evidence based research paper

Running head: EFFECTS OF MULTIDIMENSIONAL INTERVENTIONS ON DELIRIUM 1

Multidimensional interventions decreasing and preventing delirium in hospitalized adults

Megan McCarthy

The University of Scranton

EFFECTS OF MULTIDIMENSIONAL INTERVENTIONS ON DELIRIUM 2

Practice Analysis

Occupational therapists are surrounded with questions that arise from practice and

experience. It is through evidence-based research, that clinicians have the opportunity to answer

these questions and procure validation behind the techniques and theories used in treatment.

As a student, The University of Scranton has given the opportunity to conduct an

evidence based research project with the assistance of a mentor. My mentor, Robin Silver of

New York Presbyterian, has greatly assisted in the process of identifying viable questions that

have formed the foundation of this evidence-based paper. New York-Presbyterian Hospital is the

nation's largest not-for-profit, non-sectarian hospital, with approximately two million inpatient

and outpatient visits per year. Located in one of the most diversely populated cities in the world,

NY Presbyterian serves citizens of divergent cultures and ethnicities. The Hospital has been

designed to offer semi-private, private, and luxury room and suites for patience to reside in

during their stay. Some suites offer amenities such as, sleeper sofas for additional guest and have

panoramic views of the East or Hudson River. These features have been established to create an

optimal environment for patients to advance in their healing process while generating a

comfortable atmosphere for the patient and his or her supporters.

Being among the top ten hospitals in the country, NY Presbyterian is committed to

excellence in patient care, research, education, and community service. While implementing NY

Presbyterian’s vision of excellence into practice, Ms. Robin Silver works in a general medical

acute care setting where she is exposed to many diagnoses, disorders, and medical complications.

One challenge she finds in practice is the complications presented during treatment when a

patient displays symptoms of delirium. Also, another difficultly during treatment is determining

the most valid and reliable standardized assessment tool that occupational therapists can use to


properly test for delirium. In order to find viable information related to the challenges stated

above, listed below is the proposed questions of interest:

For people at risk for developing or present symptoms of delirium, does a

multidimensional intervention approach, which includes early intervention by

occupational therapists, decrease or prevent delirium deficits in hospitalized adults.


Search Strategy

Search Terms Used:

Population: Older adults with delirium, patients with delirium, patients at risk for delirium.

Intervention: Multidimensional interventions, early interventions, non-pharmacological interventions, occupational therapy.

Comparison: prevention to treatment, delirium assessment tools and evaluations, interventions to treat delirium.

Outcome: prevention of delirium, treatment of delirium.

Databases Searched: Although multiple databases were reviewed throughout the process of

obtaining articles, most of the articles that were incorporated into the research are from CINHAL

with Full Text Database, from the University of Scranton, and Google Scholar, which is a search

engine that is devised to locate scholarly articles.

Journals Retrieved From:

Arch Intern Med

International Journal of Older People Nursing

Journal of Advanced Nursing

Journal of the American Geriatric Society

Journal of Clinical Nursing

Research and Theory for Nursing Practice: An International Journal


Critically Appraised Topic (CAT) 1

QUESTION: “For people at risk for developing or present symptoms of delirium, does a multidimensional intervention approach, which includes early intervention by occupational therapists, decrease or prevent delirium deficits in hospitalized adults”.

Bottom Line: Higher levels of adherence resulted in lower delirium rates, with significant graded effects for orientation, mobility, therapeutic activity protocols, and the composite adherence measure. Also, when controlling the potential confounding variables, adherence proved to be a protective effect against delirium. Participants with the highest adherence displayed an 89% reduction in delirium risks when being compared to patients with lowest adherence.

Summary of Key Evidence

Level of Evidence: III

1) Study Design: Pre-intervention and Post-intervention2) Sample: 422 participants3) Procedure: Eligible patients were enrolled and assigned 3 protocol interventions by an Elder life specialist. All patients received an orientation, mobility, and therapeutic activity protocols while others clients were assigned based on their needs. Patients were assessed daily for changes in risk factors and if change was detected the patient’s protocol was adjusted accordingly. All intervention staff underwent quarterly standardization with completion of competency-based checklist to ensure consistent application. 4) Outcome Measures: Competency -based checklist, Geriatric Depression Scale, standard near-vision and hearing tests, Mini-Mental State Examination, Digit Span Test, The Confusion Assessment Method, Modified Blessed Dementia Rating Scale, Acute Physiological and Chronic Health Evaluation and Charles Comorbidity Index.5) Results: Patients with the highest adherence level had an 89% reduction risk of developing delirium. The highest adherence rate had a delirium rate of 2.9% when compared to the lowest adherence group, which had 38.1% delirium rate. The more interventions received by patients, the better response in the reduction of delirium. A multicomponent approached provided the best treatment outcomes.

