Journal of Critical Care 37 (2017) 85–90

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Journal of Critical Care

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Occupational therapy for delirium management in elderly patients

without mechanical ventilation in an intensive care unit: A pilot
randomized clinical trial
Evelyn A. Álvarez, MS a,b,⁎, Maricel A. Garrido, MS c,1, Eduardo A. Tobar, MD d,2, Stephanie A. Prieto, MS a,c,3,
Sebastian O. Vergara, MS c,4, Constanza D. Briceño, MS b,c,5, Francisco J. González, MD e,6
a
Escuela de Terapia Ocupacional, Facultad de Ciencias de la Salud, Universidad Central de Chile, Santiago Centro, Chile
b
Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Universidad de Chile, Independencia, Chile
c
Servicio Medicina Física y Rehabilitación, Hospital Clínico Universidad de Chile, Independencia, Chile
d
Unidad de Pacientes Críticos, Departamento de Medicina Interna Norte, Hospital Clínico Universidad de Chile, Independencia, Chile
e
Servicio Medicina Interna, Departamento de Medicina, Hospital Clínico Universidad de Chile, Independencia, Chile

a r t i c l e i n f o a b s t r a c t

Keywords: Purpose: Delirium has negative consequences such as increased mortality, hospital expenses and decreased cog-
Delirium nitive and functional status. This research aims to determine the impact of occupational therapy intervention in
Elderly duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was
Occupational Therapy
to assess functionality at hospital discharge.
Functional Outcomes
Methods: This is a pilot randomized clinical trial of patients without mechanical ventilation for 60 years.
Intensive Care Units
Patients were assigned to a control group that received standard strategies of prevention (n = 70) or to
an experimental group that received standard strategies plus occupational therapy twice a day for 5 days
(n = 70). Delirium was valued with Confusion Assessment Method and Delirium Rating Scale, and
functional outcomes at discharge with Functional Independence Measure, Hand Dynamometer, and
Mini-Mental State Examination.
Results: A total of 140 participants were recruited. The experimental group had lower duration (risk inci-
dence ratios, 0.15 [P = .000; 95% confidence interval, 0.12-0.19] vs 6.6 [P = .000, 95% confidence interval,
5.23-8.3]) and incidence of delirium (3% vs 20%, P = .001), and had higher scores in Motor Functional Inde-
pendence Measure (59 vs 40 points, P b .0001), cognitive state (MMSE: 28 vs 26 points, P b .05), and grip
strength in the dominant hand (26 vs 18 kg, P b .05), compared with the control group.
Conclusions: Occupational therapy is effective in decreasing duration and incidence of delirium in
nonventilated elderly patients in the intensive care unit and improved functionality at discharge.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction patients, the incidence of delirium is 20% to 56% [2,3]. Delirium's nega-
tive impact has been widely documented in the medical literature. It
Delirium is a frequent complication in the intensive care unit (ICU), has been associated with increased mortality and morbidity, longer hos-
with an incidence of 45% to 87% [1]. In nonventilated elderly ICU pital stays, and motor, cognitive, and functional decline [2,4-7]. Some
studies suggest that the duration of delirium affects patients' survival,
⁎ Corresponding author at: Escuela de Terapia Ocupacional, Facultad de Ciencias de la increasing mortality by 11% for every 48 hours that delirium persists
Salud, Universidad Central de Chile, Lord Cochrane #417, Santiago Centro 8330507, [7]. Therefore, preventing and managing delirium is fundamental to re-
Chile. Tel.: +56 997413610. ducing its negative impact, and it has been estimated that up to 40% of
E-mail addresses: alvarezevelyna@gmail.com (E.A. Álvarez), maricel.garrido.m@gmail.com
cases are preventable in non-ICU patients [8]. Pharmacologic protocols
(M.A. Garrido), edotobar@gmail.com (E.A. Tobar), prietostephanie@gmail.com (S.A. Prieto),
sebastian.vergara.ruiz@gmail.com (S.O. Vergara), constanza.briceno.ribot@gmail.com were proposed, including low doses of haloperidol, but they did not
(C.D. Briceño), fgonzalezandrade@gmail.com (F.J. González). show categorical evidence to support delirium prevention [9].
1
Tel.: +56 942 502 855. Nonpharmacologic strategies have been recommended in the ICU, in-
2
Tel.: +56 992 368 717. cluding measures for improving sleep (reducing noise and night proce-
3
Tel.: +56 976 426 366.
4
Tel.: +56 998 560 683.
dures), developing protocols for bundles of sedation interruption,
5
Tel.: +56 994 997 156. spontaneous breathing trials, early mobilization, and delirium monitor-
6
Tel.: +56 998 735 936. ing [8,10,11].

