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HOME > Acute Crit Care > Volume 40(3); 2025 > Article
Review Article
Nursing Nursing delirium management to promoting critically ill patients’ safety: an umbrella review
Acute and Critical Care 2025;40(3):373-392.
DOI: https://doi.org/10.4266/acc.005221
Published online: August 29, 2025

1Student in Master in Medical-Surgical Nursing - Critical Care, RN in Unidade de Urgência Médica da ULS S. José, Lisbon, Portugal

2Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR) - Escola Superior de Enfermagem de Lisboa - id. Care Project, Lisbon, Portugal

Corresponding author: Master’s in Medical-Surgical Nursing - Critical Care – Nursing School of Lisbon, Avenida Professor Egas Moniz, 1600-190 Lisbon, Portugal Tel: +35-19-3052-0453 Email: dplacido@campus.esel.pt
#Current affiliation: Daniela Carvalho Plácido: Master’s in Medical-Surgical Nursing - Critical Care – Nursing School of Lisbon, Lisbon, Portugal; Unidade Local de Saúde São José - Unidade de Urgência Médica, Lisbon, Portugal Maria do Rosário Pinto: Nursing School of Lisbon (ESEL), Lisbon, Portugal; Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), id. Care Project, Lisbon, Portugal; Health Sciences Research Unit: Nursing (UICISA: E), Coimbra, Portugal Maria Cândida Durão: Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), id. Care Project, Lisbon, Portugal Helga Rafael Henriques: Nursing School of Lisbon (ESEL), Lisbon, Portugal; Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), id. Care Project, Lisbon, Portugal Joana Ferreira Teixeira: Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), id. Care Project, Lisbon, Portugal; Health Sciences Research Unit: Nursing (UICISA: E), Coimbra, Portugal; Nursing School of Coimbra (ESEnfC), Coimbra, Portugal; CINTESIS@RISE, Porto, Portugal
• Received: December 1, 2023   • Revised: March 31, 2025   • Accepted: June 4, 2025

© 2025 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Delirium is an acute disorder characterized by changes in the patient’s cognitive function, which another neurocognitive or pre-existing disease cannot explain. It produces adverse outcomes for critically ill patients and their families related to adverse events associated with the accidental removal of medical devices that increase the risk of the patient and the length of stay at the hospital, manifested by agitation and confusion behaviors. Five reviewers conducted An Umbrella Review from May to August 2023 through research in the databases Medline, CINAHL, Scopus, Web of Science, Cochrane Database of Systematic Reviews and articles obtained through research in other sources. After verifying their eligibility, we obtained 22 systematic reviews and meta-analyses for data extraction and analysis. From the results obtained, the importance of the implementation of surveillance interventions and systematic evaluation of the presence of delirium is highlighted, with particular emphasis on the use of the scale, Confusion Assessment Method, followed by the implementation of multicomponent interventions, pharmacological or not, highlighting the use of dexmedetomidine and family as support, as well early mobilization for the management of delirium. Managing delirium in critically ill patients based on Meyer and Lavin's theory, is an area sensitive to nursing care with an impact on the prevention of complications and consequent promotion of the safety of these patients, which also translates into positive results for the family and health organizations, reducing morbidity, mortality, length of stay and health costs.
  • Key Words: critical care; delirium; delirium management; nursing care; safety
Delirium is an acute or subacute disorder characterized by disturbances in attention, consciousness, and other aspects of the cognitive domain that another neurocognitive disease or a pre-existing one cannot explain. It can be developed quickly or act in a fluctuating form [1,2]. The most current thinking of pathophysiology of delirium is based on the decrease of dopamine’s activity, resulting in an improvement of the levels of the neurotransmitter, giving the possibility of the cholinergic activity to increase, helping prevent delirium in critically ill patients [3].
There are risk factors that predispose the critically ill patient to the occurrence of delirium, such as age, male sex, neurological comorbidities, history of an ischemic event, respiratory diseases, ethanolic habits, dementia processes, hydro electrolyte imbalances, the need for vasopressor use, high doses of opioids or metabolic acidosis, and others [3,4]. Delirium can also be triggered by other causes, including critical illness, trauma, or surgery [5]. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM)–V [6], delirium can be divided into three categories: hyperactive, in which the patient has a level of psychomotor hyperactivity represented by mood changes, agitation, and even refusal to provide health care; hypoactive, that can be accompanied by lethargy, prostration or stupor; and mixed, in which the patient is calm and collaborative. However, the level of attention and awareness is altered. The two most common subtypes of delirium are mixed (54%) and hypoactive delirium (44%) [3].
Delirium is a common complication in adults’ hospitalisation, with a negative impact on the outcomes of critically ill patients and healthcare institutions [1,3,7-9]. The incidence of delirium in the emergency department appears in 5% to 20% of the persons admitted, while in the intensive care unit (ICU), it is around 83% to 87% [7]. Some of the delirium complications are associated with adverse events related to the accidental removal of medical devices [10]. Thus, there is a need for delirium management improvement, with the creation of protocols to promote safety and risk prevention [11]. Preventing and managing delirium is critical for improving outcomes in critically ill patients, as delirium is associated with significant adverse effects, including prolonged hospital stays, increased healthcare costs, and higher morbidity and mortality rates [3,7-9]. Nurses play a pivotal role in surveillance, monitoring, and implementing interventions to mitigate delirium in these patients, emphasizing the importance of a comprehensive understanding of delirium management, according to Meyer and Lavin's theory, Vigilance: The Essence of Nursing [12,13].
It is difficult to quantify the cluster of interventions dedicated to patient safety because surveillance, monitoring, prevention and promotion of safety are integral parts of nursing care delivery. This awareness was evident in the study about nursing interventions for people in critical situations, in which highlighted two distinct domains of nursing practice: integrating technology to enhance safety and ensuring the continuous surveillance and monitoring of the individual's well-being [12,14]. Given the extensive number of systematic reviews on this topic, we recognized the need for a comprehensive synthesis of key nursing interventions in delirium management. This prompted the development of an umbrella review [15]. Conducting such a review is crucial to collating and synthesizing interventions that enhance safety in managing delirium among critically ill patients [16].
Design and Research Question
An Umbrella Review was conducted from May to August of 2023 by five reviewers whose protocol is registered in PROSPERO (CRD42023440127). As a result of a quick search on PROSPERO, we concluded that this one was the last protocol reported about delirium management promoting critically ill patients’ safety.
