Delirium prevention in hospices

Background
Delirium is common and distressing for hospice in-patients, with a prevalence of 58%-88% in the period before death. Systematic reviews have found that interventions targeting delirium’s modifiable risk factors significantly reduce its incidence (by approximately 40%- 50%) in hospitalised patients. Due to differences from other healthcare settings in risk factors and approaches to end- of- life care, interventions are needed which are tailored to the in-patient hospice context.
Aim
To develop evidence to inform the design of a behaviour change intervention for delirium care in hospice in-patient units.
Methods
My research was informed by the Medical Research Council framework for the development of complex interventions and behaviour change theory.
I conducted a systematic review of delirium risk factors. My qualitative synthesis, interviews and focused ethnography explored individual and contextual influences on hospice clinicians’ delirium prevention and management behaviours. Synthesis of these findings supported identification of target behaviours, mechanisms of action and behaviour change techniques for intervention design.
Results
My review of delirium risk factors found a positive association for opioid use with some evidence for dehydration, hypoxaemia, sleep disturbance and infection. However, the certainty of the evidence, from 28 included studies, was graded as low/ very low.
The current practice and research focus was on management, rather than prevention, of delirium. Many preventative behaviours were carried out as part of fundamental care, without the explicit intention of delirium prevention, but these behaviours reduced during illness progression.
My proposed intervention targets specific mechanisms of action (Knowledge, Emotion, Norms) to increase clinicians’ delirium prevention behaviours including routine assessment of risk factors, inclusion of delirium prevention in care decision-making and continuation of preventative behaviours during illness progression.
Conclusions
Evaluation of the feasibility and acceptability of this intervention is needed, before evaluating its effectiveness in reducing delirium, and related distress, for hospice patients.