Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol.

BACKGROUND: Delirium is a clinical condition characterised by acute and fluctuating deterioration of the cognitive state, generally secondary to an acute pathology. Delirium is associated with negative outcomes in older adults, such as longer hospitalisations, higher mortality, and short and medium-term institutionalisation. Randomised clinical trials have shown that delirium is preventable through non-pharmacological prevention measures, decreasing its incidence by 30-50%. These interventions include promoting physical activity, facilitating the use of glasses and hearing aids, cognitive stimulation, and providing frequent reorientation of time and space, among others. These measures are currently seldom applied in hospitals in Chile and around the world for reasons including the heavy workload of clinical staff, the lack of trained personnel, and in general the absence of a systematic implementation processes. We developed a software called PREVEDEL, which includes non-pharmacological strategies such as cognitive stimulation, early mobilisation, orientation, and pain assessment. We propose a randomised clinical trial to evaluate whether cognitive stimulation guided by PREVEDEL software prevents delirium status (full/subsyndromal delirium) in hospitalised older adults. METHOD: A randomised controlled trial, with parallel, multicentre groups. We will recruite patients 65 years or older who have been hospitalised for less than 48 h in the general ward or the intermediate care units of four hospitals in Santiago, Chile. The participants in the intervention group will use a tablet with cognitive stimulation software for delirium prevention for five continuous days versus the control group who will use the tablet without the software. We will evaluate the incidence, duration, density of delirium, subsyndromal delirium with the Confusion Assessment Method, cognitive with the Montreal Cognitive Assessment, and functional status with the Functional Independence Measure at discharge. Moreover, we will evaluate the adherence to prevention measures, as well as demographic variables of interest. DISCUSSION: The use of cognitive PREVEDEL software could increase and improve the implementation of non-pharmacological prevention measures for delirium in hospitalised older adults, thus reducing its incidence and contributing to patients and health professionals. TRIAL REGISTRATION: NCT05108207 ClinicalTrials.gov. Registered 4 November 2021.

Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial.

Background: Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures. Methods: A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium. Results: In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery. Discussion: Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery. Clinical trial registration: www.ClinicalTrials.gov, identifier NCT03704090.

Discurso y micropoder en la intervención con personas mayores con delirium hospitalizadas: reflexión en torno a las narrativas ausentes / Discourse and micropower in the intervention with hospitalized elderly people with delirium: reflection on absent narratives

Resumen Este ensayo analiza ¿cómo son las interacciones entre las personas mayores (PM) hospitalizadas con delirium y el personal de salud? Para reflexionar en la construcción de estas interacciones, nos basamos en el filósofo Michel Foucault, en su presentación y libro del "Orden del Discurso", donde consideramos como las relaciones sociales de micropoder pueden presentarse en diversos contextos, dialogando la interacción descrita desde las estrategias y tácticas de exclusión del discurso. Enfocamos sobre i) la razón y la locura, al identificar en las PM hospitalizadas con delirium, una narrativa desde el trastorno neurocognitivo, presentando una experiencia de aislamiento y por otro lado ii) el personal de salud, que se basa en determinar lo verdadero de lo falso, utilizando su conocimientos y tácticas desde el proceso de diagnóstico e intervención, el cual no logra recoger las experiencias de las PM con delirium. Por último, proponemos desde el realismo agencial una nueva construcción del fenómeno, que integre el conocimiento del personal de salud y la experiencia de las PM con delirium.

Abstract In this essay, we analyze the interactions between elderly people (EP) hospitalized with delirium and the health team. To reflect on the construction of these interactions we rely on the philosopher Michel Foucault, in his presentation and book "Order of Discourse", where we consider how micro-power social relations can be presented in various contexts, landing the interaction described from the strategies and discourse exclusion tactics. It is emphasized mainly i) reason and insanity, identified in EP hospitalized with delirium, which may have a narrative from the neurocognitive disorder, presenting an experience of isolation; on the other hand ii) the health team is based on determining what is true from what is false, using its knowledge and tactics from the process of diagnosis and intervention, which cannot collect the experiences of EP with delirium. Finally, we propose a new construction of the phenomenon from agency realism that integrates the knowledge of the health team and the experience of the EP with delirium.

[Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units]. / Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile.

BACKGROUND: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). AIM: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. MATERIAL AND METHODS: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. RESULTS: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. CONCLUSIONS: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Risk factors for dental caries in Latin American and Caribbean countries.

Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile / Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units

Background: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). Aim: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. Material and Methods: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. Results: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. Conclusions: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program.

OBJECTIVE: To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium. METHODS: A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method. RESULTS: Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99). CONCLUSIONS: Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Risk factors for dental caries in Latin American and Caribbean countries

Abstract Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

The applicability and feasibility of occupational therapy in delirium care.

PURPOSE: To perform a narrative review of studies on the applicability and feasibility of occupational therapy in persons with delirium by analyzing evaluation and procedural methods in the therapeutic settings. METHODS: Starting from the international classification of disability, the focus was to understand if and how occupational therapy as a multi-component intervention can reduce the duration and intensity of delirium to prevent future disabilities. This review also includes scientific studies demonstrating the benefits of occupational therapy in terms of increased functional and occupational outcomes. Finally, the evaluation modalities and the therapeutic procedures performed by the occupational therapist have been analyzed. RESULTS: The non-pharmacological treatments occupational therapists perform in people with delirium in intensive care settings are supported by scientific evidence. CONCLUSIONS: There is preliminary evidence of the benefit of including occupational therapy in early stages of rehabilitation in acute care to prevent and treat delirium. Nevertheless, further studies are necessary to define the different aspects of the multidisciplinary approach that is common in geriatric practice, primarily determining the adequate timing, and intensity of interventions as well as its appropriate settings.

Delirium en el adulto mayor hospitalizado / Delirium in elderly hospitalized patients

El delirium corresponde a un síndrome clínico frecuente y relevante en el adulto mayor hospitalizado. Su incidencia e impacto han sido reconocidos desde hace más de 30 años y su importancia en la atención del adulto mayor hospitalizado es creciente debido a que abarca diferentes escenarios clínicos (atención de urgencia, en pacientes hospitalizados por patologías médicas o quirúrgicas, en pacientes admitidos a unidades de cuidados intensivos, entre otros), y al envejecimiento poblacional, que ha conducido a que la atención hospitalaria moderna concentre cada vez una mayor cantidad de adultos mayores portadores de diversas condiciones crónicas, con grados diversos de fragilidad y discapacidad que requieren de nuestra mejor atención, de forma de reducir la aparición u optimizar el manejo de esta condición que puede ser devastadora para la evolución del adulto mayor posterior al egreso hospitalario. El presente capítulo pretende resumir el estado del arte de esta condición señalando, cuando corresponda, algunos de los elementos en controversia y donde nos parece necesario que la investigación nos señale innovadoras respuestas que permitan reducir su impacto.

Delirium is a frequent and relevant clinical syndrome in the elderly hospitalized. Incidence and impact has been recognized for more than 30 years, and its importance in the care of hospitalized older adults is increasing because it occurs in different clinical units (patients admitted in units of emergency, medical or surgical rooms, to intensive care units, among others), and the ageing population, which has led to modern hospital care concentrating a greater number of older adults with various chronic conditions, with varying degrees of frailty and disability that require our better attention, in order to reduce the occurrence or optimize the management of this condition, that can be devastating for the evolution of the elderly after hospital discharge. This chapter aims to summarize the state of the art of this condition, pointing out some controversial elements and where it seems necessary that the research shows us innovative answers that reduce its impact

A software to prevent delirium in hospitalised older adults: development and feasibility assessment.

