Background: Delirium, an acute and fluctuating decline in attention and cognition, is a common problem in hospitalized older adult patients. It is a familiar occurrence especially in patients with chronic conditions and physiological impairments and may be amplified when surgery is involved as a component of the treatment plan. Delirium is known to result in poor clinical outcomes including functional decline, falls, nursing home placement and death. Understanding interventions that prevent delirium can provide improved care to the hospitalized elderly patient.
Objectives: The primary focus of this systematic review was to synthesize the best available evidence on non-pharmacological multi-component interventions for prevention of delirium in hospitalized non-intensive care older adult patients.
Inclusion criteria
Types of participants: Adults who were hospitalized in a non-intensive care setting, who were 60 years and over and who were identified to be at risk for delirium or experiencing delirium.
Types of intervention(s): This review considered studies that evaluated non-pharmacological, multi-component interventions for the prevention of delirium in the hospitalized older adult when compared to usual care.
Types of outcomes: This review considered studies that included incidence of delirium, duration of delirium and also severity of delirium.
Types of studies: This review considered randomized controlled trials, controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies and case control studies.
Search strategy: A three-step strategy was utilized to find both published and unpublished studies using identified keywords and Medline Subject Headings. The first step was limited to MEDLINE and CINAHL. The second search used keywords and index terms across databases. The final search strategy used reference lists of reports and articles to identify additional studies. Studies selected were published in English between 1990 and 2013.
Methodological quality: The Joanna Briggs Institute Critical Appraisal Checklists for Randomized Control Trial/Pseudo-randomized Control Trial and Comparable Cohort/Case-Controlled Studies were used to assess methodological quality.
Data collection/extraction: Data was extracted using the standardized data extraction tools from the Joanna Briggs Institute.
Data synthesis: Meta-analysis using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument was conducted for the following outcomes: incidence of delirium, duration of delirium and severity of delirium. Additional outcomes were presented in a narrative summary.
Results: Ten research articles were included in this review. Measurement of delirium incidence was found in all 10 studies; delirium duration was found in five studies and delirium severity was found in four studies. The effect of multi-component interventions, when compared to usual care, on the prevention of delirium was found to be statistically significant. Patients who received multi-component interventions had a 31% lower risk of developing delirium (relative risk 0.69, at 95% confidence interval 0.60, 0.78, p<0.0001). These interventions were also found to lessen the duration of delirium, although the findings were not statistically significant. The meta-analysis for the severity of delirium overall shows no difference between intervention and control.
Conclusions: The use of non-pharmacological, multi-component interventions in older patients in areas other than critical care can lower the risk of delirium.
Implications for practice: Primary prevention is the most effective strategy to prevent delirium. To decrease the incidence of delirium, to keep patients safe, maintain their functionality, or plan for safe discharge to their original place of residence, all older adults admitted to non-intensive care units in the hospital should have appropriate non-pharmacological multi-component intervention initiated. Family members of patients identified as high risk must be made aware of the patient's increased risk of delirium and of the need to prevent its onset to the extent possible. They will need to be educated and included in planning the care of their loved ones.
Implications for research: Future research should investigate which interventions and what portions of those interventions, are most successful in reducing the incidence of delirium and also separate incident from prevalent delirium (delirium present on admission) in order to find effective interventions for the primary prevention of delirium. Evidence can be strengthened by additional larger comparative effectiveness studies that use standardized delirium prevention protocols.