This review follows the methodological guidelines and the evaluation of the quality of the studies according to the Joanna Briggs Institute (JBI) [15], and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for reporting systematic reviews [17]. An Umbrella Review offers the possibility of approaching the best evidence on a theme, even when widely studied, to the extent that it allows a synthesis of the best available evidence and if there are congruent, contradictory or discrepant issues, enabling the exploration and detail of these changes, which support evidence-based practice [18]. The results were extracted according to the JBI [15] methodology, illustrated with Prisma flow diagram [17], as represented in Figure 1, that show us the selection process of the final articles, and its synthesis is described as a table (Table 1). The research question was delineated using the PICO mnemonic [19] and consists of the following question: In critically ill patients, what are the effective nursing intervention for delirium management that promote patient safety?
Eligibility Criteria
For this Umbrella Review, inclusion and exclusion criteria have been defined. As inclusion criteria: in terms of target population, adults (18 years or older) were considered in a critical situation, given that the presence of delirium in children and adolescents is lower than in adults, according to studies conducted in the United States of America and Europe, which report a prevalence of about 4% in this last group [5]; the interventions included were the nursing interventions that contemplate the management of delirium (prevention, identification, intervention planning and re-evaluation), in which the recognition of delirium requires a systematic and systematized approach, and not only a management of the signs and symptoms of the same, so it should be approached with a view to its prevention, evaluation, subsequent intervention and new evaluation [20]; regarding the outcomes, all documents addressing delirium management aimed at promoting safety in critically ill patients were considered, and their impact on families and health organizations was also taken into account [1]; regarding the typology of studies, systematic reviews and meta-analyses were considered.
As exclusion criteria, there is to highlight the critically ill patient with the presence of delirium (psychosis) and not delirium, as justified by Luttrull et al. [21], which describes that delirium is a medical diagnosis that according to the DSM-V, diverges from the definition of delirium, the last one is being characterized by the presence predominantly of delusions and hallucinations as the primary psychotic symptomatology. However, the level of consciousness does not change [6]. The critically ill patient with hypoactive delirium is also excluded from our population because there is more possibility of adverse events in terms of managing the risk and safety of the critically ill patient with mixed or hyperactive delirium subtype. After all, with the increase in psychomotor activity associated with agitation and mood changes, the difficulty of implying safety interventions to the patient increases, and the risk of the removal of medical devices is higher [6,22,23]. As exclusion criteria, we also considered all documents that did not answer the research question and could not be translated and/or understood by the researchers. In this review, a date limitation was not applied as an exclusion criterion since it is intended to confront the evolution of specialized interventions in managing critically ill patient with delirium in promoting their safety over time.
Databases and Search Strategy
Initially, to identify the state of the art and search terms, a literature review was carried out in the electronic databases to perceive the existing evidence on the subject under study and identify the main terms to be used. After this stage, the search in the databases began on Medline, CINAHL, Scopus, Web of Science e Cochrane Database of Systematic Reviews, according to the following search strategy: (("critical care" OR "intensive care unit*" OR ICU OR "emergency department" OR "critically ill patient*" OR "critical illness") AND ("delirium management" OR "delirium instruments" OR "delirium scales" OR "multicomponent strategie*" OR "delirium intervention*" OR "delirium assessment" OR "pharmacological intervention*" OR "non-pharmacological intervention*") AND ("risk control" OR high-risk OR prevalence OR agitation OR "length of stay" OR mortality OR incidence OR control OR delirium OR prevention OR safety OR "incident rates")). The documents obtained through this strategy and other sources were verified for eligibility through the previously outlined criteria.
Data Collection and Extraction
The documents were selected, and the Rayyan software [24] was extracted in blind-on mode. Initially, all duplicate articles were excluded. Subsequently, the articles were excluded by the type of study and later, according to the reading of the title and abstract. Then, the final sample was selected by reading the full text performed by the two reviewers. Any disagreements in the process were solved by discussion between the five reviewers. The data extraction was based on the Prisma Flow Diagram [17], and the analysis of the final documents and their validation were carried out by the five reviewers, according to the recommendations of JBI [15]. According to the eligible criteria for this Umbrella Review, the final documents are described in Table 1.
Methodological Quality
The analysis of the methodological quality of the final articles was carried out independently by two reviewers according to JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses [15]. Any discrepancies between the two reviewers were solved by a third author. The methodological quality of the reviews was generally comparable. Only three studies demonstrated a quality score below 50% [25-27]. Nevertheless, the average methodological quality across the studies was 81%. This umbrella review shows significant heterogeneity. The most included reviews report high I2 values, indicating substantial variability among the primary studies they analyzed [28]. The I2 value of the results it shown in Table 1.
Data Analysis
The results obtained are shown in Table 1, adapted from JBI table for umbrella reviews, and are described below, based on a multimodal approach, which includes the prevention and identification of delirium, and the pharmacological and non-pharmacological interventions, as well as the subsequent evaluation of the outcomes produced to improve the quality of nursing care and promote patient safety, according to Meyer and Lavin's theory, Vigilance: The Essence of Nursing [12,29].
Study Selection
Data extraction of final results is represented in the PRISMA Flow Diagram (Figure 1), according to PRISMA guidelines [17]. Out of the initial 1,415 documents retrieved from database searches, 20 articles were selected for analysis after removing duplicates and applying the eligibility criteria and two articles from other sources were introduced, resulting in a total of 22 final articles.
General Characteristics of Included Studies
The final sample consists of nine systematic reviews, nine systematics reviews with meta-analyses and four meta-analyses, both quantitative and qualitative. These reviews are from 2013 and 2022, the date was not stablished because, being an umbrella review an overview of existing systematic reviews, we wanted to show the evolution of the interventions used to managed delirium [15]. The average methodological quality across the studies was 81% as shown in the materials and methods section.
Participants
The articles analyzed had a sample known between 1,156 and 29,935 participants, all with more than 18 years old. During the analysis of results, the presence of multiple particularities of patients in acute and/or critical situations was addressed, such as the adult patient hospitalized in the ICU in the context of perioperative and long-term hospitalisation [9,16,27,30-40].
Nursing Interventions Used in Delirium Management
The management of delirium is based on a multimodal approach, which includes the prevention, identification, and pharmacological and non-pharmacological interventions and subsequent evaluation of the outcomes produced to improve the quality of nursing care and promote patient safety [29]. During the provision of care to the critically ill patient, the concept of surveillance becomes a guiding thread for the evaluation, with scientific, intellectual and experienced precision, of the possible identification of clinically relevant signs and observations, calculate the risk inherent to the practice of nursing interventions, and respond, act promptly and efficiently to minimize risk and respond to threats like described in Meyer and Lavin's theory, Vigilance: The Essence of Nursing [12].
