Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing Facilities

Abstract

Objectives-To determine whether a Delirium Abatement Program (DAP) can shorten the duration of delirium among new admissions to post-acute care (PAC). Design-Cluster randomized controlled trial.Setting-Eight skilled nursing facilities specializing in PAC within a single metropolitan region.Participants-Four hundred fifty-seven participants with delirium at PAC admission.Intervention-The DAP consisted of four steps: 1) assessment for delirium within 5 days of PAC admission, 2) assessment and correction of common reversible causes of delirium, 3) prevention of complications of delirium, and 4) restoration of function.Measurements-Eligible patients were screened by trained researchers. Those with Confusion Assessment Method defined delirium were eligible for participation via proxy consent. Two weeks and one month after enrollment, regardless of location, participants were re-assessed for delirium by researchers blind to intervention status. Conflict of InterestThe editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Dr. Marcantonio is a Paul Beeson Physician Faculty Scholar in Aging Research. The authors retained full autonomy in the preparation of this manuscript. Authors ContributionMarcantonio: Conception and design, acquisition of data, analysis and interpretation of data, drafting the manuscript, obtaining funding, supervision Bergmann: Acquisition of data, analysis and interpretation of data, critical revision of manuscript, administrative, technical, or material support, supervision Kiely: Analysis and interpretation of the data, critical revision of the manuscript, statistical analysis Orav: Conception and design, analysis and interpretation of the data, critical revision of the manuscript, statistical analysis Jones: Conception and design, analysis and interpretation of data, critical revision of the manuscript, statistical analysis, supervision Dr. Marcantonio had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Sponsor's Role: The funding agencies had no role in the preparation of this manuscript. The authors retained full autonomy in the preparation of this manuscript. Results-Nurses at DAP sites detected delirium in 41% of participants vs. 12% in usual care (UC) sites (p<.001) and completed DAP documentation in most delirium-detected participants. However, the DAP intervention had no impact on delirium persistence based on two measurements at 2 weeks (DAP 68% vs. UC 66%) and 1 month (DAP 60% vs. UC 51%), adjusted p values ≥ 0.20. Adjusting for baseline differences between DAP and UC participants and restricting analysis to delirium-detected DAP participants did not alter the results. NIH Public AccessAuthor Manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2011 June 1.Conclusion-Detection of delirium improved at the DAP sites, however, the DAP had ...

Reconceptualizing models of delirium education: findings of a Grounded Theory study

“…Taken together, these research findings suggest that educational strategies should be incorporated into routine clinical practice to improve hospital care for the delirious older patient (Tabet and Howard, 2006). However, other clinically focused studies suggest that key educational messages are difficult to implement and adherence to non-pharmacological interventions remains a significant challenge outside the research setting (Young and George, 2003;Marcantonio et al, 2010). For example, the highly pragmatic study by Young and George (2003) shows that guidelines supported by teaching had little effect on practice behaviors.…”

Outcomes in delirium: same but different

“…46 Several nursing studies have been performed attempting to show that interventions targeted at these complications may reduce adverse outcomes among delirious patients. 40,44 However, it appears that insufficient research has been conducted on the frequency of adverse outcomes resulting from each of these complications in hospitalized delirious patients to allow us to posit whether or not poor outcomes are attributable to complications of delirium or arise from other cause(s) altogether.…”

“…Injurious falls, infections (including aspiration pneumonia), pressure sores, malnutrition, over-sedation and urinary incontinence have been described as more common in delirium. 19,27,28,40,44,45 It is conceivable that each of these complications may contribute independently to adverse outcomes or interact in a multiplicative risk scenario. 46 Several nursing studies have been performed attempting to show that interventions targeted at these complications may reduce adverse outcomes among delirious patients.…”

Improving delirium care through early intervention: from bench to bedside to boardroom

“…Interventions include many common elements: assisting orientation, enhancing efficacy (eg, sensory), promoting healthy sleep–wake cycles, pain relief, optimising physiological parameters (electrolytes, hydration), mobilisation and active review by specialist nurses or geriatricians/geriatric psychiatrists 29–32. Success relates closely to degree of implementation; Marcantonio et al ,33 for example, trebled detection in postacute nursing facilities with a nurse-led delirium detection and treatment programme but achieved only modest implementation rates for the actual intervention and did not reduce delirium persistence at 1-month follow-up.…”

“…Novel programmes that are tailored to the needs of specific settings such as postacute facilities,33 community-based care homes36 and palliative care services34 reflect the demands of providing targeted and individualised care for a multifactorial condition. Moreover, existing evidence suggests that preventative measures are more effective in patients at high risk of delirium for reasons other than dementia 32 33 37–39. A key concern for future work will be to enhance alignment between specific interventions and the needs of individual patients.…”