http://dx.doi.org/10.1016/j.jcrc.2016.09.002
0883-9441/© 2016 Elsevier Inc. All rights reserved.
86 E.A. Álvarez et al. / Journal of Critical Care 37 (2017) 85–90

Occupational therapy (OT) promotes good health and welfare by b) Positioning: use of devices and adaptations to prevent edema and
keeping patients active in their activities of daily living [12], with de- bedsores on vulnerable body areas. It has to be performed in all ses-
monstrable benefits in diverse pathologies [13]. There is evidence that sions (twice a day)[19].
early physical therapy and OT in mechanically ventilated ICU patients c) Cognitive stimulation: pool of exercises with an objective of activat-
improve function at discharge and shorten episodes of delirium and ing mental functions, which include the following areas, among
length of the patients' stay [14,15]. However, to our knowledge, there others: alertness, visual perception, memory, calculus, problem solv-
is no research on OT interventions for elderly nonventilated patients ing, praxis, and language. Each patient received a notebook for cog-
in the ICU. We designed a pilot randomized clinical trial (RCT) in nitive exercises, as well as tools such as sequencing cards and
nonmechanically ventilated patients hospitalized in the ICU, to evaluate games (cards, dominoes and memory, and visuospatial construction
the impact of early and intensive OT in delirium management (duration, games). This task has to be performed in all sessions (twice a day).
incidence, severity) and the patients' functional outcomes at hospital d) Basic activities of daily living (BADLs): group of activities that pro-
discharge (functional independence, cognition, and grip strength). For motes independent living based on BADL that include hygiene, per-
this, we compared 2 strategies: standard nonpharmacologic prevention sonal grooming, and eating, in all morning sessions
(nPP) based on evidence vs early and intensive OT plus standard nPP. e) Stimulation of upper extremity motor function: exercises to keep
the patient's upper extremities active and functional [20]. It was per-
formed in all afternoon sessions.
2. Materials and methods
f) Family participation: daily visits by trained family members [21]
2.1. Selection and description of participants
During the intervention phase, occupational therapists used a check-
list to confirm that at least 5 of the 6 areas of the intervention protocol
The study was a pilot randomized controlled trial that included el-
were applied on a daily basis with each patient. More detail on both in-
derly nonintubated patients at the ICU of the University of Chile Clinical
tervention protocols can be found in the Electronic Material Supple-
Hospital. Patients were recruited between April 2011 and December
mentary (EMS).
2012 from the Medical and Surgical Intermediate Care Units. Patients
met the following study inclusion criteria: 60 years or older, hospital-
2.3. Randomization and blinding
ized within 24 hours in the ICU for postsurgical observation or for
acute or chronic decompensated illness, and signed informed consent
Patients were recruited continually for 22 months during mornings
forms. Researchers excluded patients with cognitive decline (defined
by a team of internal medicine physicians, which obtained the informed
with score N3.3 in the Informant Questionnaire on Cognitive Decline
consent for each patient. An intensivist then assigned the patients to 1 of
in the Elderly [IQCODE] [16] and N6 points in the Spanish version of
the 2 groups. Randomization was performed with computer-generated
Functional Activity Questionnaire [FAQ]) [17], severe communication
random permuted blocks using a centralized, secure Web-based ran-
disorders, delirium before ICU admission, or a requirement for invasive
domization service. Enrollers, randomizers, evaluators, physiotherapist,
mechanical ventilation. The hospital's ethics committee approved the
and statisticians were blinded [22]. The professionals of the experimen-
research, including patients' consent.
tal group (occupational therapist), nurses (due to clinical responsibili-
ties), and the supervisor for verifying the status of interventions could
2.2. Procedures and randomization
not be blinded.
More details on the randomization and blinding procedures are pro-
2.2.1. Control group
vided in the EMS.
Patients received standard nPP for delirium, consisting of the follow-
ing interventions: (a) reorientation by nursing staff twice daily, which
2.4. Measuring results
included delivering information about time, date, location and reason
for hospitalization; (b) early mobilization 3 times daily by a physiother-
The primary outcome measure was management of delirium, which
apist, which included passive and active mobilization of limbs, rolling
included duration, incidence, and severity. The secondary outcome was
and supine activation, supine to sitting transference, sitting, sitting to
functional outcomes, which included functional independence, grip
standing transference, walking in place, and ambulation; (c) correction
strength, and cognitive status.
of sensory deficits (encouraging patients to use glasses and hearing
Before enrollment and during the first 24 hours of the patient's ad-
aids); (d) management of the environment, which included avoiding
mission into the ICU, staff collected information using the following
physical restraints (replaced by supervision from a medical professional
measures: (a) Sequential Organ Failure Assessment [23], (b) Acute
or relative) and installing a clock and calendar in the patient's room to
Physiology and Chronic Health Evaluation (APACHE II) [24], (c)
avoid disorientation; (e) sleep protocols that included dimmed lights,
IQCODE [16], and (d) FAQ [17]; the last 2 measures are used to assess
promotion of quiet and calm environments, and avoidance of medicat-
