Effective Interventions for Preventing and Reducing Delirium in Acute Hospital Setting

This review aims at ascertaining the most effective intervention in reducing and preventing the incidence of delirium in the hospital setting. The study recommends the non-pharmacological intervention in the prevention of delirium in an acute hospital because it resulted in a 5.6% reduction in the incidence of delirium.

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Which Interventions are Effective in Preventing and Reducing the Incidence of Delirium in
the Acute Hospital Setting?
Search strategy
An electronic search of the PMC, Oxford, MEDLINE, and Cochrane Collaboration of clinical
trials was carried out using the following keywords “delirium”, “prevent delirium”, “reduce
delirium”, “the incidence of delirium”, and “acute hospital setting”. The search was restricted to
primary research articles, published in the English language and not older than 8 years. A
PRISMA flow diagram was used to determine the articles to be included in the review. A total of
10 articles were identified during the database search using the key terms. The screening was
then done and the articles were limited to primary research articles leading to the exclusion of
four articles, after reviewing of the abstracts, two more articles was excluded. The rest of the
articles were assessed for eligibility and one article was excluded because it was restricted to
cancer patients diagnosed with delirium. Three articles were included in the final analysis. Data
was then extracted using the data extraction table obtained from Cloud Deakin.

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Record identification through database
search using key terms (n=10)
“delirium”, “prevent delirium”, “reduce
delirium”, “the incidence of delirium”, and
“acute hospital setting
Limited to primary research
(n=6)
2 Articles eliminated after
review of abstracts
(n=4)
Primary research articles
assessed for eligibility (n=4)
Records excluded (1)
• restricted to cancer
patients diagnosed
with delirium
n=3
Articles included in the final
analysis (n=3)
IdentificationScreeningEligibilityIncluded

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Extraction tables
Article by Martinez, Tobar, Beddings, Vallejo, and Fuentes (2012).
Areas of Analysis Analysis
Purpose/aim of the study To evaluate the efficacy of multicomponent
intervention in delirium prevention in acute
hospital
Sample The sample of the study consisted of 287
hospitalized patients with high risk or
intermediate delirium at Hospital Naval
Almirante.
Design Single-blind randomized control trial
Key findings There were no significant variations in the
baseline features of the two groups (group
receiving non-pharmacological intervention
using the family members and the one
receiving the standard management. A 13.3%
primary outcome was observed in the control
group whereas 5.6% was observed in the
intervention group. Non-pharmacological
prevention of delirium when delivered using
family members is more effective in the
prevention of delirium.
Level of evidence Level II
Article by Colombo et al. (2012)
Areas of Analysis Analysis
Purpose/aim of the study To determine the efficacy of reorientation
strategy in the reduction of incidences of
delirium in the intensive care unit.
Sample All patients admitted to ICU and meeting the
inclusion criteria, i.e. n=314
Design A two-stage prospective observational study
was used to examine the prevalence of
delirium, risk factors and the its effect on

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patient outcome. Phase I was observational
and phased II was interventional
Key findings The incidence of delirium was noticeably
lower in the second group (22%) compared to
the first group (35%). The reorientation
strategy was found to be most effective
protective predictor of delirium based on the
Cox’s Proportional Hazard model (HR
0.504), while age and sedation both were
negative predictors with HRs of 1.034 and
2.145 respectively
Level of evidence Level III
Article by Allen et al. (2011)
Areas of Analysis Analysis
Purpose/aim of the study To elaborate on the effectiveness of a system-
wide quality improvement project in the
improvement of the early recognition,
treatment, and prevention of delirium.
Sample All patients admitted to the acute care for
seniors (n=97 post-protocol, and n = 102 pre-
protocol)
Design The system-wide quality improvement project
consisted of three stages represented by the
acronym ABC implementation (agree, build
and commence).
Key findings The actualization of the protocol resulted in
significant reduction in the average number of
days the patients were diagnosed with
delirium (7 days for the pre-protocol and 4
days for the post-protocol). Additionally,
there were decline in the mortality rate (23%
against 9.5%), monthly re-admissions )31%
against 5%), and intensive care unit transfers
(18% against 0%).
Level of evidence Level III

