REVIEW QUESTION

What interventions are effective in preventing delirium in older adults living in institutional long-term care (LTC)?

TYPE OF REVIEW

A systematic review of three cluster randomized controlled trials (RCTs).

RELEVANCE FOR NURSING

Delirium is characterized by a spectrum of behaviors, including cognitive and attention deficits and fluctuating levels of consciousness. It is often associated with an underlying physiological disturbance, and risk factors include a previous history of delirium and dementia or cognitive impairment. Delirium is estimated to occur in up to 50% of older hospitalized adults, and adults living in institutional LTC are at particularly high risk.

An episode of delirium increases risks of hospital admission, cognitive decline, and death. If recognized in the early stages, delirium can be prevented or mitigated. Hospital studies have shown it is possible to prevent about one-third of cases by providing an environment and care plan that target the main delirium risk factors, including providing better lighting and signs to avoid disorientation, avoiding unnecessary use of catheters to help prevent infection, and avoiding certain medications that increase the risk of delirium. It is unclear whether interventions to prevent delirium in LTC are effective.

CHARACTERISTICS OF THE EVIDENCE

The objective of this review was to assess the effectiveness of interventions in preventing delirium among older adults in institutional LTC settings. Inclusion criteria were RCTs and cluster RCTs of single and multicomponent nonpharmacological and pharmacological interventions for preventing delirium in older adult (ages 65 years and older) permanent residents of LTC facilities. The primary outcomes were prevalence, incidence, and severity of delirium, and mortality.

The review included three trials, for a total of 3,851 participants. One study assessed the effect of a weight-based hydration intervention on the incidence of delirium in nursing homes, the second study assessed the introduction of a computerized system to identify medications that may contribute to delirium risk and trigger a pharmacist-led medication review, and the third assessed whether an enhanced education intervention to deliver training sessions to staff and develop targets for delirium prevention reduced the incidence of delirium. All three were cluster RCTs.

It wasn't possible to determine if the hydration intervention reduced the incidence of delirium in the first study because it was small and the design was problematic (very low-certainty evidence). The introduction of a computerized system to identify medications that may contribute to delirium risk and conduct a medication review was probably associated with a reduction in delirium incidence (moderate-certainty evidence) but had little or no effect on mortality (moderate-certainty evidence). It wasn't possible to determine if the education intervention reduced delirium incidence (very low-certainty evidence) or delirium prevalence (very low-certainty evidence) because of serious imprecision in the results. It had little or no effect on mortality (moderate-certainty evidence).

BEST PRACTICE RECOMMENDATIONS

Although the introduction of a software-based intervention to identify medications that could contribute to delirium risk and trigger a medication review was probably associated with a reduction in delirium incidence in one large RCT, this was the finding of only one study, and comparable information technology services in LTC settings are necessary before any change in practice can be recommended. Based on the limited evidence of the effectiveness of interventions for preventing delirium in older adults in LTC settings, changing current practice is not recommended. The findings suggest the value of further exploration of computerized medication management and enhanced education.

SOURCE DOCUMENT