Appraisal and Application:

Strengths: 1) Detailed daily tracking of adherence with each intervention protocol; 2) daily assessment of delirium by means of a standardized instrument by blinded research staff; and 3) a comprehensive patient-related data on severity of illness, comorbidity, and other, potential cofounding variables.

Weaknesses: 1) The three intervention protocols were targeted toward specific patient risk factors, which made it difficult to compare effectiveness and the related effect of adherence on effectiveness across all protocols.


Applicability to Practice Scenario: Effectiveness of adherence in a nonpharmacological multicomponent intervention

strategy to treat delirium. Impact of decreased adherence on delirium.

Citations: Inouye, S., Bogardus, S., Williams, C., Leo-Summers, L., & Agostini, J. (2003). The role of adherence on the effectiveness of nonpharmacologic interventions. Arch Intern Med, 163, 958-964.


CAT 2


Bottom Line: A multicomponent, non-pharmacological intervention integrated into routine practice reduces delirium during hospitalization in older adults, improves quality care, and can be implemented without additional resources in a public healthcare system.

Summary of Key Evidence

Level of Evidence: II

1) Study Design: Prospective Controlled Clinical Trial2) Sample: Total N=542; Intervention group: 170 participants; unusual group: 372 participants.3) Procedure: Patients underwent a series of evaluations and data was obtained through interviews and medical record reviews. Once the assessments were completed, participants were divided into either a usual group or intervention group. The usual group received the standard care, provided by hospital staff, while the intervention group received a more invasive treatment specific to their diagnosis of delirium. Some interventions given to the intervention group were: education, environment management, sensorial perception, sleep preservation, early mobilization, hydration, nutrition, and medication management. 4) Outcome Measures: CAM, MMSE, APACHE II, Snellen Test.5) Results: The rate of new delirium episodes, incidence of delirium and functional decline were lower in the intervention group than usual group. The study shows that an early multicomponent intervention strategy is the most effective to treating delirium.


Strengths: 1) Measurements were proven valid through extensive research of previous studies and assessment tools; 2) intervention scores thoroughly represent a positive correlation in early multicomponent interventions and delirium.

Weaknesses: 1) Participants were lacking. Out of 1,027 patients screened, only 542 made into the study because of other preexisting diagnoses. 2) The study was not randomized.

Applicability to Practice Scenario: Effects of preventative measures and early intervention to treat delirium.

Citations: Vidan, M., Sanchez, E., Alonso, M., Montero, B., Ortiz, J., & Serra, J. (n.d.). An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. (2009). Journal of the American Geriatric Society, 57(11), 2029–2036. doi: 10.1111/j.1532-5415.2009.0248.


CAT 3


Bottom Line: Multicomponent interventions to prevent delirium are the most effective and should be implemented through synergistic cooperation between healthcare disciplines. Nurses should play a pivotal role in prevention, early recognition and treatment.

Summary of Key Evidence:

Level of Evidence: I

1) Study Design: Systematic Review.2) Sample: 7 studies met the inclusion criteria for this systematic review; 3 random control trials, 3 controlled studies, and one before-after study.3) Procedure: A comprehensive search was conducted in order to find articles that met the inclusion criteria for the systematic review. The selection criteria were: evaluation of a multicomponent intervention for delirium, inclusion of an operational definition for delirium consistent with the Diagnostic and Statistical Manual of Mental Disorders-criteria, randomized controlled trials, studies with a quasi-experimental design and reporting on primary data. To generate a description of the characteristics of these multicomponent strategies, the components of these programs were identified and categorized. Effects on incidence of delirium, cognitive functioning, duration and severity of delirium, functional status, hospital length of stay, and mortality were analyzed. 4) Outcome Measures: N/A.5) Results: Intervention strategies to prevent delirium proved to be the most efficacious in reducing its incidence, both with surgical and medical patients. Some additional positive effects of preventive strategies were found on the duration and severity of delirium, and functional status.