This theory contemplates five elements that are crucial in nursing surveillance, which are: "Attaching meaning to what is," in which the nurse, as soon as he enters the patient's environment, begins to observe the patient's environment in order to find signs that allow him to infer possible changes in the patient's health status, centered on the prevention; "Anticipating what might be," where the possible hypotheses of oscillation of the person's clinical status are anticipated, where we can fit the identification; "Readiness to act" is an intrinsic aspect of the knowledge of the Nursing discipline that allows awareness of the need for immediate action, designed by the intervention on the management of delirium; "Calculating the risk" in which there is an understanding of the risks inherent in any course of action with the "Monitoring results/outcomes" when this action is performed, the nurse is able to verify the effectiveness of their interventions, make clinical judgments about the situations experienced, continuously adjusting the care to the patient [12]. The Figure 2 illustrates how the results of this review are connected to this theory, explaining is correlation.
"Attaching Meaning to What is" for Prevention
In managing delirium in critically ill patient, the most impactful intervention described for the prevention, with about 81.5% effectiveness, compared to the implementation of standard interventions, is using a multicomponent intervention to promote a significant reduction in the incidence of delirium. This strategy includes interventions for pain management and control (PM), sleep promotion (SP), strategies to reduce noise and optimize care provided at night, early mobilization (EM) and physical activity, family participation (FP), cognitive stimulation (CE), reorientation (RO), sensory stimulation (ES), environmental management, systematic evaluation (SA), hormonal intervention, automatic prevention system, daily suspension of sedation (SDS) and readjustment of intervention planning. The interventions, when implemented in an isolated form, have a lower effectiveness in reducing the incidence of delirium: health education about 57.4%, 57.1% for the FP, 50,1% when EM is implemented, 44.8% for relaxing measures, clinical adjustment about 43.4%, physical activity 42.3% and standard care 23.4% [33,34,39,41,42].
In the article of Matsuura et al. [42], it was observed that two bundles ([SP, CE, EM, PM, SA] and [SP, CE]) were influential in the reduction of delirium incidence. According to the guidelines about prevention and management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep disruption (PADIS), in addition to the strategies described above for preventing delirium, optimizing vision and hearing in critically ill patients, should be promoted. Although non-pharmacological multicomponent strategies are effective in delirium management, there are described barriers to their application, such as lack of time, high workload, and high complexity in the applicability of all in the ICU environment [42].
The use of ventilatory mode optimization strategies to improve ventilatory asynchrony, the use of earplugs and eye masks, music therapy, massage or foot hygiene, and aromatherapy, among others, do not seem to have significance in the prevention of delirium [37,43]. Hospitalisation in a critical care unit causes stress, emotional emptiness, and social problems, which impact the risk for critically ill patients to develop delirium, and the intervention of health professionals allows the prevention of about one third of the cases [4,39].
"Anticipating What Might Be" for Identification
The difficulty for health professionals in this area begins with distinguishing delirium from other psycho and neurocognitive conditions due to the non-use of appropriate assessment tools [39]. The evolution of delirium assessment demonstrated by Schuurmans et al. [44] reveals that much effort has been made to develop instruments that diagnose, evaluate, and quantify the severity of the symptomatology associated with patient delirium facilitated by expert professionals. However, the subjectivity of the clinical assessment is an obstacle to its reliability. The various instruments used in the evaluation of delirium addressed are: clinical assessment of confusion A, Confusion Assessment Method (CAM), Confusion Rating Scale, Confusional State Evaluation, Cognitive Test For Delirium (CTD), Delirium Assessment scale (DAS), delirium index (DI), Delirium observation screening scale (DOSS), Delirium Rating Scale, Delirium Symptom Interview, Delirium Severity Scale, Memorial Delirium Assessment Scale, the Neelon and Champagne Confusion Scale [44].
The Pain, Agitation, and Delirium (PAD) guidelines of 2013 [30] served as a guide to implementing the guidelines in the management, evaluation, and prevention of pain, agitation, oversedation, and delirium in critically ill patients, which included the psychometric analysis of six behavioral pain scales, ten sedation/agitation scales, and five delirium assessment scales, referring, already at that time, that the CAM and the Intensive Care Delirium Screening Checklist (ICDSC) would be the most reliable and valid scales, suggesting that the ICDSC would have a higher sensitivity comparing to the CAM for the ICU (CAM-ICU) in the detection of delirium in ICU patients. However, it is more time-consuming and challenging to apply. Its high specificity becomes clinically more helpful to exclude delirium. However, the heterogeneity in the typology of patients and care practice hinders its applicability.
The CAM-ICU can be used in patients under invasive mechanical ventilation (IMV) through visual or auditory assessment methods, proving to be easier to use by health professionals, requires less education and training, and is faster to be applied during the provision of care to the critically ill However, it is only effective if SA of delirium is performed more than two times a day [30,36]. It is proven that the most used and recommended delirium assessment scale is the CAM-ICU in the ICU, and its use in conjunction with the Richmond Agitation-Sedation Scale (RASS) scale is recommended because it is only applicable in patients with RASS above or equal to –3. However, it is essential to complement the use of these instruments with an Electroencephalogram, in a multidisciplinary perspective for a more objective diagnosis, to exclude others, such as encephalopathy and dementia, that may contribute to the existence of false positives resulting in false positives (about 20% of the cases) [16,39,45].
"Readiness to Act" for Intervention
In the presence of delirium, there are non-pharmacological and pharmacological strategies for its treatment. In an individual approach, the intervention that is most effective in reducing the incidence of delirium is the participation of the family (94%), followed by physical activity (74%), multicomponent interventions (68%), CE (58%), intervention of the physical environment (26%) and reduction of sedation (18%) [16].
An evolution in the pharmacological approach to treating delirium has been demonstrated. The use of dexmedetomidine is currently suggested as the most beneficial drug in reducing the incidence and duration of delirium, and the use of rivastigmine, dexamethasone, and risperidone is not significant; it was also demonstrated that the use of anticonvulsants in the prevention and treatment of delirium was not supported by the evidence presented; the use of antipsychotics (haloperidol and second-generation psychotics) has not been shown to improve the severity or mortality associated with delirium.; however, a sleep-inducing drug, ramelteon, emerges, which may contribute to the benefits of dexmedetomidine in the treatment of delirium, contrary to the use of lorazepam, seen as a risk factor for the development of delirium [38].
