Multi-component interventions can reduce delirium incidence. Occupational therapy (OT) has been effective in the management of dementia. We designed a real-world feasibility study of an OT intervention in the management of delirium superimposed on dementia (DSD).
We included a convenient sample of 22 patients older than 65 years of age with delirium and moderate dementia admitted to a nursing home (NH). The OT procedures were standardized according to the level of agitation or sedation of the patient and based on a structured OT evaluation. The Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution.
The mean age was 86.45 ± 6.46 years. The first daily treatment was delivered in the entire sample, while the second was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6. The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min. The mean time of the first treatment varied day 1 through day 6 from 14.8 ± 8.5 to 20 ± 0 min, while the second treatment from 3.9 ± 6.7 to 20.1 ± 0 min. The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution.
This is the first study to report the feasibility of an OT intervention for the management of DSD in a NH setting. The results are important to support future trials on delirium management in a setting often understudied and underrepresented.
Delirium is an acute brain dysfunction characterized by inattention and disturbance of awareness, which develops over a short period of time and fluctuates during the course of the day; additional disturbances in cognition might be present . When delirium occurs in patients with dementia is named delirium superimposed on dementia (DSD) and the diagnosis can be challenging . DSD prevalence is up to 80% according to the definition and the settings . DSD is linked to adverse clinical outcomes, including worsening of dementia and functional status, mortality, and institutionalization [3,4,5,6,7]. Additionally, DSD is distressing for the patients, caregivers, and health care staff [8,9,10].
Pharmacological prevention and treatment trials failed to show any efficacy and effectiveness in the treatment of delirium. Indeed, the use of antipsychotics is not supported for the prevention and treatment of delirium . Interestingly, Inouye and colleagues 20 years ago reported a significant reduction of the incidence of delirium with a multicomponent and multidisciplinary intervention focused on cognitive stimulation, avoidance of sleep deprivation, early mobilization, management of dehydration, and visual and hearing impairments . Since this trial was published, several investigations have been conducted and it is now accepted that multicomponent interventions can reduce the incidence of delirium by 40% [13, 14].
Only recently, researchers focused their attention on the role of occupational therapy for the management of patients with delirium [15, 16]. One trial combined early occupational therapy and physical therapy for the management of critically ill ventilated patients showing a reduction of duration of delirium and better functional outcomes . Another pilot trial showed a reduction of delirium incidence and duration, and improved functional status in non-ventilated acutely ill elderly patients in the intensive care unit . However, occupational therapy has been shown to be effective, especially in the management of patients with dementia . This evidence led to the publication of the first preliminary application of occupational therapy in a multidisciplinary team in patients with DSD admitted to rehabilitation settings .
Therefore, we designed a feasibility study in the real world to evaluate the applicability of a structured occupational therapy intervention in the management of patients with moderate dementia and delirium admitted to a nursing home (NH) to provide key information to support future intervention trials.
We performed a feasibility study of 22 patients older than 65 years of age with moderate dementia and delirium admitted to 80-beds ward of the NH Fondazione Luigi Boni (Suzzara, Italy) between June and December 2017. We excluded patients with a standardized S-Mini Mental State Examination > 20 (s-MMSE) , a Clinical Dementia Rating Scale ≥ 3 or ≤ 1 , life expectancy < 6 months, or refusal of consent. The local ethics committee approved the study protocol. Informed consent was obtained from patients’ authorized surrogates.
Demographics and clinical variables
Age, gender, and the total number of drugs were collected. Co-morbidity was evaluated with the CIRS co-morbidity index . The functional status was ascertained using the Barthel Index (BI) and the Tinetti Scale [22, 23]. The BI was recorded before the delirium episode (i.e., the last evaluation available in the NH records), at the time of delirium and at delirium resolution. The Tinetti scale was evaluated at the time of delirium and at delirium resolution.
