JBI Database of Systematic Reviews & Implementation Reports 2013;11(7)

Transcription

1 The effectiveness of non-pharmacological multi-component interventions for the prevention of delirium in non-intensive care unit older adult hospitalized patients: a systematic review protocol Elizabeth Thomas, MSN, RN, 1* Jane E. Smith, MSN, RN, 1* D. Anthony Forrester, PhD, RN, ANEF 2 Gerti Heider, PhD, RN, 1 Yuri T. Jadotte, MD, 1, 2 Cheryl Holly, EdD, RN 1, 2 1.Rutgers School of Nursing 2.The Northeast Institute for Evidence Synthesis and Translation (NEST): A Collaborating Center of the Joanna Briggs Institute Rutgers School Of Nursing *Equal contribution as Primary Reviewer Corresponding author: Elizabeth Thomas thomase3@sn.rutgers.edu Review question/objective In older adult hospitalized non-intensive care unit (ICU) patients, are targeted non-pharmacological, multicomponent 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, doi: /jbisrir Page 361

2 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 colleagues 12 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 colleagues 14 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 paramount 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 doi: /jbisrir Page 362

3 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 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, but no systematic review. In 2005, Milisen and colleagues published a systematic review on multicomponent interventions for delirium in hospitalized older adults. 33 However, they did not exclude the ICU population. Keywords non-pharmacological; delirium; prevention; multi-component; effect; hospitalised; adult patient doi: /jbisrir Page 363

4 Inclusion criteria Types of participants This review will consider studies that include hospitalized patients aged 60 years and over, who are identified to be at risk for delirium or experiencing delirium using one of the standard published delirium screening, recognition and diagnostic tools: Diagnostic and Statistical Manual of Mental Disorders (DSM IV), 34 Mental Status Questionnaires, 35 Mini Mental State Examination (MMSE), 36 Confusion Assessment Method (CAM), 21 and International Classification of Diseases (ICD10). 37 Types of intervention(s)/phenomena of interest This review will consider studies that evaluate non-pharmacological, multi-component interventions for the prevention of delirium compared to usual care. Typical multi-component interventions will include use of specialized clinical staff/volunteers, geriatric/psychiatric consultation, staff education, patient orientation, addressing visual and hearing needs, sleep enhancement, medication review, hydration and nutrition, early mobilization, pain management, addressing bowel and bladder functions, prevention and treatment of medical complications etc. Types of outcomes This review will consider studies that include the following outcome measures: Incidence of delirium, which is the number of new cases occurring during hospitalization, and length of delirium time defined as the onset of delirium symptoms to resolution of delirium symptoms. Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, and case control studies. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL through EBSCO host will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English language will be considered for inclusion in this review. Studies published from 1990 to the present (2013) will be considered for inclusion in this review. In the 1990s, multi-component intervention strategies began to appear in published literature investigating prevention of delirium doi: /jbisrir Page 364

5 The secondary search will be divided into four components: (a) primary search of MEDLINE, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials using all identified index terms and keywords. (In addition, RSS feeds will be created for MEDLINE, CINAHL, and PsycINFO to identify additional articles once the primary search is complete), (b) search of non-indexed databases using identified keywords, (c) search of the grey literature using identified keywords, and (d) relevant journals will be electronically hand-searched to identify articles that were not indexed in any of the identified databases. The databases to be searched via EBSCO and OVID platforms will include: MEDLINE, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials Academic Search Premier, Health Source: Nursing / Academic Edition, ProQuest, PsycARTICLES, Sage, Salem Health, and Science Journals to take into account the differences in controlled vocabulary and syntax rules. The search for unpublished studies will include: Websites of Agency for Healthcare Research and Quality (AHRQ), Dissertation Abstracts Online, Institute for Healthcare Improvement, MedNar, NY Academy of Medicine (NYAM), Science.gov, Scirus.com, Theses Canada, Virginia Henderson International Nursing Library, and Worldcat: Libraries Worldwide. Relevant journals for hand searching will include: American Journal of Nursing; Journal of Clinical Nursing; Journal of Advanced Nursing, Journal of Professional Nursing, Nursing Research, Applied Nursing Research, New England Journal of Medicine, British Medical Journal. Initial keywords to be used will be: Delirium Acute confusion Acute confusional state Acute altered mental state Medical surgical inpatients Hospital in-patient Hospitalization Non-ICU Non critical care Older adults Elderly Prevention Interventions Multi-component interventions doi: /jbisrir Page 365

6 Non pharmacological interventions Nursing care Usual care Outcomes Delirium incidence Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. The following components will be extracted from each of the studies: Setting of the program Method of sample selection Patient demographics Patient inclusion / exclusion criteria Detailed description of the intervention program and control Length of intervention Description of the method(s) for statistical analysis Description of outcomes Summary of author(s) conclusions Reviewer s notes/comments In addition, attempts will be made to obtain data missing from the study report(s) by contacting the authors. doi: /jbisrir Page 366

7 Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and where appropriate also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest None to disclose. Acknowledgements This systematic review is undertaken in partial fulfillment of the requirements of the Doctor of Nursing Practice degree (ET, JS). We would like to acknowledge D Anthony Forrester, PhD, RN, ANEF, for his personal guidance and support in the development of this proposal and for being the chair of our capstone committee. Thank you to Cheryl Holly, EdD, RN, and Yuri T Jadotte, MD, for their valuable feedback to this proposal. Thank you also to Gerti Heider, PhD, RN, for her feedback and for serving on our capstone committee. We also thank Rita Musanti, PhD, MSN, ANP, for introducing us to the Joanna Briggs Institute systematic review program. Special thanks to Mercedes Echevarria, DNP, APN, for encouraging us to enroll in the DNP Program. doi: /jbisrir Page 367

