Overview and Strategy Analysis of Technology-Based Nonpharmacological Interventions for In-Hospital Delirium Prevention and Reduction: Systematic Scoping Review

Introduction

Background

Delirium is an acute brain dysfunction with a disturbance in attention, awareness, and cognition [1], which is common, especially in critically ill patients. It occurs in about 40% of patients in the intensive care unit (ICU) [2], and in case of ventilated patients, the proportion goes up to about 65%-80% [2,3]. Nonetheless, delirium can be often underestimated due to differences in the severity of illness in populations and underrecognition of delirium [4,5]. Delirium is frequently associated with a significant increase in the ICU length of stay [6], risk of long-term cognitive impairments [7], and 6-month mortality rates after leaving the ICU [8]. At the organizational level, delirium is associated with an increase in the cost of ICU care [9], ICU readmission [10], and mental stress of ICU nurses who take care of patients with delirium [11]. At the societal level, delirium costs up to $152 billion per year in health care in the United States [12]. Prevention of delirium may be the most effective way to avoid these negative outcomes. In case of in-hospital patients, at least 30%-40% of delirium cases are preventable by reducing the risk factors of delirium [13,14]. There are 2 types of interventions used for preventing delirium: pharmacological and nonpharmacological interventions (eg, reorientation).

Nonpharmacological multicomponent interventions are recommended over pharmacological interventions as a safe and promising way of preventing delirium [15]. Nonpharmacological multicomponent interventions aim at reducing delirium risk factors that are modifiable by, for instance, promoting better sleep, early mobilization, and cognitive training/stimulation [15]. In order to support the implementation of nonpharmacological interventions, several methods [16,17] have been introduced. As an example, the ABCDEF bundle provides practical ways to provide optimal care of ICU patients [16]. Despite the benefits of using these methods [18], there are still barriers, as the way in which nonpharmacological interventions are applied is often highly dependent on the medical staff. Technology-based interventions might help to overcome these barriers. In this review, “technology” is defined as equipment that is used or developed based on scientific knowledge for practical purposes. Ironically, while the ICU room has been one of the most technology-intensive places in hospitals, when it comes to delirium prevention, the use of technology-based interventions in the ICU room often remains limited to, for example, the use of earplugs [19].

With recent developments in technology, there is large potential for the diversity of technology-based interventions. Examples include a modified ICU room design providing, among others, a personalized light therapy system and noise reduction to support cognitive stimulation and a normal sleep-wake cycle of patients [20]. Another example is an interactive app using a conversational agent, which provides patients social interactions and medical advice [21]. The app enables personalized care for patients without frequent physical visits of bedside nurses. These examples showcase some of the possibilities that recent developments in technology can bring. However, understanding how to optimize technology-based interventions is limited, and therefore, it is worthwhile to further and more systematically study the topic.

Prior Work

Recently, several (systematic) reviews have been performed to provide overviews and to highlight the potential of existing nonpharmacological interventions for preventing delirium [18,22-28]. However, none of the existing reviews focused exclusively on technology-based interventions for preventing delirium. Moreover, none of the previous reviews [25-27] provided information necessary for improving the design and development of new technology-based interventions. For instance, a vision outlining what is needed to build a better care environment for patients in the context of intensive care and clear guidance for technology-supported improvements are lacking.

Goal of This Study

To close this gap, this paper will provide a comprehensive review of technology-based interventions used for preventing and reducing in-hospital delirium. To our knowledge, this is the first systematic effort to provide such an overview. Taking a bottom-up approach, we will first investigate what types of technologies are used in current nonpharmacological interventions and how these interventions contribute to delirium prevention and reduction in hospitalized patients. Second, we will identify underlying strategies of technologies applied in the technology-based interventions. Finally, following our analysis, we will discuss the limitations of the current technology use and the opportunities for further research and development of technology-based interventions aimed at delirium prevention in the ICU and for other hospitalized patients. This systematic scoping review was conducted to answer the following questions: (1) what are the technologies currently used in nonpharmacological technology-based interventions for preventing and reducing in-hospital delirium? and (2) what are the strategies underlying these currently used technologies? This review will provide insights into technologies that can be used for in-hospital delirium prevention and reduction and suggest directions for future design and development of innovative technology-based interventions. We propose that incorporating these insights will optimize the use of technologies and enhance the effectiveness of technology-based interventions.