Delirium and dementia definition
Each patient was screened daily by the nurses using the RADAR . The RADAR has been shown to have a sensitivity of 100% and a specificity of 77% to detect delirium in long-term care facilities when compared to the DSM-5 criteria.  The RADAR consists of three items the nurse should evaluate during the drug administration: (1) was the patient drowsy? (2) did the patient have trouble following the instructions?; (3) were the patient’s movements slowed down? A RADAR screening is considered positive when at least one item is checked. However, given the higher sensitivity and specificity when the RADAR is administered more than once a day, for the purpose of our study, we considered it positive when at least two evaluations were positive. Then the patient was assessed by an expert geriatrician (IS, LPDV) following the DSM-5 criteria to confirm the presence of delirium and monitored the presence of delirium daily until delirium resolution . Patients’ alertness was assessed using the m-RASS.  The m-RASS ranges from + 4 (combative, violent, immediate danger to staff) to − 5 (unarousable to voice or physical stimulation). The severity of delirium was evaluated using the Delirium-O-Meter (D-O-M), a nurses’ rating scale for monitoring delirium severity in geriatric patients . Total scores range from 0 to 36, with higher scores representing greater symptom burden. The D-O-M was filled out by an expert geriatrician, simultaneously with the DSM-5 delirium evaluation.
Dementia was defined as moderate according to a previous s-MMSE score between 10 and 20 and a clinical Dementia Rating Scale (CDR) 2–3. [19, 20] The s-MMSE and the CDR are routinely administered every 6 months in the nursing home as part of the clinical evaluation.
Occupational therapy intervention
When delirium was diagnosed, the occupational therapy service in the NH was activated. We used on purpose the staff occupational therapist to further test the applicability of the protocol in the real world. The occupational therapist intervention was structured in a daily 60 min protocol divided into two sessions of 30 min, Monday through Friday, until delirium resolution or for a total of maximum 3 weeks. At the beginning of each occupational therapy session, the m-RASS was administered and the procedures of the occupational therapist were standardized according to the patient’s level of agitation or sedation classified via m-RASS scale, as described in Table 1. A comprehensive goal-setting evaluation was determined using goal-setting instruments for occupational therapy (MOHO Interest Checklist by Kielhofner and Occupational Profile)  and the Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution . For the purpose of the study, the proxy was identified in the nurses’ assistants (NAs) of the NH staff. The COPM was developed as a client-centered tool to enable individuals to identify and prioritize everyday issues that restrict or impact their performance in everyday living. One of the strengths of the measure is its broad focus on occupational performance in all areas of life, including self-care, leisure and productivity, taking into account development throughout the lifespan and the personal life circumstances. The COPM score ranges from 1 (very dissatisfied with the occupational performance) to 10 points (very satisfied with the occupational performance). The occupational therapy protocol included the possibility to delegate part of the interventions (e.g., transfers, dressing, hygiene) to the NAs and to the physical therapists (PTs) to allow the OT to focus on other specific interventions identified via the MOHO evaluation. This approach was chosen since in the NH, where the study was carried out there was only one occupational therapist. This situation is in line with the Italian context.
In addition to the treatment protocol administered by the occupational therapist, the patients enrolled received a standard nursing and medical treatment for the management of delirium as described in the NICE guidelines (https://www.nice.org.uk/guidance/cg103).
Demographics and clinical variables were summarized using median and interquartile range (IQR) for continuous variables or proportions for categorical variables at the time of delirium and at delirium resolution. All statistical analyses were performed using STATA version 11(http://www.stata.com/stata11/).
A convenient sample of 22 patients with moderate dementia was included in the study. Demographics and clinical characteristics are summarized in Table 2.
As expected, the cognitive and function status worsened at delirium onset as shown by the mean s-MMSE, the BI, the Tinetti scale and partially recovered at delirium resolution (Table 2). The main causes of delirium were pulmonary (N = 4, 18%) and urinary tract infections (N = 11, 50%), drugs changes (N = 2, 9%), bowel obstruction (N = 2, 9%), and dehydration (N = 3, 14%). Among the 22 patients, 50% (N = 11) were still delirious on day 2, 18% (N = 4) on day 3 and 4, and only in one patient delirium lasted for a total of 6 days. On the first day of delirium, 68% of the patients were categorized with hypoactive delirium (N = 15) with an m-RASS score ranging from − 3 to − 1, whereas 32% (N = 7) were categorized with hyperactive delirium, m-RASS score ranging from + 1 to + 3.
