- Email: [email protected]
Preliminary Evidence of a Positive Effect of Occupational Therapy in Patients With Delirium Superimposed on Dementia
JAMDA xxx (2017) 1e2
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Preliminary Evidence of a Positive Effect of Occupational Therapy in Patients With Delirium Superimposed on Dementia To the Editor: It has been reported that delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients.1 The nonpharmacologic approach is the first step for delirium prevention and treatment.2 Previous studies suggest that early psycho-cognitive and motor activation, performed by a multidisciplinary team, may reduce delirium duration and, consequently, future disability.3 In addition, 2 studies of critically ill patients have shown that occupational therapy (OT) reduces the duration of delirium and improves the functional status at hospital discharge.4,5 Here we focus on the novel methodology of the application of OT for the treatment of patients with delirium and dementia of a multidisciplinary geriatric team in a rehabilitation setting through the presentation of clinical cases. We analyzed 6 patients admitted with delirium and dementia to the Department of Rehabilitation of Fondazione Camplani, Cremona, Italy between March and May 2016. Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. The OT was activated in a multidisciplinary geriatric team, including a geriatrician, physical therapists, nurses, speech therapists, social workers, and psychologists. The OT sessions were performed twice daily Monday through Friday, for a total of 40 minutes until delirium resolution. The purposes of the OT were functional recovery and participation in activities of daily living (ADL). The procedures used to reach this goal were (1) A caregiver interview (Model of Human Occupation concept, history interview) to be acquainted with the occupational story of the patient and of the caregiver and to collect key information to begin the reorientation into the reality and to identify ordinary significant occupations for the patient6; (2) An external multisensory and cognitive stimulation by personal and significant occupations, which were identified as important for the patient through the caregiver interview7; (3) A basic ADL group of activities that promote independent living, which include mobilization, hygiene, personal grooming, and eating, in all morning sessions8; (4) A family education and involvement (education about implementation of base activities) that are necessary for a proper assistance and explanation of the phenomenology of delirium; and (5) Changes of the environment to promote rest, sleep-wake cycle, and spatial-temporal orientation. https://doi.org/10.1016/j.jamda.2017.09.005 1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The activity performed during the occupational therapy session was adapted and based on the psychical and cognitive level of the patient, which was evaluated with the modified Richmond Agitation and Sedation Scale.9 The mean age was 84.1 6.4 years, and all the patients were living at home before hospital admission. Of the 6 patients, 4 were admitted after a hip fracture and 2 after an acute stroke. The mean duration of delirium was 10 6.3 days, and the activation of the OT occurred 3.5 3.8 days after the rehabilitation admission. The mean Barthel index (BI) was 81.3 16.9 on pre-admission and 8.6 13.7 on admission. On admission, the mean Standardized-Mini-Mental State Examination score was 8.6 7.8 and the Tinetti score was 0.2 0.4 (indicative of inability to walk). The OT used, on average, 10 sessions 4.9 to complete his intervention, and in 25% of the cases cooperated with the main caregiver. At discharge, we recorded a partial recovery in the ADL (BI 24 10.9) in balance and walking abilities (Tinetti scale score 6.7 4.6) and in cognitive performances (S-Mini-Mental State Examination: 10.6 7.8). It is interesting to report that 83% of the patients were discharged to home; at a 2month follow-up, they were still at home. One patient was institutionalized and died in the month after the rehabilitation discharge. This preliminary study has several limitations including the small number of patients and the lack of effectiveness assessment. Nonetheless, it suggests that OT is a discipline that could be applicable in the rehabilitation of patients with delirium and dementia given its multidimensional perspective of a multidisciplinary team. It should be emphasized that the OT sessions were carried out adapting the procedures according to the vigilance of the patient, assessed with the modified Richmond Agitation and Sedation Scale. This approach is similar to a previous study of early physical therapy and OT in critically ill patients.2,5 Planning the discharge in the early phases of recovery and intense education of the family could have influenced the subsequent possibility of returning home, despite the delirium severity and functional disability. Prospective research studies are necessary to evaluate the efficacy of the integration of OT in the management of delirious patients with dementia. References 1. Morandi A, Davis D, Fick DM, et al. Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc 2014;15:349e354. 2. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669e676. 3. Brummel NE, Girard TD, Ely EW, et al. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014;40:370e379. 4. Álvarez EA, Garrido MA, Tobar EA, et al. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. J Crit Care 2017;37:85e90. 5. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874e1882. 6. Apte A, Kielhofner G, Ward AP, et al. Therapists and clients perceptions of the occupational performance history interview. Occup Ther Health Care 2005;19:173e192. 7. Fisher A. Occupation-centred, occupation-based, occupation-focused: Same, same or different. Scand J Occup Ther 2014;21:96e107.
2
Letter to the Editor / JAMDA xxx (2017) 1e2
8. Schaller SJ, Anstey M, Blobner M, et al. Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. Lancet 2016;388:1377e1388. 9. Chester JG, Beth Harrington M, Rudolph JL. Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med 2012; 7:450e453.
