Intervention Review

Interventions for preventing delirium in hospitalised patients

  1. Najma Siddiqi1,*,
  2. Rachel Holt2,
  3. Annette M Britton3,
  4. John Holmes4

Editorial Group: Cochrane Dementia and Cognitive Improvement Group

Published Online: 18 APR 2007

Assessed as up-to-date: 11 JAN 2007

DOI: 10.1002/14651858.CD005563.pub2


How to Cite

Siddiqi N, Holt R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub2.

Author Information

  1. 1

    University of Leeds, Academic Unit for Psychiatry and Behavioural Sciences, Leeds, UK

  2. 2

    Leeds, UK

  3. 3

    Royal Prince Alfred Hospital, Geriatric Unit, Sydney, NSW, Australia

  4. 4

    University of Leeds, Academic Unit of Psychiatry, Leeds, UK

*Najma Siddiqi, Academic Unit for Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds, LS2 9LT, UK. n.siddiqi@leeds.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 APR 2007

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 一般語言總結

Background

Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients.

Objectives

Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings.

Search methods

We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 30 September 2006. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials.

Selection criteria

Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients.

Data collection and analysis

Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus.

Main results

Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer.

Only one study of 126 hip fracture patients comparing proactive geriatric consultation with usual care was sufficiently powered to detect a difference in the primary outcome, incident delirium. Total cumulative delirium incidence during admission was reduced in the intervention group (OR 0.48 [95% CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to treat' of 5.6 patients to prevent one case. The intervention was particularly effective in preventing severe delirium. In logistic regression analyses adjusting for pre fracture dementia and Activities of Daily Living impairment, there was no reduction in effect size, OR 0.6, but this no longer remained significant [95% CI 0.3,1.3]. There was no effect on the duration of delirium episodes, length of hospital stay, and cognitive status or institutionalisation at discharge. There was also no significant difference in cumulative delirium incidence between treatment and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI 0.59, 1.36]).

In another trial of low dose haloperidol prophylaxis, there was no difference in delirium incidence but the severity and duration of a delirium episode, and length of hospital stay were all reduced.

We identified no completed studies in hospitalised medical, care of the elderly, general surgery, cancer or intensive care patients. In outcomes, no studies examined for death, use of psychotropic medication, activities of daily living, psychological morbidity, quality of life, carers or staff psychological morbidity, cost of intervention and cost to health care services. Outcomes were only reported up to discharge, with no studies reporting medium or longer-term effects.

Authors' conclusions

Research evidence on effectiveness of interventions to prevent delirium is sparse. Based on a single study, a programme of proactive geriatric consultation may reduce delirium incidence and severity in patients undergoing surgery for hip fracture. Prophylactic low dose haloperidol may reduce severity and duration of delirium episodes and shorten length of hospital admission in hip surgery. Further studies of delirium prevention are needed.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 一般語言總結

There is a lack of robust information on delirium prevention in hospitalised patients

We were only able to identify one trial with adequate power to demonstrate effectiveness of any preventive strategies. Based on this single study, proactive consultation by a consultant geriatrician before, or within 24 hours of operation may reduce the incidence and severity of delirium in patients undergoing surgery for hip fracture. Low dose haloperidol prophylaxis may be effective in reducing the severity and duration of a delirium episode and may shorten length of hospital admission. Given what is already known about how common delirium is, and how poor its outcomes are, further trials of delirium prevention are urgently needed.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 一般語言總結

預防住院患者發生譫妄的介入措施

背景

譫妄(delirium)是一種住院病患中常見的精神疾患,可能帶來嚴重的不良後果。譫妄會伴隨死亡率、身體疾患發生率、住院天數、照護機構入住率,以及醫療成本的上升。各種不同風險因子參與了譫妄的形成,包含醫院內的環境及常規照護的各個面向。從患者和照護者的觀點來看,以及為了降低醫院的支出,譫妄的預防都是一個明確需要達成的目標。然而,目前我們並不清楚譫妄的各種預防措施是否有效、能否在所有環境下成功施行,以及針對不同病患族群是否必須採取不同的介入措施。