cognitive impairment. Once the patient was enrolled, demographic in-
ing at night; and (f) avoidance, when feasible, of medications with the
formation and (e) Functional Independence Measure (FIM) scores
potential to cause delirium (anticholinergic drugs and benzodiaze-
were collected. The FIM evaluates independence in 18 activities of
pines) [8-11]. Treatment for the control group was supervised on a
daily living (13 motor and 5 cognitive items). The scale has 7 levels
daily basis. The intervention began during the first 24 hours of the
(1-7, from lower to higher levels of independence). The motor FIM
patient's admission into the ICU.
score ranges from 13 to 91, cognitive FIM from 5 to 35 points, and
total FIM from 18 to 126 points; higher scores indicate greater indepen-
2.2.2. Experimental group
dence [25]. If the total FIM score was at least 75 points, the patient was
Patients received standard nPP plus early and intensive OT, begin-
considered to be an independent [26].
ning in the first 24 hours of the patient's admission into the ICU and de-
The duration of delirium was evaluated twice daily using the Confu-
livered twice a day with sessions of 40 minutes each, one in the morning
sion Assessment Method (CAM) for the first 5 consecutive days [27].
and another in the evening, for 5 consecutive days. Occupational thera-
The CAM has a sensitivity of 94% to 100%, specificity of 90% to 95%, pos-
py techniques were as follows:
itive predictive accuracy of 91% to 94%, negative predictive accuracy of
a) Polysensory stimulation: intense external stimulation with an objec- 90% to 100%, and interrater reliability of 0.81 to 1.00 [28]. If the CAM
tive of increasing the patient's level of alertness, in case of patients test result was positive for delirium, the Delirium Rating Scale was ap-
with Sedation-Agitation Scale scores of 2 and 3 [18] plied to determine severity [29].
 E.A. Álvarez et al. / Journal of Critical Care 37 (2017) 85–90
Secondary outcomes were assessed 48 hours before hospital
discharge, using the following measures: FIM, Jamar Hydraulic
Hand Dynamometer, Gilroy, CA, USA [30], and Mini-Mental State Ex-
amination (MMSE) [31].
2.5. Statistical analysis
The duration of delirium is important in critically ill patients
[7,15,32]. For this reason, the sample size was calculated in relation to
the duration of delirium in ICU nonintubated patients. Considering the
mean duration of 6 ± 4 days [14,31], and expecting a reduction of 33%
with a power of 80% to decrease 4 ± 3 days, the sample size was 398 pa-
tients (for more information, see EMS). The analysis was conducted on
an intent-to-treat basis.
The Kolmogorov-Smirnov test was used to determine the distribu-
tion of the variables. Descriptive statistics including median and p25-
p75, mean and SD, or frequencies and percentage were applied depend-
ing of the characteristics to each variable. The primary outcome was
expressed as density of delirium, understood as the ratio between the
duration of the event and the exposure time (time spent in the proto-
col); for this, Poisson regression was used. Therefore, the risk incidence
ratio (IRR) was the measure used to compare the groups, Mann-
Whitney U test for numerical variables, and χ2 test for categorical vari-
ables, with a 2-tailed significance level of P b .05. Post hoc analysis in-
cluded a logistic regression analysis with the main predictors of age,
APACHE II, sepsis, and the intervention itself; calculus patient-days
with delirium (defined as the ratio between the number of days with
a positive result for delirium and the total days when the protocol was
performed); and pre-DELIRIC score [33]. Statistical analysis was per-
formed using SPSS 19.0 software (SPSS, Chicago, Ill).
This trial is registered in ClinicalTrials.gov, number NCT01555996.
Fig. 1. Clinical trial flowchart.
87
3. Results
3.1. Patient characteristics and interventions
From April 2011 to December 2012, the research team assessed a
total number of 3768 patients eligible for the trial. One hundred forty
were chosen, recruited, and randomized. The initial analysis, which in-
cluded demographic data and the primary outcome of the assessment,
included 70 individuals in the control group and 70 patients in the ex-
perimental group. Analysis of the secondary outcome at discharge in-
cluded 65 patients in the control group and 65 patients in the
experimental group (Fig. 1). Reasons that patients were lost to follow-
up in the control group were transfer to another medical center or un-
expected discharge (3 patients) and passing away (2 patients, 1 from re-
spiratory failure and 1 from metastatic cancer). In the experimental
group, the reasons were transfer to another medical center or unexpect-
ed discharge (3 patients) and passing away (2 patients, 1 from respira-
tory failure and 1 from metastatic cancer).
The patients enrolled were included in the intent-to-treat analysis.
There were no significant differences in demographics aspects and clin-
ical characteristics including pre-DELIRIC scale (these data were collect-
ed retrospectively) between groups (Table 1).
There were no changes to the study protocol during intervention.
Compliance of the standard protocol was similar in both groups, with
high level of implementation (Table 2). The most common reason for
not receiving the intervention was that the patient was unavailable
due to other procedures; in these cases, the staff attempted to perform
the intervention at another time. Delirium was assessed for a median
of 5 days [5-5 days] (an equivalent of 10 CAM questionnaires) in the
control group. In the experimental group, delirium was also assessed
for a median of 5 days [4-5 days], with an overall adherence rate 95%
(322.5/339 patient-days), without significant differences.
88 E.A. Álvarez et al. / Journal of Critical Care 37 (2017) 85–90