Overall, following the protocol based on the m-RASS level described in Table 1, one daily treatment was delivered in the entire sample (100%) (Table 3). In details, the first daily treatment was always delivered, while the second treatment was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6 (Table 3). The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min (Fig. 1). On the first day, the afternoon treatment was not delivered due to absence of time of the occupational therapist (N = 5, 23%), aggressive behavior (N = 1, 5%) and non-compliance (N = 2, 9%) to the treatment by the patient. On day 2, 3, and 4, the afternoon treatment was not possible for absence of occupational therapist time in 27% (N = 3), 50% (N = 2), 33% (N = 1) of the cases, respectively. Finally, on the last day, the afternoon treatment was not delivered for aggressive behavior. As part of the protocol, the occupational therapist delegated the following treatments to the NAs and the PTs: dressing, transfer from bed to chair, hygiene, activities with upper limbs after appropriate training by the occupational therapist. In details, on day 1 dressing (N = 1, 5%), transfers (N = 3, 14%), hygiene (N = 3, 14%) were delegated to nursing aids (N = 4, 18%) and physical therapists (N = 3, 14%); on the second day, dressing (N = 1, 5%), transfers (N = 1, 5%), hygiene (N = 2, 4%), upper arm activities (N = 2, 4%) were delegated to nursing aids (N = 3, 5%) and physical therapists (N = 1, 5%); on the third day, transfers (N = 1, 5%), upper arms activities (N = 1, 5%) were delegated to nursing aids (N = 1, 5%) and physical therapists (N = 1, 5); on the fourth day, transfers (N = 2, 9%), upper arms activities (N = 2, 5%) were delegated to nursing aids (N = 1, 100%); on the fifth and sixth days, upper arms activities (N = 1, 5%) were delegated to nursing aids (N = 1, 100%).
The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution (Table 2).
To the best of our knowledge, this is the first study to report the feasibility of an occupational therapy intervention for the management of patients with DSD in a NH setting with a specific focus on the real-world applicability. Overall, the protocol was applied to each patient at least once a day. The occupational therapist coordinated the interventions with other figures within the NH staff, including the NAs and the PTs. The intervention was more difficult to deliver in the aggressive patients. At delirium resolution, the patients recovered almost completely from the pre-delirium cognitive and functional status.
Previous studies showed the efficacy of non-pharmacological interventions for the management of patients with dementia . Among non-pharmacological interventions, occupational therapy protocols have been effective in improving functioning, behavioral symptoms, and quality of life in frail older adults with mild-moderate dementia and in their caregivers [30,31,32,33]. Effective occupational therapy programs include: environmental assessment, problem solving strategies, interactive caregiver education, and training. Along the evidence of non-pharmacological interventions for patients with dementia, there is a convincing evidence of non-pharmacological intervention for the prevention of delirium [13, 14]. However, to date, it is not clear how the occupational therapist should interact with the patient and the multidisciplinary team.
In our study, we developed a new occupational therapy approach following a previous trial in critical care patients  and considering that the mental status evaluation and motor fluctuations are important features in the monitoring of DSD . Brummel and colleagues  described a protocol of cognitive and physical therapy with the involvement of OTs according to the m-RASS levels. Similarly, we chose to provide an occupational therapy intervention, which would not exclude the patient if he was drowsy, but we targeted the intervention according to the level of arousal providing a more intensive stimulation, when the patient was awake and alert. This allowed us to treat those patients who are usually excluded and more likely to be not mobilized for their low level of arousal. Another key point is that we used the personnel available in the NH to provide information to design future trials, considering the applicability of a structured OT protocol in the daily clinical practice. Indeed in the last years, there has been an increasing interest in obtaining real-world evidence to provide results on the effectiveness of different interventions from heterogeneous group of patients in clinical practice .
