Abstract
A novel care model was created to assess the effectiveness of OT as a nonpharmacologic, multicomponent intervention in the prevention and treatment of delirium in hospitalized patients. Given that “only 12 to 35% of delirium cases are recognized,” patients with “altered mental status” received priority evaluation from OT (Ramirez, 2014). Preliminary research has been promising and indicates benefits of OT utilization as an effective discipline in the treatment of delirium.
Primary Author and Speaker: Emma Monaghan
Additional Authors and Speakers: Ashna Rajan
Contributing Authors: Gary Blanchard
OTs are specifically equipped as a discipline to conduct cognitively stimulating interventions. Previous studies have referenced that “OT is effective in decreasing duration and incidence of delirium in non-ventilated elderly patients” - but, to our knowledge, no robust OT-driven protocol for the prevention and treatment of delirium has been studied (Alvarez, 2017). Prior to starting the project, a hospital-wide, multidisciplinary education on delirium was initiated. Pertinent staff were educated on how to order an OT delirium prevention consult through a new order set, and the importance of following through with recommendations. OTs now perform rapid assessments on patients with delirium and those at risk to aid in delirium prevention. Chosen interventions include cognitively stimulating activities and/or sensory based approaches. Examples include word puzzles, reminiscence books, weighted blankets and fidget items. OTs complete a “Head of Bed” form during the evaluation which aims to promote communication between all staff. Communication is also made to the family and/or living facility to determine prior level of function. Pertinent information is added to the form to standardized care.
A total of 153 consults were received of which 80 were appropriate and included 44 females and 36 males and the average age was 79.5 years (79.4641 ±1.881). Of these, one was made CMO, 2 refused, 1 was not assessed and 6 were not found to be delirious. Amongst the remaining 70 patients, 21 had underlying dementia and 6 patients had depression. Overall, 26 patients had hyper delirium, 28 hypo delirium, 4 mixed delirium and 3 were found to be waxing and waning. Additionally, 9 were found to be at baseline, of which 6 were found to be at risk for delirium given their history of dementia/mood disorder. Post the intervention, 60 had re-assessments done revealing improvement in a total of 42 patients including 16 with hyper delirium,17 with hypo delirium and 3 with mixed delirium. On subgroup analysis, improvement was seen in 12 patients with dementia and 6 with mood disorder. The use of sitters decreased from 11 to 4 among those who improved and from 13 to 9 among those who did not improve(chi square 3.42, p value .06); the use of restraints had decreased by more than half post the intervention although only 11 patients were restrained previously(chi square 2.52, p value .11). On the contrary, 19 patients did not improve, 1 was waxing and waning, 2 worsened and in one patient it was unclear what the turn of events were. In addition, among the 25 patients who received at least one antipsychotic prior to the intervention, 7 patients did not require any afterwards(chi square 1.42, p value .23). Overall, hospital wide usage of antipsychotics per 1000 adjusted patient days decreased from 17 to 11 per month between January 2018 and July 2019.
Early recognition and non-pharmacological treatment of delirium goes a long way in avoiding adverse effects of of antipsychoitcs, rate of readmissions, cognitive decline as well as economic consequences of untreated delirium. Preliminary data shows a trending reduction in the use of antipsychotics and restraints in patients who have had an OT delirium assessment. Individualized interventions were more effective in patients who had hyperactive delirium rather than the hypoactive form. We also noticed that the development of delirium in the “at risk” patient was lowered when an OT consult was completed and interventions were put in place. Data is promising for the use of OT delirium consults to prevent and/or lessen the need for medications/restraints and the adverse long term effects of delirium. Further study, robust data abstraction, and data analysis is currently being planned.
Ramirez, E. Mdl., Paul, M. Delirium. 2019 In: StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470399/
Álvarez, E. A., Garrido, M. A., Tobar, E. A., Prieto, S. A., Vergara, S. O., Briceño, C. D., & González, F. J. (2017). Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care, 37, 85–90. doi: 10.1016/j.jcrc.2016.09.002