A complex intervention to promote prevention of delirium in older adults by targeting caregiver’s participation during and after hospital discharge – study protocol of the TRAnsport and DElirium in older people (TRADE) project

Abstract

Background Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults. Methods The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days. Discussion TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study. Trial registration DRKS (Deutsches Register für klinische Studien) DRKS00017828. Registered on 17th September 2019. Retrospectively registered.

Impact of nursing interventions on discharge disposition in patients with postoperative delirium

“…The evidence surrounding the efficacy of transitional care for patients with delirium is limited, although current research is underway. 34 Expert consensus guidelines focused on preoperative management of older adults recommend healthcare teams discuss patient and family goals, treatment preferences, advance directives, surrogate decision-making, and palliative care consult if the prognosis is poor. 8 Nurses can promote agency, self-determination, and caregiver participation to prevent and manage postoperative delirium by engaging in early and interdisciplinary education and discharge planning processes.…”

Around the EQUATOR with clinician‐scientists transdisciplinary aging research (Clin‐STAR) principles: Implementation science challenges and opportunities

“…30 In addition, complex interventions often require care partner availability and engagement, so objectively reporting their involvement will be an essential component of reproducibility and scale-up. 31 The Caregiving Health Engagement Scale is one measure of a care partner's capacity to participate in another patient's care. 32 At the healthcare system level, describing the interconnectedness of insurance status and equitable access to services is a component of adapting interventions locally to accommodate resource constraints, yet is often unreported or provided only in general demographic tables.…”

“…The Centers for Medicare & Medicaid Services Accountable Needs Communities Health‐Related Social Needs Screening Tool is an established and commonly used instrument for a broad assessment of social determinants of health 30 . In addition, complex interventions often require care partner availability and engagement, so objectively reporting their involvement will be an essential component of reproducibility and scale‐up 31 . The Caregiving Health Engagement Scale is one measure of a care partner's capacity to participate in another patient's care 32 .…”

Frailty index and its association with the onset of postoperative delirium in older adults undergoing elective surgery

“…Risk factors for delirium are multidimensional and can be classified into predisposing non-modifiable ones like age, stroke or preexisting dementia, and modifiable ones such as drug side effects or environmental factors [ 2 , 6 , 7 ]. Thus, it is expected that by addressing modifiable risk factors clinical practitioners especially in surgical departments would be able to optimize the clinical management for those patients identified with high risk of developing postoperative delirium (POD).…”