Strengths: 1) Very detail inclusion criteria was implemented to make sure the studies incorporated a multicomponent intervention that matched the multifactorial origins of delirium; 2) two-step search strategy was used to find to most appropriate literature to include in the study.

Weaknesses: 1) Many studies lacked methodological rigor or used methods to operationalized delirium, which made it difficult to integrate findings; 2) there was a limited source of studies due to the literature’s lack of meeting the inclusion criteria.

Applicability to Practice Scenario: A multicomponent intervention for managing delirium in hospitalized older adults. Effects of a multicomponent intervention to treat delirium.


Citations: Milisen, K., Lemiengre, J., Braes, T., & Foreman, M. (2005). Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. Journal of Advanced Nursing, 52(1), 79-90.


Synthesis

A literature review was completed in order to assist in answering the following question:

For people at risk for developing or present symptoms of delirium, does a multidimensional

intervention approach, which includes early intervention by occupational therapists, decrease or

prevent delirium deficits in hospitalized adults? The literature review was initiated by searching

the electronic databases CIHNAL and Google Scholar. In order to itemize articles that met the

inclusion criteria, the following keywords were used: delirium, delirium treatment, non-

pharmacological treatments for delirium, delirium prevention, occupational therapy and delirium,

and early intervention care for delirium. Fourteen articles from these journals were selected as

being relevant to the question presented. Of these fourteen articles, seven were selected based on

the inclusion criteria of this analysis. The inclusion criteria comprised of: (1) subjects must be

eighteen years or older and have or are at risk for developing delirium. (2) studies must involve

non-pharmacological interventions for delirium. (3) studies must focus on one or more of the

following factors: adherence, orientation, sensory, mobilization, and cognitive stimulation.

The literature pertaining to delirium primarily focuses on the etiology and evaluations

used to detect the condition rather than specific factors and interventions that can assist in the

treatment and intervention. Among the studies that focus on the factors and intervention

techniques, only one was found to carry out a direct comparison of these factors to the

occupational therapy services that could potentially be provided to treat delirium. Despite this

lack of comparison, the literature indicates effects such as reorientation, cognitive stimulation,

and early mobilization, which can easily fit under the many interventions OT can offer to

successfully prevent or treat delirium.


Several studies by Inouye, Milisen, Robinson, Schweickert, and Vidan concluded that a

multidimensional intervention approach provided the most effective outcome in preventing and

treating delirium. Specifically, these studies reported a decrease in the duration and severity of

delirium. The additional component of facilitating early intervention within the first twenty-four

hours of admissions proved critical in the equation since a delay in therapy can greatly influence

a client’s progress level.

One case-control study concluded that the higher adherence level one had, the lower the

risk was for developing delirium. They also reported that the more multicomponent interventions

received by patients, the better response in the treatment outcome and reduction of delirium

(Inouye, et al 2003). Another case-control study by Robinson et al (2008) demonstrated a

positive correlation between delirium intervention and a decline in delirium diagnoses, which

decreased from 37.5% to 13.8% with the use of their protocol. Further validating Inouye and

Robinson’s studies, Milisen, Lemiengre, Braes & Foreman (2005) conducted a systematic review

on the management of delirium through multicomponent interventions and found these

intervention strategies to be most efficacious in reducing its incidence, both with surgical and

medical patients. Some additional benefits of preventive strategies were found on the duration,

severity, and functional status.

According to Vidan, et al (2009) incorporating multicomponent, non-pharmacological

intervention into daily routine practice not only reduces delirium during hospitalization in older

adults, but also improves quality care, and can be implemented without additional resources in a

public healthcare system. Researchers have concluded that the reasoning behind the paucity of

services for delirium is due to the lack of knowledge and education in the field. One pilot study

showed that most nurses viewed delirium as an age related change or normal consequence of


undergoing surgery. They also identified non-pharmacological therapies as a necessity to

managing delirium, but stated they are not normally implemented because they are considered

time-intensive measures (Day, Higgins, & Koch, 2008). These findings demonstrate the

importance of advocating for patients with delirium, educating healthcare clinicians about the

effects of this diagnosis, and teach providers how they can become proactive in preventative

care.

