345 Delirium Prevention and Treatment in the Emergency Department: A Systematic Review

Abstract

Delirium is a dangerous syndrome of acute brain dysfunction and is common in the emergency department (ED), especially among the older adults. Most systematic reviews of interventions for delirium prevention and treatment, however, have focused on inpatient settings. The objective of this systematic review was to synthesize the existing evidence on pharmacologic and non-pharmacologic interventions to prevent incident delirium or decrease the severity or shorten the duration of prevalent delirium in older adults presenting to the ED. Inclusion criteria included any study of an intervention to prevent or treat delirium in older ED and inpatient settings. Searches using subject headings and keywords were conducted from database inception through June 2020 in Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, ProQuest Dissertations and Theses Global, and Cochrane CENTRAL, as well as grey literature. Database searches were not limited by date or language. Two reviewers identified studies describing any interventions for delirium prevention and/or treatment in the ED. Disagreements were settled by a third reviewer. The risk of bias was evaluated by the Cochrane risk of bias tool or Newcastle-Ottawa (NOS) scale. We described the overall findings from selected articles for this systematic review instead of a planned meta-analysis. Our search strategy yielded 6, 838 studies of which 12 met study inclusion criteria. Our observed kappa was 0.79 (95% CI:0.56 - 1.0). Half of these studies were available in abstract only. Of included studies, two were randomized controlled trials (RCT): A total of seven studies used mixed study settings including ED. Two RCTs evaluated pharmacologic interventions for delirium prevention, three non-RCTs employed a multifactorial delirium prevention program, three non-RCTs evaluated regional anesthesia for hip fractures, two studies evaluated the implementation of delirium screening, and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium (Table). Of the 12 studies included only four studies demonstrated a significant impact on a delirium incidence and duration – one RCT of melatonin, two non-RCT studies on multifactorial program, and one case control study on the use of Foley catheter. Our review demonstrated that research into delirium prevention and treatment in the ED setting is still in its infancy. Older adults with hip fracture appear to be a target population; however, interventions studied to date have not demonstrated a significant impact. Further research is needed into effective delirium prevention and treatment interventions in the ED.