3.2. Primary outcome: management of delirium control group (P b .0001; Table 4). The experimental group had a median
score of 59 on the Motor FIM [44-82.5], which was significantly higher
The density of delirium was significantly lower in the experimental than the control group, which had a median score of 40 [25-56.5]
group (IRRs, 0.15 [P = .000; 95% confidence interval {CI}, 0.12-0.19 vs (P b .0001; Table 4). The experimental group also scored higher on the
6.6 [P = .000; 95% CI, 5.23-8.3]) (Table 3). With these results, a power Motor FIM items than did the control group (P b .0001; Fig. 2). For the
of 82% was obtained. The most common day of delirium onset for pa- cognitive FIM, the experimental group had a median score of 35 [34-35]
tients was the second day in the control group (36%) and the third , whereas the control group scored 33 [31.5-35], representing a signifi-
day in the experimental group (100%). cant difference (P = .001; Table 4). Grip strength was significantly great-
The incidence of delirium in the control group was 20% (n = 14), er in the OT group for both hands (P b .05; Table 4). Finally, the median
whereas the OT group had an incidence of 3% (n = 2, P = .001). Delir- MMSE at discharge was 28 [25-29] for the experimental group and 26
ium severity did not differ significantly between groups. The mean [24-28] for the control group (P b .05; Table 4).
score was 10 points for the control group [8-13] and 9 for the experi- There were significant differences between the results in patients
mental group [6-12] (P = .7). with and without delirium for motor FIM, cognitive FIM, grip strength,
Post hoc analysis included patient-days with delirium, defined as MMSE, and length of hospital stay, in favor of patients without delirium
days with delirium while patients were receiving the protocol. Of 335 (P b .001, P b .001, P b .001, P b .039, and P = .001, respectively; see
patient-days in the control group, delirium was present on 27.5 days Table EMS_1 in online Resource 2).
(8.2%), and of 339 patient-days in the experimental group, delirium
was present on 3.5 days (1%). Furthermore, the control group had 4. Discussion
higher risk of delirium than did the experimental group (odds ratio,
8.5; 95% CI, 1.853-38.90). Other variable associated with increased delir- This is the first pilot RCT to assess the intervention of early and intensive
ium rates were being older than 80 years compared with being between OT in elderly patients without mechanical ventilation in the management
60 and 79 years old (odds ratio, 2.5; 95% CI, 0.784-8.05). of delirium in ICU. In relation to the duration of delirium, OT intervention
had beneficial effects (positive impact) because patients had significantly
3.3. Secondary outcomes: functional outcomes at hospital discharge fewer hours of delirium, compared with the control group that used vali-
dated interventions in hospitalized elderly patients. Furthermore, it was
Patients' functional independence was evaluated using discharge FIM found that the recruited sample size obtained a high statistical power
scores. Defining a score of at least 75 as a cutoff value, 81.5% of the exper- (82%) for the primary outcome, giving greater strength to the results.
imental group was functionally independent, compared with 47.7% of the Our research has relevant findings in the overall burden of delirium,
where the experimental group had a significantly lower risk of develop-
Table 1 ing delirium, demonstrated through a decreasing on patients' days of
Baseline characteristics of study population delirium contrasted to the control group. This suggests the importance