Methods

Search Strategy

This systematic scoping review was conducted complying with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [29]. The study protocol was registered on the international prospective register of systematic reviews (PROSPERO, CRD42020175874). The search was conducted from the Scopus and Embase databases for studies that are written in English and were published between January 1, 2015 and January 6, 2020 (Scopus)/January 13, 2020 (Embase). This time period was set to focus on the state-of-the-art technologies used following our scope for this review. The initial search was conducted with the terms delirium (deliri*) and technology (technolog*) but it did not result in a sufficient number of relevant studies. Samples of search terms were identified through previous studies and extended through the search of index terms, medical subject headings, and other technological terms used for other medical purposes. The following terms were used for the final search: (1) deliri*, (2) technolog*, (3) intelligen* OR automat* OR digital* OR computer OR computing OR robot*, (4) mobile OR app, (5) visual OR virtual OR VR OR video, (6) light* OR ambien* OR aroma* OR architect*, (7) sound* OR music* OR voice OR alarm, (8) cognitive training OR tracking OR game*, and (9) 1 AND 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 (see Multimedia Appendix 1 for the full search strategy). Additional studies were sought through communication with experts. Only studies that were peer reviewed and conducted with human subjects were included. The title-abstract screening and the full-text review were performed by 2 reviewers (CMK and EMvdH) independently. Disagreements were discussed and reevaluated based on the main goal of the study. The reasons for excluding were recorded.

Eligibility Criteria and Study Selection

The studies were included based on the eligibility criteria (See Table 1).

The main goal of this review was to find papers dealing with the prevention and reduction of delirium in the ICU, but in order to not overlook the potential of a greater range of technology-based interventions, the search scope was not limited to the ICU department but included also other hospital departments (eg, pediatric ICU, geriatric ward). We also included delirium from all age groups: from acute pediatric delirium to geriatric delirium because they share a similar range of delirium symptoms [30]. Moreover, the risk factors and recommended interventions across delirium in these groups are more or less the same [31]. Although delirium consists of 3 subtypes, each of which have their own symptoms and courses [32], these subtypes were not applied in the eligibility criteria and the study selection, as most studies did not specify them. We included studies focusing on incident delirium as well as prevalent delirium in order to address the full scope of delirium interventions. As we intended to explore all existing technology-based interventions supported by scientific evidence, we did not place any inclusion restrictions on the study design.

Data Extraction and Quality Assessment

Data extracted from the studies included the primary author, year of publication, country of origin, publisher, summary of intervention content, applied technology, intervention goal, study design, type and number of participants, outcome measure, intervention outcomes, key findings, and limitations of the study. The primary data extraction was performed by CMK using the predesigned data extraction form, and the extracted data were reviewed and confirmed by EMvdH. Disagreements were resolved by discussions between CMK and EMvdH, which included revisits of the relevant data by both authors. To distinguish differences in the strength of evidence in the studies, a quality assessment was performed by CMK using a predesigned assessment form (Multimedia Appendix 2) and reviewed and confirmed by EMvdH. Disagreements were resolved by follow-up discussions. However, none of the studies were excluded based on the quality assessment in our analysis as our goal in this review was to create an overview of the existing technology-based interventions.

Data Analysis

First, all technologies used in the technology-based interventions were looked into and clustered per technology type; a total of 8 categories was identified. Clustering was performed by CMK and reviewed and confirmed by EMvdH. Next, to summarize the strategies used in the technology-based interventions, goals and content summaries of each intervention were looked into, and 14 strategies were identified. These strategies were clustered and labelled based on the overarching theme: this led to the identification of 7 pathways to delirium prevention. An extraction of 14 elements from each intervention was carried out by CMK and clustering was performed independently by CMK and 2 other experienced researchers. After each session, the results and disagreements were discussed by CMK with the other experienced researchers, and then the synthesis was finalized by CMK.

Results

Study Selection

The process of literature screening and selection is presented in the flow diagram (Figure 1). After removing the duplicates, a total of 1058 studies were screened. Among these, 67 studies were examined based on the full text and 31 studies met inclusion for the review.