"Calculating the Risk" and "Monitoring Results/Outcomes" for Evaluation/Revaluation of the Outcomes in the Promotion of Critically Ill Patients' Safety
Some outcomes translate into promoting critically ill patients' safety when evaluating the implementation of measures for preventing, identifying, and treating delirium in critically ill patient. To reduce the incidence, occurrence, and duration in about 78.6% of delirium, multicomponent strategies, which are centered on the patient, professional, and/or organization, have an impact on the number of adverse events, length of hospital stay, mortality, morbidity and duration of IMV [16,31,37,40].
The adverse events are translated by the removal of medical devices unintentionally, which imply re-intubations, the presence of arrhythmias, the need for tracheostomy, and extrapyramidal effects, but which can be avoided/controlled by the applicability of the multi-component strategy [31]. No intervention singularly appeared to reduce the time of IMV [31]. In these studies, the length of stay in the ICU and hospital can be reduced by about 71.2% after the implementation of multimodal and multicomponent interventions, highlighting the EM concomitantly with the use of dexmedetomidine when compared to other antipsychotics [16,31,40].
In some results obtained through this review, there was a reduction of about 2.9% to 12% in mortality in the ICU, in the hospital, or 30 days, after implementation of the ABCDEF bundle (Assess, Prevent, and Manage Pain; Both Spontaneous Awakening Trials [SAT] and Spontaneous Breathing Trials [SBT]; Choice of analgesia and sedation; Delirium: Assess, Prevent, and Manage; Early mobility and Exercise; and Family engagement and empowerment) [40]. On the other hand, there are qualitatively equivalent studies that show no impact on mortality or this outcome has not even been addressed [31,37], which suggests that more studies are essential to be developed in this area.
The ABCDEF bundle also indirectly includes interventions that privilege spontaneous ventilation as early as possible, EM protocols, and management of environmental measures in sleep management to achieve additional improvements in patient outcomes, especially in the ICU [30].
This umbrella review synthesizes findings from 22 articles, including nine systematic reviews, nine systematic reviews with meta-analyses, and four meta-analyses published between 2013 and 2022, highlighting the evolution of nursing interventions for delirium management in critically ill adult patients. The studies analyzed included participants aged 18 years and older. Most patients were hospitalized in ICUs under acute or critical conditions, including perioperative and long-term hospitalizations [9,16,25-27,30-42,45-48]. Delirium management relies on a multimodal approach encompassing prevention, identification, pharmacological and non-pharmacological interventions, and continuous evaluation [30]. The prevention of delirium was found to be most effective when using multicomponent interventions [33,39,41,42,47].
These interventions includes physical activity interventions, like EM, FP, CE, RO, ES, EM and adjustment of clinical intervention, which are the gold standard cluster of interventions to lower the risk of incidence of delirium that acts directly on the management of it [9,16,31,39,41,42,47,49]. These findings underscore the importance of comprehensive and evidence-based nursing practices to manage delirium in critically ill patients [47]. The evolution of the ABCDE bundle and the 2013 PAD guidelines, updated in 2018 (ABCDEF and PADIS guidelines), adding EM and SP, are new concepts and domains that have emerged since its last version of these guidelines and that aims to clarify and highlight the impact of these interventions, as well as to reinforce the need for the involvement of the multidisciplinary team in the approach of critically ill patients with delirium and their family [8,30,47]. The use of multicomponent bundles, like ABCDEF bundle, results in a decrease of the incidence and duration of delirium and, also, patients to achieve better outcomes [9,23,33,39,41,42,47]. In more recent studies, the participation of the family in the management of delirium appears as the most effective intervention to reduce its incidence by about 94%, which can be a future area to investigate [16,42]: define a multicomponent intervention for critically ill patient with delirium and evaluate its viability and effectiveness [16,47]. The patients with family members present during their first night in the ICU exhibited a lower incidence of delirium (6.3%) compared to those without family support (21.4%) [50]. Policies allowing unrestricted family presence have been associated with decreased prevalence and duration of delirium in critically ill patients [51].
When it comes to the prevention and treatment of delirium that involves pharmacological measures, dexmedetomidine is the chosen drug. However, there are still numerous studies that refer to the use of haloperidol as one of the most used drugs in delirium [27,38,48], although with worse outcomes associated with its use, namely the increase in the mortality rate [52], which highlights the need for future research related to the effectiveness of the best pharmacological treatment to be used in the management of delirium in critically ill patients.
It is crucial nurses’ education about delirium, in the means, of its assessment, approach and evaluation, because enhance their knowledge about the impact of delirium and it improves the implementation of the interventions that produces better outcomes [23,40]. This umbrella review highlights the practical challenges of implementing multicomponent strategies in ICU settings, including high workload and limited resources. To address these barriers, nursing practice should emphasize structured protocols for family involvement, practical training for multicomponent interventions, and systematic use of validated assessment tools [16,30,36,40,53]. The review aligns with Meyer and Lavin's "Vigilance: The Essence of Nursing" theory [12], underscoring the critical role of nursing vigilance in enhancing patient safety [12]. Further research is necessary to refine these strategies and explore their broader impact on clinical outcomes.
Limitations
In this umbrella review, some limitations were identified, primarily due to the high heterogeneity of the studied populations, reflected in the high I² values. This substantial variability among the primary studies made it impossible to perform a quantitative synthesis. Nevertheless, a descriptive synthesis of the study findings was conducted. The complexity of the service typology posed challenges in obtaining measurable and equitable outcomes, complicating comparisons across the diverse and intricate results. These findings highlight the need for further research on delirium management in critically ill patients within other contexts, such as the emergency department (ED) and burn units.
For example, scales such as a variant of the CAM, the brief CAM, consisting of four items, which is applicable in about 2 minutes, or the three-dimensional-CAM, whose application lasts, on average, 3 minutes, are essential for the detection of delirium and subsequent intervention in the ED [54], despite these of different instruments to assess delirium, increase the heterogeneity and complexity to identify critically ill patients with delirium. However, it is pertinent to say that is needed more studies to identify which is the most reliable tool to assess delirium [45,48].
The use of the ABCDEF bundle confines the interventions that are more effective in delirium management. Although there are some relations throughout the interventions that need to be more deeply linked, like the role of SP [34,37]. The pharmacological approach elects the use of dexmedetomidine, although there are not a gold standard pharmacological approach know to prevent and reduce delirium [27,38,46]. Further research is necessary to refine these interventions and explore their broader impact on clinical outcomes.