Control Experimental P
of implementing nonpharmacologic strategies in delirium in
group group nonintubated patients [9,34].
(n = 70) (n = 70) The experimental group had a significantly lower incidence of delir-
Age (y), median [p25-p75] 71 [63-78.5] 68 [63-75.5] .34 ium, being the lowest incidence reported in studies in that included
Female, n (%) 38 (58.4) 32 (49.4) .37 nonventilated patients [7,8,32] and elderly patients in general medical,
Years of education, median [p25-p75] 12 [8.5-14] 12 [6-15] .44 where an 11%-14% [34] of incidence is reached. A lower incidence of de-
APACHE II, median [p25-p75] 11 [8-12] 10 [9-12] .79
lirium is associated with improved functional outcomes and shorter
SOFA, median [p25-p75] 6 [5-6] 6 [4-7] .44
CACI, median [p25-p75] 4 [3-5.25] 4 [3-5] .54
hospital stays [14,15].
IQCODE, median [p25-p75] 3 [3-3,19] 3 [2,96-3,15] .66 In relation to the severity of delirium, there is scarcity of evidence to
FAQ/PFEFFER, median [p25-p75] 1 [0-3] 1 [0-2] .25 date. A study that considered elderly patients recovering from surgery
Initial motor FIM, median [p25-p75] 19 [15-22 ] 19 [13-35] .83 found that low doses of haloperidol were associated with less severe ep-
Initial cognitive FIM, median [p25-p75] 33 [30-35] 33 [24-35] .50
isodes of delirium [32]. In our study, there were no significant
Primary diagnosis on admission, n (%)
Sepsis 34 (48.6) 29 (41.2) .39
Renal or hepatic failure 13 (18.6) 15 (21.4) .67 Table 2
Hemorrhage 7 (10) 9 (12.9) .59 Description of implementing interventions
Acute respiratory distress syndrome 5 (7.1) 3 (4.3) .46
Control Experimental P
Cardiac failure 3 (4.3) 2 (2.9) .6
group group
Decompensated chronic obstructive 1 (1.4) 1 (1.4) 1
(n = 65) (n = 65)
pulmonary disease
Other 7 (10) 11 (15.7) .31 Total early mobilization, n (%) 965 (98.9) 967 (99.17) .592
Comorbidities Total reorientation by nursing, n (%) 640 (98.4) 638 (98.15) .67
Gastrointestinal disease 17 (24.3) 19 (27.1) .7 Total correction sensory deficits, n (%) 650 (100) 650 (100) 1
Hypertension 14 (20) 12 (17.1) .66 Management of the environment, n (%) 650 (100) 650 (100) 1
Cancer 12 (17.1) 11 (15.7) .82 Medication, n (%) 12 (18.46) 13 (20) .88
Diabetes 10 (14.3) 11 (15.7) .81 • Antipsychotic 2 1
Hypothyroidism 4 (5.7) 3 (4.3) .87 • Antihistamines 2 2
Heart disease 4 (5.7) 2 (3) .81 • Hypnotics (benzodiazepines–no 7 5
Other 9 (12.9) 12 (17.1) .47 benzodiazepines)
Admission unit of ICU, n (%) • Anticholinergics 1 5
IMC 26 (37) 25 (36) .86 Sitting (beginning day) 3 [2-4] 2.5 [2-4] 1
SIU 44 (63) 45 (64) .86 Total OT intervention, n (%) 642 (98.7)
Baseline pre-DELIRIC score, mean (SD) 16.47 (13.3) 16.74 (13.6) .83 • Polysensory stimulation 0 (0)a
Length of ICU stay (d) median [p25-p75] 5 [3-7] 5 [3-8] .44 • Positioning 640 (98.46)
Length of hospital stay (d), median [p25-p75] 9 [5-17] 8 [5-15] .3 • Cognitive stimulation 642 (98.7)
• BADL 318 (97.8)
APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, Sequential Organ Failure
• Stimulation of upper extremity motor 321 (98.7)
Assessment; CACI, Charlson Age-Comorbidity Index; IQCODE, Informant Questionnaire on Cog-
function
nitive Decline in the Elderly; FAQ/PFEFFER, Functional Activities Questionnaire; Motor FIM,
• Family participation 286 (88)
Motor Functional Independence Measure; Cognitive FIM, Cognitive Functional Independence
a
Measure; ICU: Intensive Care unit; IMC, Intermediate Care Unit; SIU, Surgical Intermediate Unit. No patients had Sedation-Agitation Scale scores of 2 or 3.
 E.A. Álvarez et al. / Journal of Critical Care 37 (2017) 85–90 89