This study introduces innovative and important practical implications for the management of people with delirium and dementia in NH settings. Future larger studies also in other settings are required to further understand the feasibility and the implications of this approach on delirium. The occupational therapist can act as a facilitator of the engagement in daily life activities, enabling the maintenance of a meaningful routine by implementing the best practice for the management of delirium. This comprehensive approach includes cognitive tasks, engagement in familiar daytime activity, functional tasks, timetables, both physical and non-physical activities, and environmental modifications. Each activity should be tailored to the person, only significant occupations are considered. Therefore, it is essential to provide comprehensive occupational therapy assessments with profession-specific tools such as “Interest list” by Kielhofner or COPM. Occupational therapists are also encouraged to know and administer delirium-screening scales such as 4AT, m-RASS, and RADAR.
Environmental modifications for people with delirium such as reducing stressful noises, or excess stimulus, bed space, an appropriate lighting through day and night, including natural light are appropriate as much as for people with dementia.
From a functional point of view, the participation of clients through significant occupations should include an early mobilization through sitting out and walk and stand. The delirium event is, by definition, an acute change that could have a significant impact on the family. Therefore, the occupational therapist should have a critical role in training and informing the caregiver. A well-trained caregiver can be encouraged to a conscious and proper care, in alliance with the staff of the nursing home, with a significant role of “facilitator” of the activity, because of the emotional bound and the common knowledge of roles, habits and routines of the resident.
It is therefore essential to organize the system with the main goal to promote an early diagnosis of delirium in NH settings using delirium tools. This approach would allow to correctly identify patients with delirium providing a non-pharmacological treatment delivered by an interdisciplinary team including an occupational therapist. The non-pharmacological management should be coupled with the correct and prompt identifications of the underlying causes leading to the occurrence of delirium. The correct delirium management can favor the prevention of delirium’s complications (i.e., low mobility, pressure sores, malnutrition, and dehydration) and the application of cognitive/functional intervention to help the resolution of delirium.
Occupational therapy can therefore, in our opinion, play a primary role in non-pharmacological prevention and treatment of delirium in the person with dementia and frailty, even in motivating and training both formal and informal caregivers.
This study showed the feasibility of an innovative occupational therapy intervention with tailor-made activity in the multidisciplinary team for the management of DSD in a NH setting. The results of the current study are important to support future clinical trials in a setting often understudied and underrepresented.
American Psychiatric Association A (2013) Diagnostic and statistical manual of mental disorders, 5th edn. APA, Washington
Morandi A, McCurley J, Vasilevskis EE et al (2012) Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 60:2005–2013
Fick DM, Agostini JV, Inouye SK (2002) Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 50:1723–1732
Sampson EL, Blanchard MR, Jones L et al (2009) Dementia in the acute hospital: prospective cohort study of prevalence and mortality. Br J Psychiatry 195:61–66
Fick DM, Steis MR, Waller JL et al (2013) Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med 8:500–505
Bellelli G, Frisoni GB, Turco R et al (2007) Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility. J Gerontol Ser A Biol Sci Med Sci 62:1306–1309
Morandi A, Davis D, Fick DM et al (2014) Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc 15:349–354
Morandi A, Lucchi E, Turco R et al (2015) Delirium superimposed on dementia: a quantitative and qualitative evaluation of patient experience. J Psychosom Res 79:281–287
Morandi A, Lucchi E, Turco R et al (2015) Delirium superimposed on dementia: a quantitative and qualitative evaluation of informal caregivers and health care staff experience. J Psychosom Res 79:272–280
Grossi E, Lucchi E, Gentile S (2019) Preliminary investigation of predictors of distress in informal caregivers of patients with delirium superimposed on dementia. Aging Clin Exp Res. https://doi.org/10.1007/s40520-019-01194-7