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Introduction
Delirium is a clinical syndrome characterized by disturbance of consciousness, attention,
perception, and cognition that can impair sleep, emotions, and psychomotor activity. The
disorder develops over a short period and maybe on and off and is the most prevalent psychiatric
syndrome experienced in a hospital setting with over 20% of the aged patients being diagnosed
with the disease. It is more prevalent in oncology and surgical wards and ICUs. Patients
diagnosed with the condition have extensive stays in hospitals, high disability and mortality rate
in comparison to those diagnosed with heart attacks. The high incidence of the diseased in
addition to the consequences make it worthy of repeated study. Delirium is preventable. Multiple
studies have been conducted on effective intervention for the prevention of the disorder.
However, there are mixed responses regarding the most effective strategy in the reduction of the
incidence of delirium in the hospital setting. Therefore, this review aims at ascertaining the most
effective intervention in reducing and preventing the incidence of delirium in the hospital setting.
Critical Analysis
The study by Martinez, Tobar, Beddings, Vallejo, and Fuentes (2012) examined the effectiveness
of a non-pharmacological intervention in the prevention of delirium in an acute hospital. The
sample was appropriate for the study because it only consisted of those at risk of getting the
disease and hospitalized, thus increasing the reliability of the data. The study used a randomized
control trial which enables comparability one treatment against another to establish effectiveness.
Moreover, it is the strongest empirical evidence of treatment efficacy. Randomization procedure
involved the allocation of computer-generated random numbers and the use of an independent
data analyst thus minimizing the possibility of allocation bias. Furthermore, the concealment of

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the randomization process from the researchers minimized both performance and assessment
bias.
There were no significant variations in the baseline features of the two groups (group receiving
non-pharmacological intervention using the family members and the one receiving the standard
management. A 13.3% primary outcome was observed in the control group whereas 5.6% was
observed in the intervention group. Non-pharmacological prevention of delirium when delivered
using family members is more effective in the prevention of delirium in comparison with the
normal management of patients that are vulnerable to being diagnosed with the disorder.
Colombo et al. (2012) researched to ascertain the efficacy of a reorientation strategy for reducing
acute delirium in a hospital setting. The sample for the study consisted of all patients admitted to
the ICU department over a year. Those diagnosed with cognitive disorders, morbidity after
stroke, and dementia were not included in the research. The inclusion and exclusion criteria
improved the appropriateness of the sample because the disorders could have given wrong
information on the actual cause of the symptoms. This increased the credibility of the outcomes.
Furthermore, the period of recruiting the sample was extensive enough to ensure all-inclusivity
of the appropriate patients for the study. The study used a two-stage prospective observational
study. This methodology is advantageous because it is appropriate in the collection of specific
exposure data and thus may be more complete. On the other hand, the approach requires an
extensive follow-up period while waiting for the occurrence of the illness. As a result, the
methodology is ineffective for examining disorders with extensive periods and is likely to result
in the loss of data due to a low follow-up rate. The implementation of the process of the
intervention was examined by one of the researchers. This might lead to researcher bias. On the
other hand, the approval of the study by the internal review board is likely to improve the

