Interventions

The included studies investigated multicomponent interventions in a hospital (or hospital plus
community in the case of Rahkonen 2001) setting for the treatment of delirium.
Nursing intervention protocol (Cole 1994, Cole 2002),
This intervention comprised of a multidisciplinary team consisting of geriatricians and liaison
nurse.
Consultation by a geriatrician or geriatric psychiatrist (completed within 24 hours
after referral)
Follow up by a liaison nurse :
o Follow up included daily visits during the patients stay (up to a maximum of
8 weeks), liaising with family members, recording information on patients
metal status and discuss management with the patients nurses with the use of
the protocol
o Assess compliance with consultant recommendations. Where appropriate, the
nurse discussed management problems with the geriatrician or geriatric
psychiatrist and where necessary patient was reassessed by the specialists.
The intervention protocol targeted the following risk factors:
o Environment (not having excessive, inadequate or ambiguous sensory input,
medication not interrupting sleep, presenting one stimulus or task at a time);
o Orientation (room should have a clock, calendar, and chart of the days
schedule; evaluate need for glasses, hearing aid, interpreter)
o Familiarity (objects from home, same staff, family members staying with
patient, discussion of familiar areas of interest),
o Communication (clear, slow, simple, repetitive, facing patient, warm, firm
kindness, address patient by name, identify self, encourage verbal expression)
o Activities (avoid physical restraint, allow movement, encourage self care and
personal activities).
The intervention in the later trial (Cole 2002) was described as more intensive than in the
earlier study (Cole 1994) and the following components were added to the intervention:
Consultant not only assessed initially but also followed up the patients;
The study nurse visited the patient 5 days per week;
 The intervention team (2 geriatric psychiatrists, 2 geriatric internists and the study
nurse) met after every 8 to 10 patients were enrolled to discuss delirium management
problems; and
The study investigator met the nurse weekly to discuss problems of diagnosis,
enrolment and interventions.
Multicomponent geriatric intervention (Pitkala 2006)
Patients received a comprehensive geriatric assessment, which included history taking,
interview with caregiver, physical examination, assessment of cognition and physical
functioning, screening for depression, nutrition, and medication review. Other aspects of the
intervention included:
Recognising delirium and any underlying conditions
Orientation (with calendars, clocks, photographs)
Physiotherapy
General geriatric interventions (calcium and vitamin D supplements; nutritional
supplements for those at risk of malnutrition or malnourished; hip protectors)
Comprehensive discharge planning (including consultation of a social worker,
occupational therapists home visit, involvement of caregivers).
Medical management (avoiding neuroleptics; administering atypical antipsychotics
for hyperactive/psychotic symptoms; use of cholinesterase inhibitors if patients
cognition did not improve to MMSE score above 23).
Nurse-led interdisciplinary intervention (Milisen 2001)
This intervention involved nurse education to identify high-risk patients which included:
Education: a poster was developed to educate all nurses on the essential aspects of
delirium, depression and dementia. This poster included the core symptoms of
delirium according to the CAM criteria, comparative features and differences between
delirium, dementia and depression and the relevance of correct and early recognition
of delirium;
Systematic screening of cognitive function using the NEECHAM Confusion Scale
following training;
Pain management: scheduled pain medication to provide effective post-operative pain
control; and
 Consultative service: access to a resource nurses who were given training in
identifying patients by a geriatric nurse specialist in the identification and
management of older hip-fracture patients. If necessary, the resource nurses could
consult with a geriatric nurse specialist or psycho geriatrician; resource nursed to help
the primary nurses in implementing appropriate antidelirium interventions.
The nurses were provided with A nursing guide for the evaluation of causes of
delirium in elderly hospitalised patients (as reported in Milisen 1998). The guide
advised a nurse to report to the attending physician of any changes in patients status
on the following: medication, pain, hypoxemia, dehydration, electrolyte and
metabolic disturbances, and infection. The interventions are briefly described below:
o Medication: to be vigilant of polypharmacy, especially anticholinergics,
antiparkinsonian drugs, histamine H2-receptor antagonists;
o Pain: inquire systematically about pain; observe verbal and nonverbal
expressions; use of as many possible analgesics based on nonopiod drug (e.g.
paracetamol) and where required minimum dose of opioids combined with
non opioid drug;
o Hypoxemia: monitor abnormalities in rate, depth and quality of respiration,
cyanosis, PO2 32; administer oxygen as ordered; determine source of
hypoxia; low respiration (<10 l/min) due to opioid intoxication; consult
attending physician for treatment with naloxone as antidote; in patients
undergoing surgery: monitor hypothermia and postoperative shivering;
maintain optimal patient temperature by applying warming [fluids and blood;
gowns and blankets; humidified oxygen]; be alert for nocturnal desaturation
during the first 3 days postoperatively and especially in obese patients;
administer 2 l of O2 (unless contraindicated);
o Dehydration: encourage patient to drink water regularly and when necessary
prepare for blood or fluid replacement;
o Electrolyte and metabolic disturbances: monitor abnormalities of blood and
urine chemistry; give frequent small meals and add nutritional supplements,
such as calorie/protein rich drink;
o Infection: be alert for urinary tract, respiratory, mouth and feet infections;
stimulate patient for adequate water intake (2 l/day) (unless contraindicated);
 observe for abrupt onset for fever (rectal temperature >100F) and apply
cooling techniques as needed.
