
Intervenon Control Total 4 100 10 100
Delirium occured Delirium not occured
a
Haloperidol and olanzapine (when haloperidol is contraindicated).
b
Fig. 2. The distribution of delirium incidence in the intervention and control groups. Physical limitation.
 C. Karadas, L. Ozdemir / Geriatric Nursing xx (2016) 1e6
to the ROM exercises. The patients suffered from delirium just after
an infection due to an acid-base imbalance and renal function
disorder in the intervention group. Such complications and serious
diseases provide potential reasons why not all of the participants
responded to the ROM exercises. When we compared the length of
stay in the ICU (4.5 days) with exercise duration (2 days) in the
patients with delirium, we found fewer ROM exercise days due to
the development of respiratory instability and intracranial arterial
conditions. This limited exercise duration and the severe medical
conditions in the intervention group may have reduced the effec-
tiveness of the ROM exercises and contributed to the development
of delirium.
We found no statistically signicant difference between the
intervention and control groups in terms of the duration of
delirium (p > 0.05). However, the median delirium duration was
15 h in the intervention group and 38 h in the control group. In
agreement with this result, a randomized-controlled study
administering a progressive exercise and resistance program re-
ported that the decrease in the delirium duration did not reach
statistically signicant level (intervention: 2.4 days, control: 2.1
days).28 Additionally, according to a meta-analysis examining the
effect of randomized-controlled interventions on delirium dura-
tion, delirium duration changed with a wide range, results from
little impact to signicant reduction.29 Within the context of this
meta-analysis, early physical and occupational therapy signicantly
decreased delirium duration.20
The literature recommends assessing the delirium scale items
during delirium screening because of their effect on patient out-
comes.30e33 Therefore, scale items were examined in our study.
Although there was no statistically signicant relationship between
the CAM-ICU Scale items in the intervention and control groups,
the incidence rates of all the scale items were lower in the inter-
vention group. In a study conducted by Meagher et al on 133 par-
ticipants, 56.3% of patients were not diagnosed with delirium
according to the CAM-ICU.33 However, 96% of patients were posi-
tive for at least one of the scale items, and 13.2% were positive for at
least two scale items (n 41). In our study, the highest improve-
ment in the intervention group was observed in the item, difculty
in maintaining or shifting attention, compared to the control group
(intervention n 7, control n 14). Considering that attention
disorder is the most common issue in patients with delirium, the
clinical importance of this item is evident.
In conclusion, although a decrease of approximately 2.5-fold
was observed in delirium development and duration, there was
no statistically signicant difference in patients using ROM exer-
cises. The effect of ROM exercises on delirium development and
duration was limited in critically ill elderly patients. Therefore,
instead of offering only one type of mobility choice, such as ROM
exercises, an individualized exercise therapy from passive ROM to
active mobility, according to patient tolerance, could be more
promising for preventing delirium development and shortening
the duration of delirium. Furthermore, considering the multifac-
torial nature of delirium, certain precautions, such as controlling
infection, maintaining hydration, establishing a multidisciplinary
team approach, and accurately implementing the ABCDE bundle
may be benecial for strengthening the effect of ROM exercises on
combating delirium symptoms.
Limitation of study
The current study was limited to the patients aged 65 and over
in a medical ICU with the non-invasive mechanical ventilation. The
sample size of the study was totally 94 patients. This was another
limitation for our study.
5
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