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credibility of the study, though as effective as when an independent researcher was involved in
the review of the intervention process.
The incidence of delirium was noticeably lower in the second group (22%) compared to the first
group (35%). The findings of the sensitivity analysis agreed with that of Cox’s model because
there was a bivariate converse association between the incidence of delirium and reorientation
strategy. Additionally, ICU and the hospital had crude death rates of 10.8% and 14.7%
respectively. The mortality rate for acute patients with delirium was low (Log-Rank 6.024,
P=0.014). Delirium patients that were not participating in the reorientation program were found
to have a high mortality rate though it was statistically insignificant (Log-Rank 0.020, P=0.887).
The reorientation strategy was found to be a most effective protective predictor of delirium based
on the Cox’s Proportional Hazard model (HR 0.504), while age and sedation both were negative
predictors with HRs of 1.034 and 2.145 respectively
Allen et al. (2011) also undertook a quantitative research study to assess the effectiveness of a
system-wide continuous quality improvement project in the prompt detection, treatment and
prevention of delirium. The sample study consisted of all patients admitted to acute care for the
aged unit. The sample may be inappropriate for the study because it is not clear on the inclusion
and exclusion criteria. This implies that the analyzed patients might be suffering from other
diseases such as myocardial infarction, cognitive disorders and dementia with relatively similar
symptoms to delirium. This may affect the credibility of the outcomes.
The study used a retrospective observational approach which is more often vulnerable to recall
or information bias. The researcher has minimal control over the control of data, and the data is
obtained from the patients might inconsistently be measured between subjects 2. But, the

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approach is less costly and takes a shorter time since the project is not being implemented during
the evaluation but instead, it's being assessed for effectiveness. The actualization of the protocol
resulted in a significant reduction in the average number of stays for the patients were diagnosed
with delirium (7 days for the pre-protocol and 4 days for the post-protocol). The incidence of
delirium decreased from 8.8% to 7.2%. Additionally, there was a decline in the mortality rate
(23% against 9.5%), monthly re-admissions )31% against 5%), and intensive care unit transfers
(18% against 0%).
Recommendations for the best intervention
Three prevention intervention strategies for delirium have been analyzed namely a
multicomponent intervention (non-pharmacological intervention), a reorientation strategy, and a
system-wide quality improvement project. The findings of the studies show that the strategies
were effective in the reduction and prevention of the incidence of delirium in hospital settings.
However, some weaknesses of the disadvantages were observed in some of the strategies. For
instance, the reorientation strategy adopted a two-stage prospective observational study which is
in itself ineffective for examining disorders with extensive periods and is likely to result in the
loss of data due to low follow-up rate. This affects the credibility of the findings and efficacy of
the approach. Moreover, the study was at risk of researcher bias. The system-wide quality
improvement project was a retrospective observational study which is more often vulnerable to
recall or information bias and thus making it a challenge to ascertain the accuracy of the strategy.
Based on the findings of the review, this study recommends the non-pharmacological
intervention in the prevention of delirium in an acute hospital because it resulted in a 5.6%
reduction in the incidence of delirium. Additionally, a randomized control trial enabled
comparability of one treatment against another to establish effectiveness. Moreover, it is the

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strongest empirical evidence of treatment efficacy and reduce any possible researcher and
allocation bias.

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References
Allen, K. R., Fosnight, S. M., Wilford, R., Benedict, L. M., Sabo, A., & Holder, C. (2011).
Implementation of a system-wide quality improvement project to prevent delirium in
hospitalized patients. JCOM, 18(6), 253-258. Retrieved from
https://pdfs.semanticscholar.org/7444/895ef0a359f89e5d502ab1d18485441fda87.pdf
Colombo, R., Corona, A., Praga, F., Minari, C., Giannotti, C., Castelli, A., & Raimondi, F.
(2012). A reorientation strategy for reducing delirium in the critically ill. Results of an
interventional study. Minerva anestesiologica, 78(9), 1026. Retrieved from
https://www.researchgate.net/profile/Riccardo_Colombo/publication/228444923_A_reori
entation_strategy_for_reducing_delirium_in_the_critically_ill_Results_of_an_interventio
nal_study/links/5593064208aed7453d4650f4/A-reorientation-strategy-for-reducing-
delirium-in-the-critically-ill-Results-of-an-interventional-study.pdf
Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing
delirium in an acute hospital using a non-pharmacological intervention. Age and
ageing, 41(5), 629-634. https://doi.org/10.1093/ageing/afs060