The management of delirium in the promotion of the safety of critically ill patient is based on specialized interventions of the nurse in its prevention, identification, intervention, and evaluation of the outcomes produced, being this one of the areas sensitive to nursing care. As such, nurses continuously seek the excellence of their professional practice and the prevention of complications, two of their practice's key elements. In this, the early identification of potential problems is contemplated, which the nurse must identify, then implement measures directed to their prevention or intervention and evaluate their contribution to the results obtained, minimizing the risk of their development and the promotion of patient safety, always based on the most current scientific evidence and the involvement of the multidisciplinary team [55].
The existence of a balance in the multidisciplinary approach, centralizing the nurse's intervention in the applicability and coordination of the multi-component strategy, which encompasses the management of the physical environment, the orientation of the patient to reality, CE, pain management, the SDS, the SA of delirium, the promotion of sleep, EM and the promotion of physical activity have an impact on the production of better outcomes for the promotion of critically ill patients' safety. The evidence as the drug of choice for the management of delirium suggests dexmedetomidine [56].
The evidence suggests the growing importance of family involvement in managing delirium, and primary research should be developed on the efficacy/effectiveness of a complex, multimodal/multicomponent intervention in this area.
▪ Delirium is frequent in critical care and is a sensitive area of nursing care that impacts the promotion of patient safety and the reduction of health costs.
▪ More research is necessary to understand the reality in emergency departments, the effectiveness of family interventions and the best pharmacological approaches for delirium management.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This review is incorporated into the id. Care Project – “Centered-care for complex chronic patients in critical and acute care: managing physical environment and supporting clinical decision-making and self-management,” which was approved by the Research and Development Center of a Portuguese School of Higher Education in Nursing.

ACKNOWLEDGMENTS

The authors would like to thank the id. Care Team and the Documentation Center of ESEL for her library support.

AUTHOR CONTRIBUTIONS

Conceptualization: DCP. Methodology: JFT. Formal analysis: DCP, MRP, MCD, HRH, JFT. Data curation: DCP, JFT. Visualization: DCP, MRP, MCD, HRH, JFT. Project administration: HRH, JFT. Writing - original draft: DCP. Writing - review & editing: DCP, MRP, MCD, HRH, JFT. All authors read and agreed to the published version of the manuscript.

Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram.
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Figure 2.
Nursing interventions according to Meyer and Lavin [12]. SP: sleep promotion; CE: cognitive stimulation; EM: early mobilization; PM: pain management and control; SA: systematic evaluation; RO: reorientation; ES: sensory stimulation; CAM-ICU: Confusion Assessment Method for the intensive care unit.
acc-005221f2.jpg
acc-005221f3.jpg
Table 1.
Characteristics of included studies
Study Year Objective Result and implication for clinical practice Nursing intervention Heterogeneity Conclusion and limitation Quality
Matsuura et al. [42] 2022 To evaluate the efficacy of non-pharmacological interventions and to determine which combinations of them are effective in preventing delirium in ICU patients Significant effects were observed in the % occurrence of delirium with the use of multi-component non-pharmacological strategies (sleep promotion, cognitive stimulation, early mobilization, pain control, assessment) used in the prevention of delirium in critically ill patients. In this study they observed that two bundles (PS, EC, MP, CD, AS) and (PS, EC) were effective in reducing the incidence of delirium. According to the PADIS guidelines, in addition to the strategies described above for the prevention of delirium, optimization of vision and hearing in critically ill patients. Despite multi-component non-pharmacological strategies (sleep promotion, cognitive stimulation, early mobilization, pain management, assessment) if prove effective in preventing the incidence of delirium, there are barriers in its application such as lack of time, high workload and the high complexity of the applicability of all components in the ICU environment. It has been suggested that neurologically delirium is developed due to changes in the prefrontal and anterior cortex, parietal lobes, basal ganglia, superior colliculi, and thalamic pulvinar nucleus as they are entirely linked with the cholinergic response that is associated with cognitive function. Implications for practice: this review incorporated sleep promotion, with strategies such as reducing noise and luminosity and optimizing night care interventions. (1) The combination of sleep promotion, cognitive stimulation, early mobilization, pain control, and AS Significant heterogeneity as either I2 more than 50% or P<0.1 for Cochran Q test. If the synthesized data were heterogenous. In this study they observed that two bundles (PS, EC, MP, CD, AS) and (PS, CE) were effective in reducing the incidence of delirium. The second bundle has a greater impact on reducing the incidence of delirium (76%). The first bundle should have a multidisciplinary approach (nursing, medicine, pharmaceutical, physiotherapy). Limitations: this study included several types of interventions, types of studies and characteristics of the participants, being these critically ill surgical or trauma. 10/11
(2) Combination of sleep promotion and cognitive stimulation
Bannon et al. [41] 2019 To evaluate the effect of non-pharmacological interventions vs. standard care on the incidence and duration of delirium in critically ill patients The evaluation of the efficacy of non-pharmacological interventions when compared with standard care or pharmacological interventions in the incidence and duration of delirium, hospital mortality, sleep quality, cognitive function, quality of life or adverse events in critically ill patients has been shown to have very variable outcomes but that only one or several non-pharmacological interventions have not been shown to have a significant effect on incidence or duration of delirium. A pilot study revealed that a multi-component intensive occupational therapy intervention significantly reduces the incidence of delirium, in its duration and cognitive function, but when studied in meta-analysis this effect disappeared. Interventions should be more personalized with the existing type of patients (cardiac, medical, surgical). Four interventions of the multicomponent strategy seem to contribute positively to the outcomes of patients, such as the use of white light and earplugs (improves sleep quality), physiotherapy for 6 months (standard rehabilitation), hospital mortality (multicomponent strategy). (1) Multicomponent physical therapy Statistical heterogeneity was evaluated using the chi-square test (P<0.1, significant heterogeneity) and I2 statistic (I2 >50%, significant heterogeneity). There is poor-quality evidence to suggest that one or more non-pharmacological interventions are effective in reducing the incidence and duration of delirium in critically ill patients. Delirium has a multifactorial etiology; multicomponent strategies seem to be more useful. Limitations: heterogeneity of the interventions studied; how interventions are carried out; and the measurement of outcomes; The duration of delirium has been reported in several ways. 9/11
(2) Bright light therapy
(3) Earplugs
(4) Occupational therapy
(5) Multicomponent orientation and cognitive stimulation
(6) Protocolized sedation with daily sedation interruption
(7) Multicomponent targeting risk factors
(8) Structured mirrors
(9) Range of motion exercises
