Contributed by Evelyn Alvarez1,2,3 & Juan Pablo Saa4
1 Centro de Estudios en Neurociencia Humana y Neuropsicología, Facultad de Psicología, Universidad Diego Portales, Chile, 2 Facultad de Ciencias de la Salud, Universidad Central de Chile, Chile, 3 Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Facultad de Medicina, Universidad de Chile, Chile, 4 Florey Institute of Neuroscience and Mental Health, Austin Site, Melbourne, Australia.
Delirium is a complex and multifactorial disturbance of brain function that can be prevented with non-pharmacological management.1 These interventions include multidimensional and interdisciplinary approaches, among which occupational therapy (OT) can play an important role.2–6
OT is a patient-centered profession that promotes health and wellbeing through the use of occupations. The primary goal in OT is for patients to independently carry out occupations and activities of daily living (ADLs) e.g. getting dressed, walking, eating. To meet these goals, OTs target interventions at the person, the occupation and/or the environment.
Delirium management strategies utilized by Occupational Therapists
OT professionals can help in both preventing and managing delirium through non-pharmacological interventions,6,9 where the main purpose is to identify modifiable, triggering factors (e.g. pharmaceuticals, infections), and to decrease the impact of risk factors (e.g. pre-existing cognitive impairment). With two case-scenarios in mind (see Table 1), we will now refer to some intervention strategies that OTs use for the management of delirium (Figure 1).3
Assessment of different areas is crucial before determining any goal or intervention. An important area of assessment in delirium is cognition. Occupational therapists normally evaluate cognition to have an idea of the patient’s previous level of functioning. Different assessments can be used with this purpose, for example: AD8, IQCODE, mBDRS. Other relevant areas to evaluate are the patient’s prior functional (e.g. FIM, Barthel Index, and by conducting a structured interview of the patient or family member); and occupational status (e.g. assessment of interests, personal history and roles that can guide the intervention).
During the hospitalization, OTs also aim to identify the current state of functioning by evaluating the daily presence of delirium (CAM), cognitive (MMSE, MoCA, O-Log, and qualitative observation) and functional status of the patient.
2) Environmental modification / adaptation.3,12,14
In this area, the aim is to regulate and customize environmental stimuli, so that the patient can understand the hospital context. Through environmental cues, which can include the use of calendars, clocks, hospital information, maintenance of light during the day, use of personal objects, photographs, use of sensory devices (e.g. glasses, earpieces), one can promote an environment that supports the person’s normal functioning without providing an overload of information. On the other hand, the social environment of the person with delirium (i.e. health personnel, family and caregivers), should be educated to create this environment to further support the daily engagement and functioning of their patients.
3) Cognitive intervention
Reality orientation techniques are utilized to focus on current social, personal, spatial, and temporal orientation skills. In addition, more specific tasks/activities that promote cognitive stimulation or rehabilitation can be implemented in the domains of attention, memory, praxis, executive function and language.
4) Early mobilization
In this area, ergonomic positioning is implemented with the purpose of minimizing contractures, pressure ulcers, and promoting comfortable and anatomical positions. For instance, sitting or standing positions can facilitate alertness during the day; and the supine position can improve resting at night.
Mobilization of upper extremities can also aid with the maintenance of motor skills such as grasp, pinch and grip strength during the hospital stay. This mobilization can be completed through movement of objects, reaching, fine and gross motor skills, oculomotor and bimanual coordination, all of which are necessary to maintain basic functions such as eating and getting dressed.
5) ADL training
ADL training supports routine and independent maintenance of activities such as hygiene, dressing, sphincter control, and transfers. Training should start with the tasks that are simpler (e.g. eating) and then progress to more complex ones (e.g. those involving multiple skills such as transferring to a different location). All ADLs should be graded and completed in a comfortable position (e.g. sitting on the bed, then on the edge of bed, then move on to chair, and essential spaces such as the bathroom). It is important to always respect each individual’s pace, so as to not induce fatigue or frustration3,14.
The previously described actions will promote a good hospital routine, facilitate the performance of activities during the day and rest at night. Furthermore, a carefully selected evaluation and intervention plan will be more likely to offer occupations related to the interests and capabilities of each patient. We will now portray these practices in two case-scenarios, with examples to prevent delirium, and to treat it in people who already present with it.
Occupational therapists have a fundamental role in the prevention and intervention of delirium through non-pharmacological strategies that contribute to the allied health teamwork with this population. However, there are still gaps to fill about OT interventions, such as generating more robust evidence detailing the effect of each intervention strategy independently, the dose, and the writing of protocols according to different stages of delirium. The development of this evidence will help create a more complete picture of the patient’s historical, motivational, physical, cognitive and contextual factors leading to delirium. This evidence will also be highly useful in delivering a personalized intervention that supports patients, their family, and the healthcare team.
- Oh, E. S., Fong, T. G., Hshieh, T. T. & Inouye, S. K. Delirium in Older Persons. JAMA 318, 1161 (2017).
- Morandi, A. et al. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). doi:10.1186/s12877-019-1264-2.
- Álvarez, E. A. 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 37, 85–90 (2017).
- Schweickert, W. D. et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373, 1874–1882 (2009).
- Needham, D. M. et al. Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Arch. Phys. Med. Rehabil. 91, 536–542 (2010).
- Rains, J. & Chee, N. The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care. J. Intensive Care Soc. 18, 318–322 (2017).
- World Federation Occupational Therapy (WFOT). About Occupational Therapy | WFOT. https://www.wfot.org/about-occupational-therapy.
- Fernández-López, J. A., Fernández-Fidalgo, M., Geoffrey, R., Stucki, G. & Cieza, A. Funcionamiento y discapacidad: La clasificacion internacional del funcionamiento (CIF). Rev. Esp. Salud Publica 83, 775–783 (2009).
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- Law, M. et al. The Person-Environment-Occupation Model: A Transactive Approach to Occupational Performance. Can. J. Occup. Ther. 63, 9–23 (1996).
- Black, M. H. et al. Understanding the meaning and use of occupational engagement: Findings from a scoping review. Br. J. Occup. Ther. 82, 272–287 (2019).
- Brummel, N. E. et al. Occupational Therapy in the Intensive Care Unit. in Occupational Therapy for Older People 55–75 (Springer International Publishing, 2020). doi:10.1007/978-3-030-35731-3_4.
- Kielhofner, G. Model of human occupation : theory and application. (Lippincott Williams & Wilkins, 2008).
- Alvarez, E. & Sthepanie, P. Protocolo de Intervención. https://deliriumenchile.cl/wp-content/uploads/2019/03/TO-Protocolo-de-Internvención.pdf doi:ISBN 978-956-353-242-5.
- Taekema, D. G., Gussekloo, J., Maier, A. B., Westendorp, R. G. J. & de Craen, A. J. M. Handgrip strength as a predictor of functional, psychological and social health. A prospective population-based study among the oldest old. Age Ageing 39, 331–337 (2010).