目標

我們的主要目標為:針對專門用以預防住院患者發生譫妄的介入措施,測定其有效性。我們也企圖針對此等情境下,進行譫妄預防的相關研究證據,凸顯其質與量

搜尋策略

我們在2005年9月28日搜尋了Specialized Register of the Cochrane Dementia and Cognitive Improvement Group資料庫。由於在MEDLINE、EMBASE、CINAHL及PsycINFO中針對Specialized Register所進行的搜尋未必能找到所有的譫妄預防相關試驗,因此我們在2005年10月28日再度對這些資料庫進行搜尋。我們也檢視了所取得之論文、回顧與書籍的參考文獻清單。另外也與此領域的專家取得聯繫,並搜尋網際網路,以尋求更多參考文獻並找出未發表的試驗。

選擇標準

我們納入了:評估任何用以預防住院患者發生譫妄的介入措施之隨機對照試驗(randomised controlled trials;RCTs)。

資料收集與分析

資料收集與品質評估作業係由3位作者獨立進行,再透過討論達成共識。

主要結論

我們找到、並納入了6項研究(共833位受試者)。所有研究均於外科單位下進行:5項探討骨科手術,而1項探討因胃癌或結腸癌接受切除手術的病患。

只有一項針對126位髖關節骨折患者、比較積極性老人諮詢(proactive geriatric consultation)與常規照護的研究,其檢定力足以偵測主要預後指標(後發性譫妄〔incident delirium〕)上的差異。結果,住院期間譫妄的總累加發生率在介入治療組中較低(OR:0.48 [95% CI:0.23, 0.98];RR:0.64 [95% CI:0.37, 0.98]),代表成功防止1個病例出現的「需治療人數」(number needed to treat)為5.6人。此介入措施對重度譫妄的預防特別有效。根據骨折前的失智症(dementia)及日常生活活動(Activities of Daily Living)障礙校正後的邏輯迴歸分析(logistic regression analysis)發現:效應大小(0.6的OR)並未下降,但卻不再顯著(95% CI:0.3, 1.3)。介入治療不影響譫妄事件的持續時間、住院天數,以及出院時的認知狀態或照護機構入住與否。而在50位失智症患者次組中,治療組與對照組之間在譫妄的累加發生率上,也有顯著的差異(RR:0.9 [95% CI:0.59, 1.36])。

在另一項探討低劑量haloperidol預防療法的試驗中,譫妄的發生率上無差異,但譫妄事件的嚴重度、持續時間,以及住院天數均下降。

我們並未找到已完成、且針對內科、老人科、一般外科、腫瘤科或加護病房之住院病患所進行的研究。預後指標方面,沒有任何研究檢視:死亡、精神藥物(psychotropic medication)的使用、日常生活活動、精神疾患發生率、生活品質、照護者或醫護人員的精神疾患發生率、介入措施的成本,以及醫療服務的成本。預後指標只報告至出院時,沒有任何研究報告中期或長期效果。

作者結論

針對各種介入措施對譫妄的預防功效,相關的研究證據非常稀少。僅根據單一研究指出:積極性老人諮詢療程可能在因髖關節骨折而接受手術的患者中,降低譫妄的發生率及嚴重度。低劑量haloperidol預防性療法可縮短髖關節手術的住院時間,以及譫妄事件的嚴重度與持續時間。未來仍須進行更多關於譫妄預防的研究。

 

一般語言總結

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 一般語言總結

預防住院患者發生譫妄的介入措施

預防住院患者發生譫妄的介入措施

針對任何的預防策略,我們只能找到一項檢定力足以證實其有效性的試驗。根據此單一研究,由老人專科顧問醫師於術前、或術後24小時內所進行的積極性諮詢療程,可能在因髖關節骨折而接受手術的患者中,降低譫妄的發生率及嚴重度。低劑量haloperidol預防性療法,可有效降低譫妄事件的嚴重度與持續時間,也可縮短住院時間。有鑑於我們已經瞭解譫妄有多常見、其預後有多差,因此我們迫切需要未來出現更多關於譫妄預防的試驗。

譯註

East Asian Cochrane Alliance 翻譯
翻譯由 台灣衛生福利部/台北醫學大學實證醫學研究中心 資助