Chen et al. [33] 2022 To compare the effects of non-pharmacological interventions by directly and indirectly combining the evidence regarding the incidence and duration of delirium in ICUs Incidence of delirium in the ICU: the use of a multi-component strategy (81.5%) significantly reduced the incidence of delirium when compared to standard care. Then health education (57.4%), family participation (57.1%), environmental management (50.1%), relaxing measures (44.8%), clinical adjustment (43.4%), physical activity (42.3%) and standard care (23.4%); the use of multi-component strategies that includes physical activity interventions, family participation, cognitive stimulation, reorientation, sensory stimulation, environmental management and adjustment of Clinical interventions significantly reduce the risk of incidence of delirium (87.4%) when compared to standard care. However, the effects of the combination of health education, reorientation, effective communication, management of the environment and adjustment of clinical interventions, relaxing measures and early mobilization when compared with the effects of standard care there is no significant difference in their impact. Duration of delirium in the ICU: no single intervention contributes to the decrease in the duration of delirium. However, the combination of the multi-component strategy contributed more effectively to the reduction of the duration of delirium when compared to the implementation of non-pharmacological measures. (1) Early mobilization The Cochrane Q test with a statistical significance of P< 0.1 and I2 statistics with the values of > 50% were used. An approach of a set of non-pharmacological strategies is the most effective in the prevention of delirium, but not in its duration. To optimize the quality of care provided, multiple interventions such as early mobilization and family participation should be incorporated into the delivery of critically ill patients care in the ICU. 8/11
(2) Family participation
(3) Multicomponent intervention
(4) Environmental control
(5) Physical activity
(6) Reorientation
(7) Clinical adjustment
(8) Health education
(9) Relaxion
Kim et al. [38] 2020 To create a hierarchy based on the efficacy and tolerance of pharmacological interventions to prevent and treat delirium Dexmedetomidine significantly reduces the duration of delirium and length of hospital stay, but it causes hemodynamic changes such as bradycardia and hypotension. Regarding antipsychotics, only second-generation drugs (quetiapine and risperidone) showed benefits in the prevention and treatment of delirium, unlike haloperidol. Ramelteon is the most effective therapeutic agent in the prevention of delirium, as it is safer and more convenient to administer. The use of lorazepam has been shown to be a risk factor for the development of delirium. Pharmacotherapy on delirium (quetiapine, morphine, dexmedetomidine, dexmedetomidine, risperidone, ramelteon) I2 not available The ethology of delirium is complex and multifactorial as such its prevention and treatment should be taken into consideration. Dexmedetomidine is the best agent in the prevention and treatment of delirium in the ICU. The evidence does not suggest the routine use of antipsychotics due to their low efficacy and tolerance. For the critically ill, oral ramelteon may be convenient and safe as an alternative to antipsychotics. 8/11
Tao et al. [46] 2018 To determine the pharmacological effect of agents used in the prevention of POD after heart surgery The pharmacological agents reported in the studies are: risperidone, dexmedetomidine, ketamine, rivastigmine, clonidine, propofol, dexamethasone, methylprednisolone. Incidence of POD: there was a reduction in the incidence of POD after cardiac surgery after the use of pharmacological strategies, the most significant being dexmedetomidine; Severity of POD: this was only reported as outcome in only one study that used the delirium detection score to measure its severity, in which only the use of clonidine was associated with lower severity of POD; Cognitive disorders in POD: this type of disorders is inherent in delirium. The use of the MMSE was used to assess the cognitive function of patients with delirium. The use of dexamethasone seemed to increase the MMSE score on the 1st and 2nd postoperative days. In another study, rivastigmine did not seem to influence MMSE in the first 6 postoperative days; Duration of the POD: there was a significant reduction in the duration of the delirium with the use of prophylactic pharmacological agents, the most significant being dexmedetomidine (rivastigmine, dexamethasone and risperidone have not been shown to be significant). Length of stay in ICU and hospital: no agent seemed to be significant in reducing this outcome. Use of pharmacologic agents (1), and specifically dexmedetomidine (2), or dexamethasone (3) Pharmacological interventions:I2=66%; It is demonstrated in this meta-analysis that the use of pharmacological agents for the prevention of the development of POD in patients undergoing cardiac surgery. Limited evidence also demonstrates that this pharmacological prevention may reduce the duration of POD. However, no benefits were found in short-term mortality, length of ICU stay, or length of hospital stay. Limitations: the limitations of this study were not described, only that they exist. 8/11
Dexmedetomidine: I2=38%;
Dexamethasone: I2=44%
Kappen et al. [45] 2022 To evaluate the evidence in the field of diagnosis, incidence, risk factors and health outcomes in patients with delirium The incidence of delirium in neurosurgical patients is about 19%; however, the diagnostic method used was quite variable in the studies presented. It was not possible to investigate which scale is best suited for the evaluation of delirium due to the impossibility of the existence of a standard for this type of population, despite everything, the CAM-ICU proved to be the most used because it is the most reliable in surgical patients, second to the ICDSC (sensitivity 80% and specificity 96% to CAM-ICU, and 74% and 82% to ICDSC) which explains the incidence using CAM-ICU 19% and 15% to ICDSC): the authors suggest that in later studies the scales should be validated according to the symptoms of neurosurgical patients. Future studies should include multiple evaluations throughout the day due to the existing fluctuation in delirium throughout the day, as it was found that the daily or bidaily evaluation increases the incidence (20 to 36%); however, surprisingly when evaluated 3 times a day, it reduced about 5%. The use of sedatives can apparently reduce the incidence of delirium, due to induced coma that does not allow the evaluation of the same. The highest incidence of delirium occurred in surgical neurovascular patients (42%), which can be explained by cerebral ischemia, hypoxia, oxidative stress induced by clipping and bypass techniques, which are described as mechanisms pathophysiology of delirium; concomitantly, these patients have longer sedation time and IMV. No correlation was found between age groups and the presence of delirium. Delirium scales I2=95% Delirium is often an adverse effect in neurosurgical patients. Future studies should include scales valid for the neurosurgical population and define the impact of delirium on the prognosis of patients. Limitations: some of the studies used non-validated scales, which did not allow the diagnosis of hypoactive delirium that constitutes about 26%–58% of the diagnosis of delirium in the population studied. 10/11