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Study Characteristics

The characteristics of the 31 included studies are listed in Table 2. Most of the studies were conducted in the ICU (15/31, 48%) followed by hospital wards (13/31, 42%) and both ICU and hospital wards (3/31, 10%). The most common study population was adult patients (23/31, 74%). Seven studies were conducted with pediatric patients [33-39] and 1 study was conducted with both adult and pediatric patients [40]. Most studies were prospective studies (28/31, 90%), including randomized trials [33-49], pretest-posttest/experimental [19,21,24,50-52], organizational case study [53], observational cohort [54], and pilot studies [55-57]. There were 3 retrospective studies [58-60] (See Table 2 for further specifications).

Quality Scores of the Included Studies

The assessed quality scores ranged from 1 [24,56] to 5 [32,36-39,46,48] (Multimedia Appendix 2). The average score was 3.258 (SD 1.264). A score lower than 3 was found in 10 studies [21,24,51-53,55-58,60]. Seven studies reached the maximum score of 5 [33,36-39,46,48]. The included studies were analyzed in 2 ways: first, by focusing on extracting the different types of technologies in the interventions, and second, by focusing on identifying strategies underlying these interventions.

Types of Technologies Currently Used for Preventing Delirium

A total of 31 technology-based interventions were identified (Table 2 and Table 3). Eight categories were distinguished based on the type of technology used. These categories are audio (7 studies), light (5 studies), video/video game (5 studies), virtual reality (VR) (3 studies), sleep aids (2 studies), communication support (2 studies), and others (2 studies). Technologies used as part of a multicomponent approach were grouped into a category called multiple components (5 studies). The identified technologies varied from simple (eg, earplugs, window blinds) to more advanced (eg, dynamic light, VR) ones. These technologies were used to complement conventional delirium treatments rather than replace them by reducing the negative (psychosocial) consequences of environmental factors and their effects on patient experiences.

Of the 31 identified studies, 23 studies analyzed the effect of the interventions on direct delirium-related outcome measures (incidence and duration of delirium). The other 8 studies only assessed indirect outcome measures (eg, length of stay, precipitating risk factors of delirium such as anxiety). Of the 23 studies that evaluated direct delirium-related outcome measures, 9 studies showed a significant effect on decreasing either or both incidence and frequency of delirium. The interventions in these studies involved diverse technologies across the categories, that is, audio [33,49], light [42], sleep aids [19], communication support [21], others [46], and multiple components [24,51,52]. Of the 14 studies without significant effect on direct outcome measures, 8 studies, however, showed significant effects on delirium risk factors or symptoms, including pain [40], anxiety [35,36,38,50], agitation [54], hallucination [54], and factual memory encoding [45]. Six of the 8 studies using diverse technology-based interventions showed a significant effect on indirect outcome measures, including anxiety [39], agitation [43], sleep deprivation [44], or ICU readmission [59]. The technologies used in these studies were audio [39,48,55], video/video game [43], sleep aids [44], and multiple components [59]. It is notable that across all technology categories, significant positive effects were found on either or both direct and indirect delirium outcome measures. An explanation and further analysis of each category is given as follows.

Audio

The interventions using audio had either music or prerecorded voice messages. Music interventions involved, in general, slow tempo music with a duration of 20 minutes to 1 hour. The music was provided 2 or 3 times a day by using a television audio system or headset. These interventions aimed at addressing anxiety [39,53], mood [55], pain [40,53], and engagement [55] for adult patients. Across these interventions, we found differences in the level of personalization and autonomy: the level of personalization varied from the provision of music preselected by a music expert to the creation of a music playlist based on a patient’s own choice and the level of autonomy ranged from patients listening to music with dose and frequency predecided by a researcher to patients deciding on dose and frequency. Interestingly, delirium incidence was reduced in the study with personalized music allowing patients autonomy [53]. While the majority of studies used a passive format such as music listening, 1 study used a participatory format providing an interactive music therapy and showed significant improvement in mood and engagement [55]. Prerecorded voice messages contained mainly patient’s name and information about the care environment using either a familiar or unfamiliar voice. These interventions aimed to provide reorientation and a feeling of comfort. Two studies were carried out with different patient age groups: one with pediatric patients and the other with adult patients. The use of a prerecorded voice message reduced direct delirium outcome in both groups [33,49]. Likewise, one of the studies showed that a familiar voice was more effective than an unfamiliar one [49].