Systematic intervention (Rahkonen 2001
The intervention consisted of a case manger (nurse specialist) and an annual one-week
rehabilitation period at a Brain Research and Rehabilitation Centre. Patients rehabilitation
team included the study physician, the nurse specialist, physiotherapist, neuropsychologist
and occupation therapist.
A nurse specialist trained in geriatrics and care of the elderly acted as the case
manager. Patients received continuous and systematic support provided by the case
manager with responsibility in supporting the patients during community care through
out the 3 year follow-up acting as a counsellor and advocate and in the rehabilitation
unit (as the primary care nurse);
Care in the community: arranged in consultation with relatives and health and social
care services, and continuity of care was achieved with regular follow-ups, including
in-home visits and phone calls by the case manager. Study physician was also
available for consultation and medical care throughout the follow up; and
Rehabilitation period: individually structured physiotherapy once or twice daily;
mobility and other special aides for daily living (e.g. hearing aids and special shoes)
were arranged when needed; patients were encouraged to participate in occupational
therapy and free-time events.
Education and management intervention (Naughton 2005)
The intervention was designed to improve the recognition of delirium in medically ill older
adults evaluated in the emergency department [ED triaged these patients with delirium
specifically to the acute geriatric unit (AGU)]. This was achieved by addressing the following
factors:
Education:
o The charting procedures in ED were changed and physicians were reminded to
evaluate adults aged 75 years and older for cognitive impairment and delirium
and direct the admission to the AGU. Nurses and physicians were trained to
triage patients using yes/no answers to four questions from the history and
mental status examination. A study nurse periodically reported the proportion
of older adults correctly admitted to the AGU from the ED.
 The education component for the AGU nurses (provided by geriatricians and geriatric
nurse) involved:
o Educating on prevalence and outcome of delirium;
o Sensitivity training on cognitive impairment;
o Training on methods of mental status assessment;
o Guidelines on medication management of cognitive impairment and delirium.
o Small group consensus process used to develop assessment and charting
procedures; and
o AGU physicians were provided with information on cognitive impairment and
delirium in the elderly, recommended metal status assessment procedures, and
review of the intervention guidelines.
Treating underlying medical factors;
Treating precipitating factors (removing precipitating medications; addressing
immobility);
Providing family support;
Using non-pharmacological support for: physically non aggressive behaviour and
episodes triggered with ADL care;
Medication management: reduce the use of psychotropic medications
(benzodiazepines and anticholinergics); consider using synergistic agents such as
neuroleptics or antidepressants that supplement behaviour treatment; sleep
medication: trazadone 50 to 100 mg; zolpidem: 5 mg;
Fewer patients in the AGU received benzodiazepines (22.6% compared with 30.9% at
baseline); antihistamines (6% compared with 15.5%; p<0.02); increased use of
antidepressants (22.7% compared with 10% at baseline; p<0.02); and neuroleptics
(27.4% compared with 10.9% at baseline; p<.01)
Simplifying pain regimen (minimise p.r.n.); and
Environmental stimuli: addressing problems with environmental stimuli for example,
noise, sleep disruption, disruptive room mate,
None of the studies included more than two study arms, and the comparator in all
studies was usual medical care (no further details given).
12.2.4. Comparisons
The following comparison was carried out:
 Multicomponent intervention versus usual care.
o Two RCTs followed patients up to 8 weeks (Cole 1994, Cole 2002) and one
followed patients up to 1 year (Pitkala 2006). Of the non-RCTs, one study
followed patients up to 12 days (Milisen 2001), 2 months (Naughton 2005)
and 3 years (Rahkonen 2001).
Two studies (Naughton 2005; Pitkala 2006) reported concurrent medications:
Opiates (42.7%); benzodiazepines (30.9%); antihistamines (15.5%); antidepressants
(10.0%); neuroleptics (10.9%)
Conventional neuroleptics (22%); atypical antipsychotics (14%) and cholinesterase
inhibitors (6%) (Pitkala 2006).
12.2.5. Outcome measures
The following primary and secondary outcome measures were reported:
Primary outcomes:
o Complete response (Pitkala 2006 RCT; Naughton 2005 non RCT)
o Duration of delirium (Milisen 2001 non RCT)
Secondary outcomes:
o Cognitive Impairment (Cole 1994; Pitkala 2006)
o Length Of Stay (Cole 1994; Cole 2002)
o Health related quality of life (Pitkala 2008)
o Discharge (higher dependency: Cole 1994: Cole 2002; long-term care: Pitkala
2006)
o Days in new long-term care (non RCT: Rahkonen 2001)
o Mortality (RCTs: Cole 1994; Cole 2002; Pitkala 2006; non RCT: Rahkonen
2001)

DAFPUS : https://www.ncbi.nlm.nih.gov/books/NBK65539/