8 References 1. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106 (5): Aging Ao. A profile of older Americans: In: Services USDoHaH, editor. United States Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine. 1998: 14 (4): Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? J Gen Intern Med. 1998;13(4): Fan Y, Guo Y, Li Q, Zhu x. A review: nursing of intensive care unit delirium. J Neurosci Nurs. 2012;44(6): McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. 2002; 162(4): American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999; 156: Suppl: Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(4): Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing. 2009;38(1): Inouye SK. Current concepts: delirium in older persons. N Engl J Med. 2006;354 (11): Young J, Inouye SK. Delirium in older people. BMJ. 2007;334 (7598): Sloss EM, Solomom D, and collegues. Selecting target conditions for quality of care improvement in vulnerable older adults. Journal of the American Geriatrics Society. 2000; 48 (4): Ljubisavljevic V, Kelly B. Risk factors for development of delirium among oncology patients. Gen Hosp Psychiatry. 2003;25 (5): Contín AM, Perez-Jara J, Alonso-Contín A, Enguix A, Ramos F. Postoperative delirium after elective orthopedic surgery. Int J Geriatr Psychiatry. 2005;20 (6): O'Keeffe S, Lavan J. The prognostic significance of delirium in older hospitalized patients. J Am Geriatr Soc. 1997;45(2): Cole MG. Delirium in elderly patients. Am J Geriatr Psychiatry 2004;12 (1): McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc. 2003;51(11): McAvay GJ, Van Ness PH, Bogardus Jr ST, Ying Z, Leslie DL, Leo-Summers LS, et al. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc. 2006;54 (8): Leslie D, Marcantonio E, Zhang Y, Leo-Summers L, Inouye S. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168 (1): Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The confusion assessment method: a systematic review of current usage. J Am Geriatr Soc. 2008;56(5): Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A. & Horwitz R. Clarifying confusion: the confusion assessment method. Annals of Internal Medicine. 1990; 113(12): Inouye S, Foreman M, Mion L, Katz K, Cooney L, Jr. Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001;161(20): Kalisvaart KJ, Vreeswijk R, de Jonghe JFM, van der Ploeg T, van Gool WA, Eikelenboom P. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model. J Am Geriatr Soc. 2006;54(5): Flagg B, Cox L, McDowell S, Mwose J, Buelow J. Nursing identification of delirium. Clin Nurse Spec. 2010;24(5): Miller M. Evaluation and management of delirium in hospitalized older patients. Am Fam Physician. 2008;78(11): Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New Engl J Med. 1999;340 (9): doi: /jbisrir Page 368

9 27. Nurses AAoCC. AACN practice alert: delirium assessment and management 2011, November. Available from: Sloss EM, Solomon DH, Shekelle PG, Young RT, Saliba D, MacLean CH, et al. Selecting target conditions for quality of care improvement in vulnerable older adults. J Am Geriatr Soc. 2006;48 (4): Siddiqi N, Holt R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalized patients. Cochrane Database of Systematic Reviews DOI: / CD pub Tufanaru C. Delirium: screening and assessment [Evidence Summary on the Internet]. Adelaide: Joanna Briggs Institute; Available from: JBI Connect+ 31. Tufanaru C. Delirium: prevention [Evidence Summary on the Internet]. Adelaide: Joanna Briggs Institute; Available from: JBI Connect+ 32. Tufanaru C. Delirium: management [Evidence Summary on the Internet]. Adelaide: Joanna Briggs Institute; Available from: JBI Connect+ 33. Milisen K, Lemiengre J, Braes T, Foreman MD. Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. Journal of Advanced Nursing. 2005;52 (1): American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington, DC: American psychological Association, Author 35. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic deficit in elderly patients. J Am Geriatr Soc. 1975;23(10): Folstein M, Folstein S, McHugh P. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3): Organization WH. ICD-10 classifications of mental and behavioural disorder: clinical descriptions and diagnostic guidelines. Geneva: World Health Organisation; Zimberg M, Berenson S. Delirium in patients with cancer: nursing assessment and intervention. Oncology Nursing Forum. July 1990; 17(4): Morency C. Mental status change in the elderly: recognizing and treating delirium. Journal Of Professional Nursing. 1990; 6(6): Wanich C, Sullivan-Marx E, Gottlieb G, Johnson J. Functional status outcomes of a nursing intervention in hospitalized elderly. Image: Journal Of Nursing Scholarship. 1992; 24(3): Holt J. How to help confused patients. American Journal Of Nursing. 1993; 93(8): Wilson L. Sensory perceptual alteration: diagnosis, prediction, and intervention in the hospitalized adult. Nursing Clinics Of North America. 1993; 28(4): Bleasdale S, George J. Managing delirium in elderly people. Elderly Care.1996;8(5): Kelley F. Planning care for acutely confused critically ill older persons. Critical Care Nursing Quarterly. 1996; 19(2): Taguchi T, Yano M, Kido Y. Influence of bright light therapy on postoperative patients: A pilot study. Intensive and Critical Care Nursing (23): Taguchi T. Bright light treatment for prevention of perioperative delirium in elderly patients. Journal of Nursing Education and Practice, 2013, Vol. 3, No. 10 DOI: /jnep.v3n10p McCaffrey R, Locsin R. The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery. International Journal of Older People Nursing in association with Journal of Clinical Nursing, 2004: 13 (6b) Tabet N, Hudson S, Sweeney V, Sauer J, Bryant C, MacDonald A, Howard R. An educational intervention can prevent delirium on acute medical wards. Age and Ageing, 2005 (34): doi: /jbisrir Page 369

10 Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message Insert page break doi: /jbisrir Page 370

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13 Appendix II: Data extraction instruments MAStARI data extraction instrument Insert page break doi: /jbisrir Page 373

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