Neufeld KJ, Yue J, Robinson TN (2016) Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc 64:705–714
Inouye SK (1999) Predisposing and precipitating factors for delirium in hospitalized older patients. Dement Geriatr Cogn Disord 10:393–400
Abraha I, Rimland JM, Trotta F et al (2016) Non-pharmacological interventions to prevent or treat delirium in older patients: clinical practice recommendations The SENATOR-ONTOP series. J Nutr Health Aging 20:927–936
Siddiqi N, Harrison JK, Clegg A et al (2016) Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 11:CD005563
Alvarez EA, Garrido MA, Tobar EA et al (2017) Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit. A pilot randomized clinical trial. J Crit Care 37:85–90
Schweickert WD, Pohlman MC, Pohlman AS et al (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874–1882. https://doi.org/10.1016/S0140-6736(09)60658-9
Pozzi C, Lanzoni A, Lucchi E et al (2018) A pilot study of community-based occupational therapy for persons with dementia (COTID-IT Program) and their caregivers: evidence for applicability in Italy. Aging Clin Exp Res 31:1299–1304
Pozzi C, Lucchi E, Lanzoni A et al (2017) Preliminary evidence of a positive effect of occupational therapy in patients with delirium superimposed on dementia. J Am Med Dir Assoc 18:1091–1092
Molloy DW, Standish TI (1997) A guide to the standardized mini-mental state examination. Int Psychogeriatr 9:87–94
Berg L (1988) Clinical dementia rating (CDR). Psychopharmacol Bull 24:637–639
Parmelee PA, Thuras PD, Katz IR et al (1995) Validation of the cumulative illness rating scale in a geriatric residential population. J Am Geriatr Soc 43:130–137
Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. Md State Med J 14:61–65
Tinetti ME, Williams TF, Mayewski R (1986) Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 80:429–434
Voyer P, Champoux N, Desrosiers J et al (2015) Recognizing acute delirium as part of your routine [RADAR]: a validation study. BMC Nurs 14:19
Chester JG, Beth Harrington M, Rudolph JL (2012) Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med 7:450–453. https://doi.org/10.1002/jhm.1003
de Jonghe JF, Kalisvaart KJ, Timmers JF et al (2005) Delirium-O-Meter: a nurses’ rating scale for monitoring delirium severity in geriatric patients. Int J Geriatr Psychiatry 20:1158–1166. https://doi.org/10.1002/gps.1410
Kielhofner G (2008) Model of human occupation: theory and application, 4th edn. Lippinicott Williams & Wilkins, Philadelphia
Law M, Baptiste S, Carswell A et al (2014) Canadian occupational performance measure (COPM). CAOT publications, Ottawa
Dyer SM, Harrison SL, Laver K et al (2017) An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. Int Psychogeriatr 30:295–309
Piersol CV, Jensen L, Lieberman D et al (2018) Occupational therapy interventions for people with Alzheimer’s disease. Am J Occup Ther 72:7201390010p1–7201390010p6
DiZazzo-Miller R, Samuel PS, Barnas JM et al (2014) Addressing everyday challenges: feasibility of a family caregiver training program for people with dementia. Am J Occup Ther 68:212–220
Gitlin LN, Arthur P, Piersol C et al (2018) Targeting behavioral symptoms and functional decline in dementia: a randomized clinical trial. J Am Geriatr Soc 66:339–345
Graff MJ, Vernooij-Dassen MJ, Thijssen M et al (2006) Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. BMJ 333:1196
Brummel NE, Girard TD, Ely EW et al (2013) Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the activity and cognitive therapy in ICU (ACT-ICU) trial. Intensive Care Med 40:370–379
Morandi A, Han JH, Meagher D et al (2016) Detecting delirium superimposed on dementia: evaluation of the diagnostic performance of the richmond agitation and sedation scale. J Am Med Dir Assoc 17:828–833
Chen P, Dowal S, Schmitt E et al (2015) Hospital elder life program in the real world: the many uses of the hospital elder life program website. J Am Geriatr Soc 63:797–803
Conflict of interest
The authors declare no conflicts of interest.
All procedures performed in the study were in accordance with the ethical standards of the Ethical Committee Val Padana (Protocol 34788/17) and with the 1964 Helsinki declaration.
Informed consent was obtained from patients’ authorized surrogates at study enrollment.
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Pozzi, C., Lanzoni, A., Lucchi, E. et al. Activity-based occupational therapy intervention for delirium superimposed on dementia in nursing home setting: a feasibility study. Aging Clin Exp Res 32, 827–833 (2020). https://doi.org/10.1007/s40520-019-01422-0
- Occupational therapy
- Nursing home
- Tailor-made activity