Most of the literature that explored multidimensional intervention as a key factor in the

recovery of delirium suggested that immediate implementation of therapy, within twenty-four

hours of admission, had the best outcome regarding patient progress. Also the research displays

the importance of how detecting early signs can act as a preventative measure to the full onset of

delirium. According to Vidan (2009), who conducted a prospective control clinical trial study on

immediate therapy vs. usual therapy, discovered correspondence between immediate therapy and

a decrease in duration and prevalence of the disease. Another aspect to make note of, so

immediate therapy can proceed, is properly educating clinicians in sign, symptoms, and the use

of proper assessments to evaluate for delirium. Inouye (2006) states that delirium increases

hospital costs by $2,500 per patient, which calculates to more than $6.9 billion in hospital cost

per year due to the poor recognition of delirium. Also suggested by McCDonnell and Timmins

(2012), the incidence of delirium can be reduced by 30% through early detection of symptoms

and use of preventative measures. One valid and reliable evaluation tool that is widely

researched and can assist in detecting delirium is the Confusion Assessment Method (CAM). The

CAM provides health care clinicians a standardized method to asses delirium and is designed to

be scored based on observations made during formal cognitive testing such as the MMSE

(Wasznski, 2007). In most practice settings, occupational therapists are the ones who administer


formal cognitive testing, which makes this an assessment tool that can be easily implemented

into OT practice. A systematic review on the application of the CAM by Wei, et al (2008)

displays an overall sensitivity rate of 94% and specify of 89%. Additional findings state that the

CAM has been adapted for use in the ICU, emergency setting, institutional setting, and for

scoring severity, sub-syndromal delirium, has a short and long version and is offered in ten

different languages, making this an exemplary tool to utilize within multiple settings.

Among the literature that examines whether a multidimensional intervention is the best

approach to preventing or treating delirium, very few mention occupational therapists having a

role in delirium treatment. Most of the studies mention and refer to services that represent

relevant to OT such as ADL, PROM, AROM, orientation and sensory stimulation. One

randomized-control trial particularly tests the effects of early occupational and physical therapy

intervention during periods of daily interruption of sedation in mechanically ventilated patient.

After therapy was performed, researchers found that patients who receive immediate OT and PT

had decreased the duration of delirium, ventilation, length of stay, mortality, and showed a

higher return to independent functional status at discharge (Schweickert et al, 2009).

The literature examining non-pharmacological interventions to treat delirium is not

plentiful, but existing studies do reveal that a significantly increased positive outcome toward

treatment occurs when early intervention, multidimensional treatments are provided. All of the

foregoing results that attribute importance to the presence of a multidimensional intervention to

treat delirium support the incorporation of many therapeutic activities OT’s provide. For

instance, reorientation tasks, sensory input activates, performing structural ADLs task, cognition

stimulation, and engaging the patient in P/ROM or A/ROM exercise are only some of the many

activities that branch under the profession of occupational therapy.


After thoroughly examining the literature to determine whether early occupational

therapy intervention decreases the impact of delirium on hospitalized adults, it must be

concluded that the results are inconclusive. There is a definite potential for OT to service this

population, but due to the lack of literature directly comparing OT services to delirium

prevention, there is not enough evidence to coincide with the question at hand. Further research

is necessary in order to determine whether the implementation of occupational therapy into a

multidimensional approach stands beneficial in preventing and treating adult patients with

delirium.


Implications for Occupational Therapy

Analysis of the literature on delirium suggests that further research must be conducted in

order to examine occupational therapy’s role in the prevention and treatment of delirium. It can

be stated with a fair degree of certainty that OTs have the necessary skills to become involved in

the treatment and prevention of delirium.

Prior to treating a client, occupational therapists evaluate the individual through

conducting an occupational profile and analyzing performance through the use of assessment

tools. Many of the evaluations used to detect delirium, after being educated and trained to

administer, can easily be incorporated into an occupational therapist’s screening and assessment

process. For example the Confusion Assessment Method (CAM) is an evaluation used to detect

delirium during a formal cognitive test such as the Mini-Mental State Examination. Training is

suggested in order to properly administer the test and some of the areas examined include:

inattention, disorganized thinking, and memory, which OTs already have experience in

evaluating through other various assessments. This can also be a very useful tool for measuring

improvements throughout the course of treatment in the case of a client being diagnosed with

delirium. Properly assessing for delirium will help the therapist meet the client’s needs and

incorporate validated non-pharmacological interventions shown to be effective the treatment of

delirium.