BACKGROUND: non-pharmacological interventions to prevent delirium are useful in hospitalised older adults. However, they are poorly implemented in clinical practice. We aimed to develop a software for bedside use by hospitalised older adults and to improve their access to these interventions. METHODS: a transdisciplinary team composed of healthcare professionals, designers, engineers and older adults participated in the development of the software. Scrum methodology was used to coordinate the work of the team, and the software was evaluated in a feasibility study. RESULTS: a software for touchscreen mobile devices that supports Android 5.0 or later was produced, including modules for time-spatial re-orientation, cognitive stimulation, early mobilisation, sensorial support use promotion, sleep hygiene and pain management optimisation. Horizontal disposition, use of colour contrast and large interaction areas were used to improve accessibility. The software's usability and accessibility were evaluated in 34 older adults (average age 73.2 ± 9.1 years) showing that 91.1% of them got access to all the software functions without previous instructions. The clinical feasibility assessment showed that 83.3% of the 30 enrolled hospitalised patients (76 ± 8 years) completed the 5-day protocol of software usage during hospitalisation. Software use was associated with a decreased trend in delirium incidence of 5 of 32 (15.6%) at baseline to 2 of 30 (6.6%) after its implementation. CONCLUSION: a highly accessible and implementable software, designed to improve access to non-pharmacological interventions to prevent delirium in hospitalised older adults, was developed. The effectiveness of the software will be evaluated in a randomised clinical trial.

Children's and parents' views on hospital contact isolation: A qualitative study to highlight children's perspectives.

BACKGROUND: To date, there has been a paucity of studies conducted on the experiences of children under hospital contact isolation precautions. Furthermore, the studies that have examined children's experiences at the hospital typically reflect the perspectives of their parents, and few have directly involved interviews with children themselves, and even fewer with children in isolation. METHODS: To address this gap, we conducted semi-structured, open-ended interviews with hospitalized children to assess their experiences of being placed in isolation. Where possible, the children's parents also completed written surveys to assess parental perspectives on their child's experiences. RESULTS: Two important findings of the study were the children's resilience during a difficult time and children's varying awareness of the pathophysiology of infections as it relates to isolation precautions. Examination of the parent-child dyads elucidated some discordance between parents' and children's perspectives on how children experienced their isolation, on what the children's preferred activities were while in isolation, and how much children understood about the reasons they were in isolation. CONCLUSION: This study supports earlier studies that suggest that the benefits of isolation procedures may be outweighed by how negatively isolation is experienced by patients, particularly when the patients are children. It also highlights the need for child-friendly isolation signs. Because parental and child perceptions differed in cases where data from both were available, this study suggests larger studies on children's perspectives and/or on parent-child dyads are needed.

Cognitive stimulation and occupational therapy for delirium prevention. / Estimulação cognitiva e terapia ocupacional para prevenção de delirium.

Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

O delirium é uma condição importante em pacientes críticos, com impactos em longo prazo em termos de mortalidade, condição cognitiva e funcional, e qualidade de vida. Apesar do progresso ocorrido nos anos recentes em seu diagnóstico, prevenção e tratamento, seu impacto continua relevante, de forma que é necessário explorar novas estratégias de prevenção e tratamento. Dentre as estratégias preventivas não farmacológicas, relatos recentes sugerem o papel da terapia ocupacional por meio de uma série de intervenções que podem ter impacto no desenvolvimento do delirium. O objetivo desta revisão é avaliar os estudos que discutem o papel da terapia ocupacional na prevenção do delirium em populações de pacientes críticos, além de sugerir perspectivas para pesquisas nesta área.