Sosnowski et al. [47] 2023 To systematize the synthesis of evidence of the efficacy of the ABCDEF bundle in the approach to delirium, function and quality of life of critically ill patients in ICU Incidence and duration of delirium: with the use of the ABCDEF bundle in relation to the provision of standard care, there was a reduction in the incidence and duration of delirium in the ICU; outcomes of functionality: mobility that includes sitting in bed, standing next to the bed or walking significantly improved patients' functionality when compared to standard care. These interventions improved patients' physical capacity after ICU discharge and hospital discharge; Quality of life: improvement in scores 90 days after hospital discharge were reported with an improvement in physical and mental capacity in patients who were cared for with the ABCDEF bundle. Facilitating factors and barriers: as facilitating factors to the implementation of the ABCDEF bundle were the involvement and participation of the family, the collaboration of members of the multidisciplinary team with their education and training, discussion of the applicability of the bundle in the passage of shift by the multidisciplinary team, the early introduction of early mobilization in the implemented interventions, focus on non-pharmacological strategies in the approach to delirium, fully dedicated rehabilitation professionals; adaptation of protocols and procedures; as barriers, the existence of ventilatory or hemodynamic instability of patients; tests or procedures, the fatigue of the patient, the presence of agitation or delirium, deep sedation, patient refusal, lack of auxiliary prostheses of patients, patients on dialysis, lack of knowledge or communication by the multidisciplinary team, lack of nursing resources and teams of physiotherapists, limited time and the presence of light and noise. ABCDE/ABCDEF bundle I2=96% The current evidence for the effect of ABCDEF bundles in ICU patients is low. However, positive outcomes such as reduced incidence and duration of delirium were demonstrated in this study. The ABCDEF bundle includes multicomponent interventions that are applied daily in ICUs. The idea that this bundle should be applied to both ventilated and non-ventilated patients is supported. Limitations: the heterogeneity of the included studies calls into question the reliability of the conclusions of this study. Many of the studies were only focused on one type of participants as ventilated or unventilated with a low severity of critical illness. Standard care was not always addressed in most outcomes. The heterogeneity of the outcomes evaluated prevented an extensive meta-analysis from being performed. And only the approach of articles in English may have prevented the inclusion of relevant studies from other countries. 10/11
Flannery et al. [34] 2016 To evaluate which interventions, promote sleep in the ICU and that, in association decrease delirium. Secondary outcomes include duration of delirium and length of ICU stay. Interventions for the promotion of sleep seem to improve the neurocognitive outcomes of the critically ill, common to the noticeable decrease in the rate of occurrence and duration of delirium. In the studies in which pharmacological strategies for sleep promotion were addressed; in about 12 to 43% (in the RCT) and 16 to 20% (in the pre-post-studies), there was a decrease in the rate of presence of delirium. However, there were numerous biases such as the heterogeneity of populations and interventions, the quality of the articles included (only one was strong). Sleep intervention (nonpharmacologic or pharmacologic) Not available: the heterogeneity of the existing body of literature (in terms of patient populations and concomitant interventions that confound results) and quality of data (only one study rated strong) makes the evidence base for this conclusion weak at best and precludes quantitative pooling in a meta-analysis. Although the studies evaluated the interventions directed to the promotion of sleep in the ICU, which include sleep bundles, earplugs, white light therapy and pharmacological interventions look promising, however, the methodologies are different, and a moderately significant bias exists. Limitations: although interventions related to sleep promotion improve outcomes related to delirium, studies have limitations such as the use of several methodologies, multiple biases that make the evidence limited. It is intended that there is a systematic approach to evaluate the relationship between sleep promotion interventions and delirium. recommendations for future studies: the relationship between sleep promotion interventions and outcomes should be objectively demonstrated; prospective studies of sleep promotion interventions should be conducted in settings that use recommended practices and guidelines in the prevention and treatment of delirium that allow testing of the only intervention with an impact on delirium; The assessment of delirium should be performed using validated scales; critical patient populations should be studied and should be less comprehensive in order to minimize existing bias. 10/11
Hu et al. [37] 2015 To verify the efficacy of non-pharmacological interventions for the promotion of sleep in critically ill patients in the ICU. Establish whether non-pharmacological interventions are safe and clinically effective in improving sleep quality and reducing the length of ICU stay of critically ill patients, as well as their cost effectiveness (1) In the non-pharmacological strategies for the promotion of sleep in ICU patients described: (a) The impact of the optimization of the ventilatory mode and type was not possible to evaluate by the heterogeneity of reporting of the outcomes, however it seems to be able to improve the quality of sleep and ventilatory asynchrony; (b) The use of earplugs and/or eye masks could not validate its improvement in sleep promotion due to the low quality of the evidence, however, it seems to increase the amount of hours of sleep by 2.19 hours in relation to standard care; (c) Music intervention was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (d) Relaxation techniques with and without relaxing music: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (e) Foot massage or foot washing: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (f) Other interventions: no studies addressed the use of valerian acupressure, aromatherapy, sound mask, or nursing/social interventions; (2) in the reduction of the length of stay in the ICU, none of the non-pharmacological interventions seemed to have an impact on it; (3) mortality none of the studies addressed mortality; (4) adverse events: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (5) delirium was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained, however two studies reported a decrease in the incidence of delirium when using earplugs and/or eye masks; (6) PTSD none of the studies addressed the presence of this syndrome. Non-pharmacological interventions for sleep promotion in critically ill adults I2 greater than 50% IMV is an important contributing factor to sleep deprivation. However, several studies have investigated the effects of ventilatory modes on sleep outcomes, failing to conclude their improvement. Some suggest that pressure-controlled, or assisted, mode ventilation or proportional assisted ventilation may improve the quality and quantity of sleep when compared to pressure-controlled ventilation. The use of non-pharmacological strategies such as tampons and/or eye masks seems to promote benefits in the sleep pattern and potentiate a decrease in the risk of incidence of delirium. 10/11
Burry et al. [31] 2021 To compare the effects of delirium prevention interventions with their presence in critically ill patients Occurrence of delirium: only alpha-agonists 2 seem to decrease the occurrence of delirium (dexmedetomidine); The comparison between the use of benzodiazepines, dexmedetomidine, the interruption of sedation, the use of opioids and benzodiazepines and the sedation protocol may decrease the occurrence of delirium, but the evidence is not concrete; The use of environmental management measures or multi-component interventions has no differences in the provision of standard care. Duration of mechanical ventilation: no intervention reduced the time of IMV; Compared with the use of benzodiazepines, dexmedetomidine appears to reduce IMV time; Length of stay: the use of alpha-agonists 2 (dexmedetomidine - except in one study) seems to decrease the length of ICU stay when compared to antipsychotics. Non-pharmacological interventions individually or together do not seem to differentiate the outcome with the use of standard care. Similar results were found related to the length of hospital stay, the only intervention that seems to have a positive impact on reducing the length of hospital stay is early mobilization through other therapists; Mortality: no pharmacological or non-pharmacological intervention reduces the mortality rate; Other outcomes: for the duration of delirium there is insufficient evidence to indicate that