Non‐pharmacological interventions for preventing delirium in hospitalised non‐ICU patients

Background

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non‐pharmacological interventions are thought to be important in delirium prevention. 

Objectives

To assess the effectiveness of non‐pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

Search methods

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

Selection criteria

We included randomised controlled trials (RCTs) of single and multicomponent non‐pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non‐pharmacological interventions which were designed and implemented to prevent delirium. 

Data collection and analysis

Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full‐text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre‐specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between‐group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta‐analysis fixed‐effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

Main results

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non‐pharmacological intervention. Incidence of delirium was reported in all studies. 

Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. 

Pooled data showed that multi‐component non‐pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate‐certainty evidence, downgraded due to risk of bias). 

There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low‐certainty evidence downgraded due to inconsistency and imprecision). 

No studies of multicomponent interventions reported data on new diagnoses of dementia. 

Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) ‐0.93, 95% CI ‐2.01 to 0.14 days, I2 = 65%; 351 participants; low‐certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) ‐0.49, 95% CI ‐1.13 to 0.14, I2=64%; 147 participants; very low‐certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD ‐1.30 days, 95% CI ‐2.56 to ‐0.04 days, I2=91%; 3351 participants; low‐certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low‐certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. 

Our exploratory component network meta‐analysis found that re‐orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. 

Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate‐certainty evidence downgraded due to risk of bias). 

Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. 

Authors' conclusions

There is moderate‐certainty evidence regarding the benefit of multicomponent non‐pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.