Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment.
BACKGROUND: Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance. OBJECTIVES: The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care. SEARCH STRATEGY: The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus*. The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases. SELECTION CRITERIA: Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. DATA COLLECTION AND ANALYSIS: Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply. MAIN RESULTS: No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population. REVIEWERS' CONCLUSIONS: The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.