Light

The interventions involving light used either a specially made light therapy system for dynamic/bright light or natural light through windows. Dynamic light interventions provided light consisting of diverse intensities (ranging from 50 lux to 4000 lux) and color temperatures (ranging from 2700 K to 6550 K) in the environment of patients [41,58,60]. The bright light intervention used high intensity of light (5000 lux) for 2 hours a day [42] while the natural light intervention used natural light coming through windows [54]. All studies aimed at improving the patients’ circadian rhythm and were only tested on adult patients. Only the bright light intervention showed an effect on reducing the incidence of delirium [42]. Possibly, most of the current light interventions are not effective in reducing direct delirium outcomes. Another possible explanation for why few studies found an effect on reducing incidence of delirium might relate to the amount of light (intervention) that patients actually received. In most studies, for example, the actual light intensity at patients’ eye level was not specified or the definite exposure time to light of each patient was not guaranteed as sedative patients were included who had their eyes closed [54,58,60].

Video/Video game

The interventions using video/video games were used for providing either information about the medical procedure prior to a surgery or distractions with various contents, including age-appropriate programs (eg, cartoons), family messages, or nature scenes through a handheld tablet or a specially made bedside screen. These interventions aimed to address anxiety or agitation and were effective in decreasing anxiety or agitation in all studies with either pediatric or adult patients [34-36,43,50]. Regarding direct delirium outcome measures, none of the studies showed a significant effect [34-36,50].

VR Technology

The interventions using VR technology provided either information about medical procedures, distraction, or sensory stimulation for patients. VR interventions used a head-mounted device and the VR content varied from a guided tour to the operating theatre, to the virtual scenes of real-world locations. The interventions were mainly used to address anxiety or to support restorative effect for both pediatric and adult patients [37,38,57]. The effects of using VR to provide information (a preoperative VR tour to the operating theatre) differed in the studies. Of the two, 1 study showed a significant effect on reducing the anxiety of pediatric patients [38]. For none of these studies, the use of VR resulted in any effect on delirium-related outcome measures [37,38,57].

Sleep Aids

The interventions related to sleep aids were wearable devices such as earplugs and eye masks [19,44], and environmental modifications such as closing doors and window blinds were applied [19]. They aimed at reducing noise and light during nighttime to improve the sleep quality of adult patients. The application of both wearables and environmental modifications showed an effect on reducing the incidence of delirium [19]. Moreover, the use of a wearable showed an improvement in sleep quality [44]. It is notable that this study also highlights the potential negative side-effects of using wearables due to discomfort experienced by vulnerable patients.

Communication Supports

The technologies used for communication supports were a conversational agent [21] and an eye-tracking device [56]. They assisted adult patients to express their needs or to participate in psychosocial activities. Both types improved the psychological well-being of patients by increasing happiness and the ability to participate and by reducing loneliness. The conversational agent was used as a digital care coach providing communication means, human interactions, and companionship. This intervention reduced the frequency of delirium [21].

Others

In this category, we found rather simple forms of technologies used for diverse purposes: an eyepatch for experiencing what will happen after surgery [46] and a structured mirror to provide patients cognitive stimuli as a means to support mobilization and communication [45]. The eyepatch was used for pediatric patients and was effective in reducing emergence delirium [46]. The structured mirror intervention was for adult patients and improved their factual memory encoding [45].

Multiple Components

Some interventions involved more than one technology as part of a nonpharmacological bundle for adult patients. Environmental modifications for noise reduction, cognitive stimulation, and reorientation reduced delirium incidences in 3 studies [24,51,52]. Zachary et al [59] had a similar focus and showed an effect on reducing the 30-day readmission. In a small feasibility study, no significant effect was found on direct delirium outcome measures for the simple technology-based intervention involving families throughout different therapies such as orientation and cognitive stimulation [47].

Seven Pathways to Delirium Prevention

Fourteen strategies to prevent delirium were identified from the technology-based interventions of the included studies (see Multimedia Appendix 3 for the 14 strategies used in the included studies and see Table 4 for full description of the 14 strategies).

