Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial

Abstract

Background Delirium is common in post-acute care (PAC) patients with dementia; its treatment is not established. We hypothesized that cognitively-stimulating activities would reduce the duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. Design Single-blind randomized clinical trial. Setting eight PAC facilities. Participants 283 community-dwelling older adults with dementia and delirium. Intervention Cognitively-stimulating activities delivered daily for up to 30 days. Measurements Primary outcomes were delirium duration (Confusion Assessment Method), and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment and CLOX) and physical function (Barthel Index). Results Mean percentage of delirium-free days were similar in both groups: 64.8% (95% CI: 59.6–70.1) (intervention) vs. 68.7% (95% CI: 63.9–73.6) (control), p = 0.37, Wilcoxon's rank sums test. Delirium severity was similar in both groups: 10.77 (95% CI: 10.10–11.45) (intervention) vs. 11.15 (95% CI: 10.50–11.80) (control), a difference of 0.37 (95% CI: 0.56–1.31, p= 0.43). Significant differences for secondary outcomes favoring intervention were found: executive function: 6.58 (95% CI: 6.12–7.04) vs. 5.89 (95% CI: 5.45–6.33), a difference of −0.69 (95% CI: 1.33– −0.06, p=0.03); and constructional praxis: 8.84 (95% CI: 8.83–9.34) vs. 7.53 (95% CI: 7.04–8.01), a difference of − 1.31 (95% CI: 2.01– −0.61, p=0.0003). After adjusting for baseline constructional praxis the group comparison was no longer significant. Average length of stay was shorter in intervention (36.09 days vs. 53.13 days, SE = 0.15, p = 0.01, negative binomial regression). Conclusion Cognitively-stimulating activities did not improve delirium but did improve executive function and reduced length of stay. Resolution of delirium may require more intense non-pharmacological management when the patient has dementia.

Length of hospital stay and dementia: A systematic review of observational studies

“…An important risk factor for longer hospitalization time in PWD is the higher risk of developing delirium during hospitalization among people with dementia, with several studies showing that interventions aimed to address delirium during hospitalization could also reduce the LOS . One major problem previous research has shown is that delirium and cognitive function are not always assessed, and the prevalence of undetected dementia varies between 43% and 58% in Europe and up to 70% in North America according to a recent meta‐analysis .…”

Cognitive Therapy for Dementia Patients: A Systematic Review

“…Furthermore, focusing on individual cognitive skills that were assessed (e.g., memory, executive functioning, language), most studies found no or only a limited effect on determinants of cognitive functioning [59,60,[62][63][64]. Some studies focused on the effect of emotions, whereby for example Buettner et al [60] and Niu et al [65] found that patients in the intervention group showed a decrease in apathy compared to controls.…”

“…Some studies included elderly at risk for dementia [67], elderly with mild cognitive impairments [63,70], patients with mild to moderate dementia [64,66], moderate to severe dementia [69], diagnosed with Alzheimer disease [61,62,64,65,68], or a combination of these patients [59,60]. Assessment of cognitive impairment was mostly conducted with the MMSE, but also with other measurements (ADAS-Cog, Clinical Dementia Ranking -CDR).…”

The Search for Effective Delirium Treatment for Persons with Dementia in the Postacute‐Care Setting

“…The present study was a single‐blind randomized controlled trial of cognitively stimulating activities applied for up to 30 minutes daily, 5 days per week in 283 older adults with DSD in eight postacute care facilities in Pennsylvania. The primary hypothesis was that individualized cognitively stimulating activities would reduce the duration and severity of delirium, but the study demonstrated no significant differences in the primary outcomes of delirium duration or severity between the intervention group and those receiving usual care.…”

“…Kolanowski and colleagues followed rigorous methodological approaches, including a randomized design achieving balanced comparison groups, carefully blinded outcome assessment with assurance of maintenance of blinding at the end of the study, verification of high interrater reliability for all critical study measures, adequate sample size and power to test hypotheses, and an intention‐to‐treat analysis approach. This was a high‐quality randomized controlled study, with a high modified Jadad score of 5 out of 6 points; 1 point was lost for single rather than double blinding, which was not feasible with the intervention approach …”