Christian Pozzi, OT University of Applied Sciences and Arts of Southern Switzerland (SUPSI) Manno, Switzerland Società Italiana di Terapia Occupazionale Rome, Italy Geriatric Research Group Brescia, Italy Elena Lucchi, PsyD Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy Alessandro Lanzoni, OT Società Italiana di Terapia Occupazionale Nursing Home Fondazione L. BonieSuzzara (MN) Rome, Italy
Simona Gentile, MD Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy Marco Trabucchi, MD Geriatric Research Group Brescia, Italy Giuseppe Bellelli, MD Geriatric Research Group Brescia, Italy Acute Geriatric Unit School of Medicine and Surgery University Milano-Bicocca Milan, Italy Alessandro Morandi, MD, MPH Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Preliminary Evidence of a Positive Effect of Occupational Therapy in Patients With Delirium Superimposed on Dementia To the Editor: It has been reported that delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients.1 The nonpharmacologic approach is the first step for delirium prevention and treatment.2 Previous studies suggest that early psycho-cognitive and motor activation, performed by a multidisciplinary team, may reduce delirium duration and, consequently, future disability.3 In addition, 2 studies of critically ill patients have shown that occupational therapy (OT) reduces the duration of delirium and improves the functional status at hospital discharge.4,5 Here we focus on the novel methodology of the application of OT for the treatment of patients with delirium and dementia of a multidisciplinary geriatric team in a rehabilitation setting through the presentation of clinical cases. We analyzed 6 patients admitted with delirium and dementia to the Department of Rehabilitation of Fondazione Camplani, Cremona, Italy between March and May 2016. Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. The OT was activated in a multidisciplinary geriatric team, including a geriatrician, physical therapists, nurses, speech therapists, social workers, and psychologists. The OT sessions were performed twice daily Monday through Friday, for a total of 40 minutes until delirium resolution. The purposes of the OT were functional recovery and participation in activities of daily living (ADL). The procedures used to reach this goal were (1) A caregiver interview (Model of Human Occupation concept, history interview) to be acquainted with the occupational story of the patient and of the caregiver and to collect key information to begin the reorientation into the reality and to identify ordinary significant occupations for the patient6; (2) An external multisensory and cognitive stimulation by personal and significant occupations, which were identified as important for the patient through the caregiver interview7; (3) A basic ADL group of activities that promote independent living, which include mobilization, hygiene, personal grooming, and eating, in all morning sessions8; (4) A family education and involvement (education about implementation of base activities) that are necessary for a proper assistance and explanation of the phenomenology of delirium; and (5) Changes of the environment to promote rest, sleep-wake cycle, and spatial-temporal orientation. https://doi.org/10.1016/j.jamda.2017.09.005 1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The activity performed during the occupational therapy session was adapted and based on the psychical and cognitive level of the patient, which was evaluated with the modified Richmond Agitation and Sedation Scale.9 The mean age was 84.1 6.4 years, and all the patients were living at home before hospital admission. Of the 6 patients, 4 were admitted after a hip fracture and 2 after an acute stroke. The mean duration of delirium was 10 6.3 days, and the activation of the OT occurred 3.5 3.8 days after the rehabilitation admission. The mean Barthel index (BI) was 81.3 16.9 on pre-admission and 8.6 13.7 on admission. On admission, the mean Standardized-Mini-Mental State Examination score was 8.6 7.8 and the Tinetti score was 0.2 0.4 (indicative of inability to walk). The OT used, on average, 10 sessions 4.9 to complete his intervention, and in 25% of the cases cooperated with the main caregiver. At discharge, we recorded a partial recovery in the ADL (BI 24 10.9) in balance and walking abilities (Tinetti scale score 6.7 4.6) and in cognitive performances (S-Mini-Mental State Examination: 10.6 7.8). It is interesting to report that 83% of the patients were discharged to home; at a 2month follow-up, they were still at home. One patient was institutionalized and died in the month after the rehabilitation discharge. This preliminary study has several limitations including the small number of patients and the lack of effectiveness assessment. Nonetheless, it suggests that OT is a discipline that could be applicable in the rehabilitation of patients with delirium and dementia given its multidimensional perspective of a multidisciplinary team. It should be emphasized that the OT sessions were carried out adapting the procedures according to the vigilance of the patient, assessed with the modified Richmond Agitation and Sedation Scale. This approach is similar to a previous study of early physical therapy and OT in critically ill patients.2,5 Planning the discharge in the early phases of recovery and intense education of the family could have influenced the subsequent possibility of returning home, despite the delirium severity and functional disability. Prospective research studies are necessary to evaluate the efficacy of the integration of OT in the management of delirious patients with dementia. References 1. Morandi A, Davis D, Fick DM, et al. Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc 2014;15:349e354. 2. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669e676. 3. Brummel NE, Girard TD, Ely EW, et al. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014;40:370e379. 4. Álvarez EA, Garrido MA, Tobar EA, et al. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. J Crit Care 2017;37:85e90. 5. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874e1882. 6. Apte A, Kielhofner G, Ward AP, et al. Therapists and clients perceptions of the occupational performance history interview. Occup Ther Health Care 2005;19:173e192. 7. Fisher A. Occupation-centred, occupation-based, occupation-focused: Same, same or different. Scand J Occup Ther 2014;21:96e107.
2
Letter to the Editor / JAMDA xxx (2017) 1e2
8. Schaller SJ, Anstey M, Blobner M, et al. Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. Lancet 2016;388:1377e1388. 9. Chester JG, Beth Harrington M, Rudolph JL. Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med 2012; 7:450e453.
Christian Pozzi, OT University of Applied Sciences and Arts of Southern Switzerland (SUPSI) Manno, Switzerland Società Italiana di Terapia Occupazionale Rome, Italy Geriatric Research Group Brescia, Italy Elena Lucchi, PsyD Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy Alessandro Lanzoni, OT Società Italiana di Terapia Occupazionale Nursing Home Fondazione L. BonieSuzzara (MN) Rome, Italy
Simona Gentile, MD Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy Marco Trabucchi, MD Geriatric Research Group Brescia, Italy Giuseppe Bellelli, MD Geriatric Research Group Brescia, Italy Acute Geriatric Unit School of Medicine and Surgery University Milano-Bicocca Milan, Italy Alessandro Morandi, MD, MPH Deparment of Rehabilitazion Fondazione Camplani Cremona, Italy Geriatric Research Group Brescia, Italy