Subsequently, the 14 strategies were clustered into 7 pathways by using a thematic analysis approach (Figure 2). As such, the 7 pathways might provide directions toward technology-based interventions for delirium prevention. The 7 pathways and a short description of each pathway are as follows:

1. Restore the circadian rhythm: helping patients to find a normal sleep-wake cycle to prevent sleep deprivation.
2. Activate the body: supporting patients to regain physical strength and endurance.
3. Activate the mind: supporting patients to prevent cognitive decline, restore cognitive function, and minimize confusion, which can cause negative emotions such as anxiety, agitation, and aggression.
4. Induce relaxation: helping patients to stay in a positive psychological state, which prevents emotional distress, makes it easier to cope with their situation, and improves the patients’ physical state (eg, through better sleep).
5. Provide a sense of security: supporting patients in feeling reassured and safe so that they can easily handle stress and emotional distress such as anxiety and fear that originate mainly from uncertainty and unfamiliarity.
6. Provide a sense of control: supporting patients by enhancing autonomy, empowerment, and control over anxiety.
7. Provide a sense of being connected: supporting patients to feel connected and socially engaged to prevent loneliness, depression, and anxiety.

Three of the 7 pathways outlined above, that is, Restore the Circadian Rhythm, Activate the Body, and Activate the Mind, are in line with strategies recommended in the ABCDEF bundle [16]. The other pathways are not directly linked, yet are associated with important predictors of well-being used in psychology: Induce Relaxation links to coping strategies [61] and Provide a Sense of Security, Control, and Being Connected are related to the universal psychological needs, which are security [62], dominance [63], and relatedness [62]. The 7 pathways, therefore, cover a broad range of delirium prevention strategies correlating physical, cognitive, and emotional aspects as shown in Figure 2.

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Discussion

Overview

The results of this review provided an overview and characteristics of technology-based interventions that have been used to prevent and reduce delirium. We also summarized the related strategies into 7 pathways. These 7 pathways include key elements for developing technology-based interventions for delirium prevention. From our analysis of the included studies and technologies, we next discuss the limitations and opportunities for future research.

Limitations in the Current Technology Use for Preventing Delirium

First, most technology-based interventions addressed only one or a few delirium risk factors. For instance, interventions that used a dynamic light system [41,60] aimed to improve the patients’ sleep-wake cycle while interventions, including video distraction [34,35,43], aimed to reduce the anxiety of the patients. Such approaches are not in line with the frequently recommended multicomponent approach, which effectively targets the multifactorial origin of delirium [15]. Second, most technology-based interventions were more momentary than continuous solutions. Although the length of stay in the ICU should be kept as short as possible, it can last from days to weeks. During this period, depending on the severity of their illness, patients are going through various clinical and emotional phases and their needs are changing respectively. During various activities (eg, clinical checkup, therapy session, cleaning, resting, family visit), patients can experience diverse feelings (eg, anxiety, fear, tiredness, worrying, relaxed, cheerful) and have different corresponding needs. In contrast to the heterogeneity of activities and patients’ needs throughout their ICU stay, the majority of the included studies focused on a short period of time. For instance, the video and video game interventions were usually planned for less than 5 minutes [34-36,43,50], and the VR interventions were used for less than 15 minutes [37,38,57]. In order to minimize delirium risk factors, it is important to understand the needs and concerns of patients throughout their whole ICU stay and to develop preventive solutions that are more continuous and seamless. Importantly, knowledge as how to develop and implement a continuous solution throughout the ICU stay of patients is missing as none of the reviewed studies evaluated it. Third, only a limited number of studies focused on the use of technology for improving the patients’ environment. Despite the negative influences of the stressors in the current ICU environment, such as overload of light and noise [64,65] on patients’ clinical progress, only a few studies [41,51,52,58,60] aim at optimizing the ICU environment. In contrast, most technologies used as interventions added extra sensory burden to the patients. Last, the effect of some technologies can be improved by a more thorough understanding of (vulnerable) patients and context-dependent needs. Understanding the patient’s needs is crucial for delivering high-quality care. However, sometimes, the implementation of technology can be challenging and might result in a suboptimal match with the patients and context. For instance, in the study of bright light therapy, patients were sedated and had their eyes closed and this resulted in insufficient amount of light exposure [41]. The use of wearable sleep-aid devices (earplugs and eye masks) by ICU patients can lead to potential discomfort, thereby limiting the effectiveness of the intervention [44].