Table 3
Delirium duration

Control group Experimental group P

(n = 65) (n = 65)

IRR 6.66 0.15 .000

CI 0.15 0.12-0.19 .000

differences detectable between groups due to the low incidence of delir-

ium in the experimental group.
These findings may be attributable to the OT intervention, which gave
patients an early and intensive routine. The protocol kept the patients
alert and active during the day, stimulating cognitive function and func-
tional independence. The outcomes of this study, coupled with results
of other studies, indicate that OT has a role in preventing delirium [14,15].
Functional outcomes are a powerful predictor of health and mortal-
ity during and after hospitalization. Therefore, creating strategies that
include early intervention to minimize the effects of hospitalization is
crucial [35]. A secondary objective of this study, therefore, was to mea-
sure the functional outcomes, defined as ability to participate in activi-
ties of daily living, as measured by tests of functional independence,
cognition, and grip strength [36]. Functional independence was signifi-
cantly higher in the experimental group, with higher total scores in
total, motor, and cognitive FIM. A total FIM score greater than or equal
to 75 points (the sum of cognitive and motor items) at discharge has Fig. 2. Motor FIM subscale scores at hospital discharge.
been used as a predictor of functional independence at home [26]. In
this study, the experimental group showed marked improvement com-
pared with the control subjects. The results indicate higher indepen- There is scarce evidence of the contribution of OT in the ICU; therefore,
dence levels and are concordant with results published elsewhere in this work is a contribution to develop feasible strategies to implement and
patients recovering from stroke, hip surgery, and mechanical ventilation replicate in elderly patients without mechanical ventilation who are cog-
[14,15,37]. In our study, subjects increased their independence in daily nitively healthy. This protocol allows us to identify procedures that could
activities such as dressing, self-care, feeding, and transfers, but the implement occupational therapists, to improve clinical practice.
scores indicated that they still required supervision in self-care, and Therefore, this pilot RCT showed results in decreasing the duration
minimal assistance for mobility and locomotion. It is plausible that OT and incidence of delirium. It may be appropriate, going forward, to ex-
intervention throughout the hospital stay would have an even greater tend this work to other medical centers.
impact. Improved functionality at hospital discharge not only impacts
on the recovery process of the elderly but also may decrease use of re-
sources in the long term and even prevents rehospitalization [38]. 5. Conclusions
Other predictors associated with function are grip strength and
cognitive status at discharge. Evidence shows that patients hospitalized This pilot RCT showed that the combination of early and intensive OT
in the ICU lose considerable strength to discharge, dropping to mean plus standard nonpharmacologic strategies is effective in decreasing the
grip strength of 15.09 kg in the dominant hand and 13.26 in the nondom- duration and incidence of delirium in the elderly without mechanical ven-
inant hand [35]; these results are similar to those obtained in our control tilation in ICU and improve functional outcomes at hospital discharge.
group. Our experimental group, however, had significantly higher grip
strength, with scores similar to those of healthy elderly people [39]. Cog-
nitive FIM and MMSE scores at discharge were significantly higher in the Contributions
experimental group, in accordance within normal range of Chilean
norms by age and education [31]. This might be due to different factors Álvarez Evelyn, Garrido Maricel, and Tobar Eduardo participated in
such as early mobilization, physical therapy, and an active routine [40]. the conception, design, analysis, and interpretation of the results;
One of this study's limitations was the exclusion of some predispos- González Francisco, Prieto Stephanie, and Briceño Constanza recruited
ing factors such as mechanical ventilation, cognitive impairment, de- patients for the study; Prieto Stephanie, Vergara Sebastián, and Briceño
mentia, or prior episodes of delirium, so the results cannot be Constanza participated in data collection; Álvarez Evelyn and Garrido
generalized, but it would be interesting to replicate this protocol in Maricel wrote and edited the manuscript; and all of the authors have
these populations to determine whether it has similar effects. read and approved the final version of the manuscript.

