Authors

1. Thomas, Elizabeth MSN, RN
2. Smith, Jane E. MSN, RN
3. Forrester, Anthony D. PhD, RN, ANEF
4. Heider, Gerti PhD, RN
5. Jadotte, Yuri T. MD
6. Holly, Cheryl EdD, RN

Abstract

Review question/objective: In older adult hospitalized non-intensive care unit (ICU) patients, are targeted non-pharmacological, multi-component interventions effective for preventing and shortening the duration of delirium when compared to usual care?

Background: An acute and fluctuating decline in attention and cognition is a common problem in hospitalized older adult patients. Labeled as delirium, it is a condition well known to have poor clinical outcomes; yet, health service planners and practitioners have largely ignored its existence.1 Since hospitalization of older adults accounts for greater than 49% of all days of hospital care,2 the potential for occurrence of delirium is high, with estimates ranging from 6% to 56%.3,4 The incidence of delirium in ICU non-intubated patients ranges from 20% to 50%, and may be as high as 80% in intubated patients.5 In the non-ICU setting, incidence of delirium is estimated to be between 10% to 50%, also a statistically significant and important independent prognostic determinant of hospital outcomes including death (22-76%),6,7 new nursing home placement (OR 2.1; 95% CI=1.1 to 4.0), and functional decline (OR 3.0 at 95% CI=1.6 to 5.8).3 Yet in these settings, where staffing, clinical acumen, and goals of care differ from critical care, delirium is often undetected or misdiagnosed, and maybe poorly treated.8,9

Delirium is especially prevalent in the older adult with chronic conditions and physiological impairments, which contribute to substantial morbidity, mortality and expense.10,11 Sloss and colleagues12 identified 21 diagnoses for quality improvement measures for the vulnerable elderly in community and nursing home settings in the Assessing Care of Vulnerable Elders (ACOVE) study. On a scale of 1 to 7 (highest to lowest) delirium ranked 1.83 on the final round behind pharmacologic problems and depression.12 A systematic review of 42 studies on delirium in medical inpatients found that the occurrence of delirium varied between 11% and 42%.13 Contin and colleagues14 reported that the incidence of delirium ranges from 13% to 41% in elective orthopedic surgery and increases to 26% to 61% in non-elective surgery. Delirium in the non-ICU patient is associated with greater functional loss, higher incidence of pressure ulcers, and incontinence as well as protracted hospital stay, increased use of health care resources, and greater caregiver burden.4,15-17 Evidence also suggests that symptoms persist in about a third of patients and that these patients will have a poor prognosis.18 For patients who continue to be delirious after hospital discharge, additional cost continues to accrue for institutionalization, rehabilitation services, formal home health care, and informal care giving.10 Total cost estimates attributable to delirium range from US$16,303 to US$64,421 per patient resulting in an overall financial burden of US$38 billion to US$152 billion each year.19 The financial return of a delirium prevention program estimated savings of more than US$7.3 million per year. It included cost savings from reduced length of stay of patients with delirium.19 Prevention of this complication is of para mount importance to patients, families and healthcare institutions due to the physical, emotional and financial burdens of caring for the older adult who is suffering from delirium.

Characteristics of delirium include a rapid onset, fluctuating course, and evidence of a physical cause, along with disturbances of consciousness, memory, thought, perception and behavior.8,9,20 It is rare for a single factor to be the cause of delirium, rather, there is an increased risk for development of delirium in hospitalized patients by the presence of predisposing factors and interaction with precipitating factors, of which the most common are medication and infection.10,13 The physical hospital environment has also been identified as a precipitating factor for the onset of delirium.17 Vulnerable patients are subject to long emergency room wait times and are exposed to a stressful environment often characterized by multiple staff, disturbed sleep, discomfort, dehydration and limited access to food, fluids and mobilization.

Despite the availability of reliable delirium screening tools like the Confusion Assessment Method (CAM),21 current US hospital standard of care does not require systematic screening for cognitive impairment, delirium, or risk factors for delirium across non-ICU inpatient populations. There is limited understanding of the syndrome among clinical staff, and delirium in many medical-surgical patients is under diagnosed, misdiagnosed and undertreated,9,22,23 resulting in limited and inconsistent access to consultation, liaison and advice from geriatricians and psychiatrists.24,25 Frequently cited medical conditions that may trigger an episode of delirium include but are not limited to hepatic/renal failure, cancer, stroke, trauma, malnutrition, infection and cardiovascular disorders.25 Acquired inpatient conditions may include dehydration, infection and combination of medications, fecal impaction, or a specific medication. Changes to the individual's environment that may activate an episode of delirium may include light, noise, temperature of room along with lack of privacy and an unfamiliar environment.5 From the individual perspective, deficits in sight and hearing, pain, lack of sleep and isolation increase the risk for delirium. Invasive tubes, such as indwelling urinary catheters, along with dressings and other devices that restrict movement may lead to increased incidence of delirium.25

Several delirium prevention programs consist of targeted multi-factorial, non-pharmacological interventions. In general, the individual components of the interventions may vary in practice. Examples of interventions that have been investigated and reported in the research literature include cognitive activities or orientation, attending to bowel and bladder functions, early mobilization, geriatric consultation, hydration and nutrition, pain management, sleep enhancement, vision and hearing protocols and staff education to name a few.26,33 At least one study of hospitalized patients that focused on multiple interventions to reduce or eliminate modifiable predisposing and precipitating factors, resulted in significant reductions in the number and duration of episodes of delirium in hospitalized patients.26 In comparison, very few studies explored the effect of a single non-pharmacological intervention on decreasing the incidence or lessening the severity of delirium.45-48

Professional organizations strongly recommend and make available evidence-based national best practice guidelines on delirium care. For example, the American Association of Critical Care Nurses has an evidence-based Practice Alert on delirium assessment and management.27 However, the team caring for the non-critical, yet acutely ill patient in the non-ICU setting, is unprepared to deal with the presentation of delirium. In fact, nurses and physicians often fail to identify delirium in two-thirds of patients due to its varied presentation and fluctuating nature.13 Delirium prevention is desirable for both patients and healthcare personnel as early recognition and prevention is a quality indicator of hospital care.8,28

We found no systematic review specific to the evidence on non-pharmacological, multi-component interventions to prevent delirium in the hospitalized older adult non-ICU population. The Cochrane Library published a systematic review on delirium prevention interventions that included pharmacological measures and was limited to randomized control trials.29 In 2012, the Joanna Briggs Institute published multiple evidence summaries on delirium screening and assessment, prevention, and management,30-32 but no systematic review. In 2005, Milisen and colleagues published a systematic review on multi-component interventions for delirium in hospitalized older adults.33 However, they did not exclude the ICU population.