By rectitude of the profession, occupational therapists have the skills to perform many of

the interventions incorporated into a multidimensional component approach to treat and prevent

delirium. Some interventions that correlate with occupational therapy practice are: early

mobilization, orienting, sensory input, adherence, visual aids, self-care, sleep preservation, pain


and medication management. Occupational therapists can provide valuable assistance to the

clients in these areas all through the use of occupations and the individual needs of the client.

A review of the existing literature reveals that there is one study that is in process of

examining how OT can be incorporated in delirium treatment. The random control trial by

Espinoza (2013) researches the efficacy of non-pharmacological prevention and intensive non-

pharmacological prevention, which contains standard non-pharmacological prevention plus early

and intensive occupational therapy, of delirium in critically non-ventilated older patients. Even

though the findings of the study have not been published yet, it is important to note and mention

that this is a question at stake and others are investigating how OT can be effective in the

treatment and prevention of delirium, which will ultimately assist in the expansion of the field.

It is imperative that occupational therapists continue the AOTA centennial vision and

stay current on emerging methods, assessments, and new developments in the field. It is

essential that OTs embrace their role as life-long learners and implement evidence based

research to ensure that all interventions being used provide the best treatment outcome for the

client. As therapeutic advancements are made, there is hope that occupational therapists will

continue review the literature and conduct research to display all the benefits occupational

therapy can serve in working with patient’s whom are at risk or diagnosed with delirium. As

healthcare services continue to reform, there are many emerging opportunities within practice

that OTs must take advantage of and further investigate in order to strengthen and protect the

integrity of occupational therapy.


References

Aguirre, E. (n.d.). Delirium and hospitalized older adults: A review of nonpharmacologic

treatment. (2010). The Journal of Continuing Education in Nursing, 41(4), 151-152.

Day, J., Higgins, I., & Koch, T. (n.d.). Delirium and older people: what are the constraints to best

practice in acute care?. (2008). International Journal of Older People Nursing, 3, 170-

177.

Espinoza, E. (in press). Early occupational therapy for delirium prevention in older patients

admitted to critical care unit.

Inouye, S., Bogardus, S., Williams, C., Leo-Summers, L., & Agostini, J. (2003). The role of

adherence on the effectiveness of nonpharmacologic interventions. Arch Intern Med, 163,

958-964.

McDonnell, S., & Timmins, F. (2012). A quantitative exploration of the subjective burden

experience by nurses when caring for patient with delirium. Journal of Clinical Nurses,

21(17-18), 2488-2498.

Robinson, S., Rich, C., Weitze, T., Vollmer, C., & Eden, B. (2008). delirium prevention for

cognitive, sensory, and mobility impairments. Research and Theory for Nursing Practice:

An International Journal, 22(2), 103-113. doi: 10.1891/0889-7182.22.2.103.

Schweickert, W., Pohlman, M., Pohlman, A., Nigos, C., Pawlik, A., Esbrook, C., Spears, L., &

Miller, M. (n.d.). Early physical and occupational therapy in mechanically ventilated,

critically ill patients: a randomized controlled trial. (2009). Lancet, 373, 1874-1882. doi:

10.1016/S0140-6736(09)60658-9.

Vidan, M., Sanchez, E., Alonso, M., Montero, B., Ortiz, J., & Serra, J. (n.d.). An intervention

integrated into daily clinical practice reduces the incidence of delirium during


hospitalization in elderly patients . (2009). Journal of the American Geriatric Society,

57(11), 2029–2036. doi: 10.1111/j.1532-5415.2009.02485.x.

Waszynski, C. (n.d.). Detecting delirium . (2007). AJN, 107(12), 50-58.

Wei, L., Fearing, M., Sternberg, E., & Inouye, S. (n.d.). The confusion assessment method: a

systematic review of current usage. (2008). Journal of the American Geriatric Society,

56, 823-830.

Yevchak, A., Steis, M., Diehl, T., Hill, N., Kolanowski, A., & Fick, D. (n.d.). Managing delirium

in the acute setting: a pilot focus group study. (2012). International Journal of Older

People Nursing, 7, 152-162.

evidence based research paper

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