Abstract
Description
The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium.
Objectives
To develop explicit and transparent recommendations for nonpharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations.
Methods
A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations.
Results
The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards).
Conclusions
Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.
Similar content being viewed by others
References
Alvarez Fernandez B, Formiga F, Gomez R. Delirium in hospitalised older persons: review. J Nutr Health Aging. 2008;12(4): 246–51. Epub 2008/04/01. PubMed PMID: 18373033.
Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age and ageing. 2009;38(1): 19–26. doi: 10.1093/ageing/afn253.
Martinez JA, Belastegui A, Basabe I, Goicoechea X, Aguirre C, Lizeaga N, et al. Derivation and validation of a clinical prediction rule for delirium in patients admitted to a medical ward: an observational study. BMJ Open. 2012;2(5). doi: 10.1136/bmjopen-2012-001599.
Witlox J, Eurelings LS, De Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. Jama. 2010;304(4): 443–51. Epub 2010/07/29. doi: 10.1001/jama.2010.1013. PubMed PMID: 20664045.
Whitlock EL, Vannucci A, Avidan MS. Postoperative delirium. Minerva anestesiologica. 2011;77(4): 448–56. Epub 2011/04/13. PubMed PMID: 21483389; PubMed Central PMCID: PMCPmc3615670.
Beauchet O, Launay C, De Decker L, Fantino B, Kabeshova A, Annweiler C. Who is at risk of long hospital stay among patients admitted to geriatric acute care unit? Results from a prospective cohort study. J Nutr Health Aging. 2013;17(8): 695–9. Epub 2013/10/08. doi: 10.1007/s12603-013-0333-z. PubMed PMID: 24097024.
Bickel H, Gradinger R, Kochs E, Forstl H. High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study. Dementia and geriatric cognitive disorders. 2008;26(1): 26–31. Epub 2008/06/26. doi: 10.1159/000140804. PubMed PMID: 18577850.
Gottesman RF, Grega MA, Bailey MM, Pham LD, Zeger SL, Baumgartner WA, et al. Delirium after coronary artery bypass graft surgery and late mortality. Annals of neurology. 2010;67(3): 338–44. Epub 2010/04/08. doi: 10.1002/ana.21899. PubMed PMID: 20373345; PubMed Central PMCID: PMCPmc3723404.
De Boissieu P, Mahmoudi R, Hentzien M, Toquet S, Novella JL, Blanchard F, et al. Predictors of Long-Term Mortality in Oldest Old Patients (90+) Hospitalized to Medical Wards via the Emergency Department: The SAFES Cohort. J Nutr Health Aging. 2015;19(6): 702–7. Epub 2015/06/10. doi: 10.1007/s12603-015-0515-y. PubMed PMID: 26054508.
Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Archives of internal medicine. 2008;168(1): 27–32. Epub 2008/01/16. doi: 10.1001/archinternmed.2007.4. PubMed PMID: 18195192.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920): 911–22. doi: 10.1016/S0140-6736(13)60688-1. PubMed PMID: 23992774; PubMed Central PMCID: PMC4120864.
Abraha I, Cruz-Jentoft A, Soiza RL, O’Mahony D, Cherubini A. Evidence of and recommendations for non-pharmacological interventions for common geriatric conditions: the SENATOR-ONTOP systematic review protocol. BMJ Open. 2015;5(1):e007488. Epub 2015/01/30. doi: 10.1136/bmjopen-2014-007488. PubMed PMID: 25628049; PubMed Central PMCID: PMCPMC4316555
Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, et al. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One. 2015;10(6):e0123090. doi: 10.1371/journal.pone.0123090. PubMed PMID: 26062023; PubMed Central PMCID: PMC4465742.
Velez-Diaz-Pallares M, Lozano-Montoya I, Abraha I, Cherubini A, Soiza RL, O’Mahony D, et al. Nonpharmacologic Interventions to Heal Pressure Ulcers in Older Patients: An Overview of Systematic Reviews (The SENATORONTOP Series). J Am Med Dir Assoc. 2015. Epub 2015/03/05. doi: 10.1016/j.jamda.2015.01.083. PubMed PMID: 25737261.
Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. Journal of clinical epidemiology. 2011;64(4): 395–400. doi: 10.1016/j.jclinepi.2010.09.012. PubMed PMID: 21194891.
Guyatt GH, Oxman AD, Sultan S, Glasziou P, Akl EA, Alonso-Coello P, et al. GRADE guidelines: 9. Rating up the quality of evidence. Journal of clinical epidemiology. 2011;64(12): 1311–6. doi: 10.1016/j.jclinepi.2011.06.004. PubMed PMID: 21802902.
Lundstrom M, Olofsson B, Stenvall M, Karlsson S, Nyberg L, Englund U, et al. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Aging clinical and experimental research. 2007;19(3): 178–86. Epub 2007/07/04. PubMed PMID: 17607084.
Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. Journal of the American Geriatrics Society. 2001;49(5): 516–22. Epub 2001/06/15. PubMed PMID: 11380742.
Deschodt M, Braes T, Flamaing J, Detroyer E, Broos P, Haentjens P, et al. Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. Journal of the American Geriatrics Society. 2012;60(4): 733–9. Epub 2012/03/21. doi: 10.1111/j.1532-5415.2012.03899.x. PubMed PMID: 22429099.
Chen CC, Lin MT, Tien YW, Yen CJ, Huang GH, Inouye SK. Modified hospital elder life program: effects on abdominal surgery patients. Journal of the American College of Surgeons. 2011;213(2): 245–52. doi: 10.1016/j.jamcollsurg.2011.05.004. PubMed PMID: 21641835.
Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age and ageing. 2007;36(2): 190–6. Epub 2007/01/30. doi: 10.1093/ageing/afl163. PubMed PMID: 17259638.
Wong D, Bruce J, GB B. Innovations in Aged Care. Delirium prevention after hip fracture Quality project to prevent delirium after hip fracture. Australasian Journal on Ageing. 2005;24(3):174–7.
Milisen K, Foreman MD, Abraham IL, De Geest S, Godderis J, Vandermeulen E, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hipfracture patients. Journal of the American Geriatrics Society. 2001;49(5): 523–32. Epub 2001/06/15. PubMed PMID: 11380743.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of internal medicine. 1990;113(12): 941–8. Epub 1990/12/15. PubMed PMID: 2240918.
Martinez FT, Tobar C, Beddings CI, Vallejo G, Fuentes P. Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and ageing. 2012;41(5): 629–34. Epub 2012/05/17. doi: 10.1093/ageing/afs060. PubMed PMID: 22589080.
Inouye SK, Bogardus ST, Jr., Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. The New England journal of medicine. 1999;340(9): 669–76. Epub 1999/03/04. doi: 10.1056/nejm199903043400901. PubMed PMID: 10053175.
Vidan MT, Sanchez E, Alonso M, Montero B, Ortiz J, Serra JA. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. Journal of the American Geriatrics Society. 2009;57(11): 2029–36. Epub 2009/09/17. doi: 10.1111/j.1532-5415.2009.02485.x. PubMed PMID: 19754498.
Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age and ageing. 2006;35(1): 53–60. Epub 2005/10/22. doi: 10.1093/ageing/afi206. PubMed PMID: 16239239.
Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesthesia and analgesia. 2010;111(2): 451–63. Epub 2010/04/09. doi: 10.1213/ANE.0b013e3181d7e1b8. PubMed PMID: 20375300.
Asplund K, Gustafson Y, Jacobsson C, Bucht G, Wahlin A, Peterson J, et al. Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources. Journal of the American Geriatrics Society. 2000;48(11): 1381–8. Epub 2000/11/18. PubMed PMID: 11083312.
Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ. 2002;167(7): 753–9. PubMed PMID: 12389836; PubMed Central PMCID: PMC126506.
Cole MG, Primeau FJ, Bailey RF, Bonnycastle MJ, Masciarelli F, Engelsmann F, et al. Systematic intervention for elderly inpatients with delirium: a randomized trial. CMAJ. 1994;151(7): 965–70. PubMed PMID: 7922932; PubMed Central PMCID: PMC1337283.
Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. The journals of gerontology Series A, Biological sciences and medical sciences. 2006;61(2): 176–81. PubMed PMID: 16510862.
Lundstrom M, Edlund A, Karlsson S, Brannstrom B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Journal of the American Geriatrics Society. 2005;53(4): 622–8. doi: 10.1111/j.1532-5415.2005.53210.x. PubMed PMID: 15817008.
Tabet N, Hudson S, Sweeney V, Sauer J, Bryant C, Macdonald A, et al. An educational intervention can prevent delirium on acute medical wards. Age and ageing. 2005;34(2): 152–6. doi: 10.1093/ageing/afi031. PubMed PMID: 15713859.
Ono H, Taguchi T, Kido Y, Fujino Y, Doki Y. The usefulness of bright light therapy for patients after oesophagectomy. Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses. 2011;27(3): 158–66. doi: 10.1016/j.iccn.2011.03.003. PubMed PMID: 21511473.
Taguchi T, Yano M, Kido Y. Influence of bright light therapy on postoperative patients: a pilot study. Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses. 2007;23(5): 289–97. doi: 10.1016/j.iccn.2007.04.004. PubMed PMID: 17692522.
Van Rompaey B, Elseviers MM, Van Drom W, Fromont V, Jorens PG. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical care. 2012;16(3):R73. doi: 10.1186/cc11330. PubMed PMID: 22559080; PubMed Central PMCID: PMC3580615.
McCaffrey R. The effect of music on acute confusion in older adults after hip or knee surgery. Applied nursing research: ANR. 2009;22(2): 107–12. doi: 10.1016/j.apnr.2007.06.004. PubMed PMID: 19427572.
McCaffrey R, Locsin R. The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery. Journal of Clinical Nursing. 2004;13: 91–6. doi: 10.1111/j.1365-2702.2004.01048.x.
McCaffrey R, Locsin R. The effect of music on pain and acute confusion in older adults undergoing hip and knee surgery. Holistic nursing practice. 2006;20(5): 218–24; quiz 25-6. PubMed PMID: 16974175.
Lapane KL, Hughes Cm Fau-Daiello LA, Daiello La Fau-Cameron KA, Cameron Ka Fau-Feinberg J, Feinberg J. Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes. 2011;(1532–5415 (Electronic)).
Colombo R, Corona A, Praga F, Minari C, Giannotti C, Castelli A, et al. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva anestesiologica. 2012;78(9): 1026–33. Epub 2012/07/10. PubMed PMID: 22772860.
Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. GRADE guidelines 6. Rating the quality of evidence—imprecision. Journal of clinical epidemiology. 2011;64(12): 1283–93. doi: 10.1016/j.jclinepi.2011.01.012. PubMed PMID: 21839614.
Partridge JS, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? International journal of geriatric psychiatry. 2013;28(8): 804–12. Epub 2012/11/01. doi: 10.1002/gps.3900. PubMed PMID: 23112139.
Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. Journal of clinical epidemiology. 2011;64(4): 401–6. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Abraha, I., Rimland, J.M., Trotta, F. et al. 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 (2016). https://doi.org/10.1007/s12603-016-0719-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12603-016-0719-9