Further Development of Technology-Based Interventions for Preventing Delirium

Despite the limitations of current technology-based interventions, the potential of technology in delirium prevention is promising [20]. Reflecting on the identified limitations, the following recommendations are proposed for the future design and development of technology-based interventions for delirium prevention. First of all, technology should not only support physical and cognitive functions but also support psychological and emotional needs. In the analysis, the proposed 7 pathways described existing approaches for delirium prevention, which cover multifaceted needs of patients. Yet, comparing the number of related strategies and studies included in each pathway, it is notable that, in general, there are far more technology-based interventions aiming to support functions than to support needs. To take a more comprehensive approach, further development of technologies should aim at meeting patients’ needs by, for instance, providing a means to allow them more control over their situation, feel relaxed, safe, and connected. Some examples are an interaction device to enable ventilated patients to easily express their needs using gestures [66], a robotic pet that lets patients cuddle and helps them feel calm [67], or an intelligent alarm system contributing to a relaxing environment for ICU patients by controlling and harmonizing alarm sounds [68]. Another way to meet patients’ emotional and psychological needs can be found in the provision of (multi-) sensorial and cognitive stimuli. For instance, aromatherapy can be a way to support patients to feel relaxed through sensorial stimuli combining pleasant tactile pressure and aromatic fragrance [69]. For the stimuli, using nature elements can be an interesting candidate as exemplified by previous cases [43,57] and other applications: examples are a VR therapy showing various nature sceneries [70] and a geriatric care environment adapting nature elements [71] to generate relaxation [70,71], increase social engagement, and reduce restlessness [71]. Second, technology could create a healing environment for patients: a more context-aware, personalized, and adaptive ICU. Despite emerging interest in patient-centered care, this review showed that such interactive technology is rare in the current ICU environment. Patient-centered care recognizes a patient as a unique individual and stresses the importance of care tailored to patients’ specific preferences, needs, and values [72-74]. In order to better adapt patient-centered care, technology should be evolved in a way that (1) it allows patients to take a more active role in their care process, for instance, by enabling them to be explicit about their specific needs and (2) enables a care environment and service system to provide real-time interventions adapted to the patients’ profiles and their changing status/needs. Advances in technologies have made this feasible. Next to the modified ICU room [20] and the conversational agent [21] described in the introduction, the intelligent ICU concept enables autonomous monitoring of patients and the ICU environment over time by using pervasive sensing [75]. Previously we pointed out that there were too few technologies aiming at improving patients’ environment despite its significant influence on patients. Luetz et al [20] emphasized the potential of environment-related innovations, arguing that the ICU should be considered as a treatment tool. In order to design a healing environment, future technology-based interventions should reinforce the main ingredients of patient-centered care: context-awareness, personalization, and adaptability.

Study Limitations

This study has some limitations. First, this review was conducted between 2015 and 2020 to focus on state-of-the-art technologies used for preventing and reducing delirium. Therefore, some technologies that might have been introduced in the studies published before 2015 and have not been studied since then were not included in this review. Second, the search strategy made use of the combination of keywords describing different types of technologies and not the keyword “technology” as this was not widely used in literature on delirium prevention and reduction. Although we tried to cover all the existing technology-related keywords, this search strategy might have left out some very rare types of technologies. Third, the 7 pathways were made based on the included studies only. Therefore, some approaches and strategies from the studies, which did not meet our criteria, were not included, such as approaches and strategies related to pharmacological interventions or delirium detection only.

Conclusions

In this review, we provided an overview of technology-based interventions and proposed the 7 pathways to delirium prevention based on evidence-based studies. These insights can be considered as starting points for transforming ICUs into a healing environment, which might be well one of the most powerful nonpharmacological technology-based interventions for preventing delirium. Further research should generate a more in-depth and complete understanding of the key components of a healing environment for patients and on designing and developing technologies that can actualize it.