Estimulação cognitiva e terapia ocupacional para prevenção de delirium / Cognitive stimulation and occupational therapy for delirium prevention

RESUMO O delirium é uma condição importante em pacientes críticos, com impactos em longo prazo em termos de mortalidade, condição cognitiva e funcional, e qualidade de vida. Apesar do progresso ocorrido nos anos recentes em seu diagnóstico, prevenção e tratamento, seu impacto continua relevante, de forma que é necessário explorar novas estratégias de prevenção e tratamento. Dentre as estratégias preventivas não farmacológicas, relatos recentes sugerem o papel da terapia ocupacional por meio de uma série de intervenções que podem ter impacto no desenvolvimento do delirium. O objetivo desta revisão é avaliar os estudos que discutem o papel da terapia ocupacional na prevenção do delirium em populações de pacientes críticos, além de sugerir perspectivas para pesquisas nesta área.

ABSTRACT Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial.

PURPOSE: Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge. METHODS: This is a pilot randomized clinical trial of patients without mechanical ventilation for 60 years. Patients were assigned to a control group that received standard strategies of prevention (n=70) or to an experimental group that received standard strategies plus occupational therapy twice a day for 5 days (n=70). Delirium was valued with Confusion Assessment Method and Delirium Rating Scale, and functional outcomes at discharge with Functional Independence Measure, Hand Dynamometer, and Mini-Mental State Examination. RESULTS: A total of 140 participants were recruited. The experimental group had lower duration (risk incidence ratios, 0.15 [P=.000; 95% confidence interval, 0.12-0.19] vs 6.6 [P=.000, 95% confidence interval, 5.23-8.3]) and incidence of delirium (3% vs 20%, P=.001), and had higher scores in Motor Functional Independence Measure (59 vs 40 points, P<.0001), cognitive state (MMSE: 28 vs 26 points, P<.05), and grip strength in the dominant hand (26 vs 18 kg, P<.05), compared with the control group. CONCLUSIONS: Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

Efecto de Lepidium meyenii (maca) sobre la producción de tres citoquinas hematopoyéticas en esplenocitos de ratones inmunosuprimidos / Effect of Lepidium meyenii (maca) on the production of three hematopoietic cytokines in splenocytes from immunosuppressed mice

Lepidium meyenii Walp, Brassicaceae (Maca) is a plant native to Peru to conferring immunostimulatory activity. The objective was to evaluate the immunomodulatory effect of the aqueous extract (EAc) of yellow ecotype on gene expression of three hematopoietic cytokines (IL-3, GM-CSF and IL-7) in splenocytes from Balb/c mice immunosuppressed with cyclophosphamide. Levels of mRNA were measured by RT-PCR. Two days after immunosuppression (IS), in splenocytes from mice treated with EAc increased expression of mRNA was demonstrated for IL-3, GM-CSF e IL-7 (p < 0.05) compared to the untreated group. Five days after IS, in mice treated with EAc found higher cell counts in bone marrow, peripheral blood and endogenous colonies formed units in spleen compared to the untreated group. It is concluded that administration of EAc in immunocompromised mice can reverse the suppressive effects of cyclophosphamide.

Lepidium meyenii Walp., Brassicaceae (Maca) es una planta oriunda del Perú a la que se atribuye actividad inmunoestimuladora. El objetivo fue evaluar el efecto inmunomodulador del extracto acuoso (EAc) del ecotipo amarillo sobre la expresión génica de tres citoquinas hematopoyéticas (IL-3, GM-CSF e IL-7) en esplenocitos de ratones Balb/c inmunosuprimidos con ciclofosfamida. Los niveles de mRNA se midieron por RT-PCR. Dos días después de la inmunosupresión (IS), en los esplenocitos de los ratones tratados con EAc se evidenció mayor expresión de mRNA para IL-3, GM-CSF e IL-7 (p<0.05) respecto al grupo no tratado. Cinco días después de la IS, en los ratones tratados con EAc se encontró mayor recuento de células en la médula ósea, sangre periférica y unidades formadoras de colonias endógenas en el bazo respecto al grupo no tratado. Se concluye que la administración de EAc a ratones inmunocomprometidos puede revertir los efectos supresores de la ciclofosfamida.