Table 4
Functional outcomes at hospital discharge

Control group Experimental group P

(n = 65) (n = 65)

Functional Independence at discharge, n (%)a 31 (47.7) 53 (81.5) b.0001

Motor FIM, median [p25-p75] 40 [25-56.5] 59 [44-82.5] b.0001
Cognitive FIM, median [p25-p75] 33 [31.5-35] 35 [34-35] .001
Grip strength dominant hand (kg), median [p25-p75] 18 [10-29.5] 26 [15-36] .02
Grip strength nondominant hand (kg), median [p25-p75] 14 [9-23] 20 [14-35] .01
MMSE, median [p25-p75] 26 [24-28] 28 [25-29] .04

Motor FIM, scale 13-91; cognitive FIM, scale 5-35; MMSE, scale 0-30.
a
At least 75 score for total FIM.
90 E.A. Álvarez et al. / Journal of Critical Care 37 (2017) 85–90
Conflicts of interest
AE, GM, VS, BC, PS, and GF received fees through an award from a
public fund research and development in health belonging to a govern-
ment commission. TE did not receive fees.
Source of funding
The trial was funded by “Fondo Nacional para la Investigacion y
Desarrollo en Salud” (FONIS—National Fund for Health Research
and Development), which belongs to the “Comisión Nacional de
Investigación Cientifica y Tecnológica de Chile” (CONICYT—Chilean Na-
tional Commission for Scientific and Technological Investigation). The
commission did not participate in any of the stages pertaining to the
study (design, application, data collection or analysis, interpretation,
writing of the present paper, or decisions regarding publishing).
Informed consent
Informed consent was obtained from all individual participants in-
cluded in the study.
Acknowledgments
The Physical Medicine and Rehabilitation Service and the Critical Care
Unit at the Clinical Hospital of University of Chile, for their support of the re-
search team. Special thanks to Elizabeth Guzman, Tatiana Donoso, Claudia
Dechent, Consuelo Alzamora, Camila Bolvaran, Camila Concha, María
Fernanda Valencia, Fabiola Villalobos, Atilio Gonzalez, Rolando Aranda,
and Sebastian Gallegos for participating in the implementation phase of
the study; Gabriel Cavada, Fernando Quevedo, and Sergio Muñoz, an exter-
nal collaborator, for assistance with analysis: and Rodrigo Cornejo, Carlos
Romero, Jean Gajardo, Boris Alvarez and Omar Ramirez for checking the
manuscript.
We would like to acknowledge to CONICYT—Chilean National Commis-
sion for Scientific and Technological Investigation for funding this research.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.jcrc.2016.09.002.
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