its use reduces it (whether pharmacological or non-pharmacological measures or standard care). The evidence was insufficient to compare interventions comparing days of absence of delirium and absence of coma, severity of delirium, incidence of subsyndromic delirium, outcomes in long-term cognition, time to discharge, and health and quality of life; Adverse events: the presence of adverse events goes through the removal of medical devices, reintubation, arrhythmias, tracheostomy and extrapyramidal effects. Except in arrhythmias (in which no intervention increases their occurrence), there is not enough evidence to make a comparison. Implications for practice: dexmedetomidine probably reduces the occurrence of delirium; The use of dexmedetomidine in comparison with the use of benzodiazepines, favoring analgesia, the existence of sedoanalgesia protocols and the daily interruption of sedation, may reduce the occurrence of delirium; The use of dexmedetomidine seems to be the only intervention that reduces the length of stay in the ICU and at the hospital level, if antipsychotics are additionally introduced, opioids, sedation strategies, there is not enough evidence to confirm it; No non-pharmacological intervention influenced mortality or the presence of arrhythmias and did not differ from standard care. The pharmacological properties of dexmedetomidine, of minimal impact at the respiratory level, with some analgesic properties, makes the use more attractive than benzodiazepines, because they increase the prevalence of delirium, alter the sleep architecture and suppress the respiratory drive; Other strategies that reduce exposure to sedation are to favor the use of analgesia or not to use sedation, the existence of sedation protocols and the daily interruption of sedation; Evidence is scarce regarding the use of antipsychotics in the occurrence and duration of delirium, duration of ventilation, length of ICU stay or mortality. Pharmacological sedation intervention (Benzodiazepines, Dexmedetomidine, sedation-minimization strategy) Not available There are no interventions to treat delirium and its high incidence in the ICU, the review provides health professionals with evidence on pharmacological measures, sedation management and non-pharmacological strategies to prevent delirium in the ICU. Compared to benzodiazepine or placebo, dexmedetomidine probably prevents delirium; The strategy of the minimum effective sedation dose that reduces exposure to sedatives can prevent delirium and antipsychotics do not. Limitations: it was not possible to compare non-pharmacological strategies with pharmacological strategies because of the number of studies that report several interventions and do not allow the connection between them. Although no effects of non-pharmacological strategies were found, further studies should be conducted to illustrate their common applicability. Future studies should include the severity of delirium, as well as the time to its resolution, patients' quality of life, and emotional stress that are not normally reported. 9/11
Zhang et al. [9] 2021 To evaluate the impact of the bundle of interventions on the prevalence of delirium in the ICU, its duration and other adverse outcomes Prevalence of delirium in the ICU: the use of bundle of interventions decreased the probability of prevalence by 8% or were not significant; duration of Delirium in ICU: no differences were identified in the duration of delirium in the ICU or in the group in which the bundle of interventions and the standard care group was implemented. Proportion of days in relation to comatose patients: patients in whom the bundle of interventions was applied, decreased the time of induced coma; Mechanical ventilation and days without ventilation: with the application of the bundle of interventions there was a statistically insignificant decrease in relation to the control group, as well as the days without ventilation; ICU admission: ICU admission days were 1.08 times lower in the group in which the bundle of interventions was implemented compared to the control group; Length of hospital stay: there was a decrease in about 1.47 days of hospitalization in the group of ICU patients in which the bundle of interventions was implemented; Mortality: studies show that the use of the bundle of interventions did not decrease mortality in the ICU, nor was it significant in mortality at the hospital level. Mortality at the 28th day showed to be decreased by about 18% with the use of the bundle of interventions in ICU patients. Bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes I2=93% This study did not prove the effects of the bundle of interventions in reducing the prevalence or duration of delirium in the ICU. However, there is evidence that refers to the effectiveness of these interventions in reducing the number of days of coma, hospitalization and mortality at the 28th day in ICU patients. Limitations: modifiable risk factors were not fully addressed in the studies presented, which may limit the efficacy of the bundle of interventions in the prevalence and duration of delirium. In future studies, the effects of the bundle of interventions on the prevalence and duration of delirium in the ICU should be considered, as well as other adverse outcomes. 9/11
Trogrlić et al. [40] 2015 To summarize the types of strategies that have improved the ability to efficiency identify, prevent and treat delirium and evaluate the effects of these strategies on outcomes. Implementation of strategies: the strategies implemented that aimed to change the behavior of health professionals (professional-oriented strategies: distribution of educational material (81%) or educational sessions (100%) and organizational strategies (change in the structure of care delivery) were the most implemented strategies. The strategies implemented oriented to the intervention to the patient, such as the evaluation of delirium with the CAM-ICU (86%); Length of stay in the ICU: after the implementation of PAD or ABCDE bundle strategies, there was a significant reduction in the length of stay in the ICU. Mortality: there was a reduction of about 2.9 to 12% in mortality (this being defined either by mortality in the ICU, in the hospital or at 30 days). The risk of mortality was significantly reduced in studies in which a greater number of implementation strategies were used. In the studies that were used, the PAD or ABCDE bundle guidelines reduced mortality by a higher % compared to studies that applied implementation strategies. Note: implementation strategies: professional (distribution of educational materials; training sessions; local consensus; visits; patient-mediated intervention; audits and feedbacks; reminders; marketing; mass media) organizational (provider-oriented interventions; patient-oriented interventions; structural interventions) financial (patient or caregiver interventions) regulatory (changes in medical practice; management of patient complaints; by the literature). Interventions to assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes Not available, but the Systematic Review has “strong heterogeneity”. The use of measures that include the evaluation, prevention and management of delirium in the ICU proved to be effective in changing adherence to the evaluation of delirium and knowledge on the same, targeting not only the use by health professionals as well as the results at the level of the organization. With the use of these bundles in delirium management that integrate pain and agitation management, coordinated waking and ventilation and early mobilization, there was an improvement in outcomes. However, to confirm this benefit more study is needed of more effective implementation strategies and the importance of focusing on delirium as the form of organ failure. 8/11
Gélinas et al. [35] 2018 To analyze the development and psychometric properties of delirium rating scales in critically ill patients. The CAM-ICU and the ICDSC are the most valid and reliable tools for the evaluation of delirium in critically ill patients in the ICU. The CAM-ICU and the ICDSC are the most sensitive scales (74 to 80% in both scales), and the CAM-ICU is the most specific with 95%, when compared to the 5 delirium assessment scales. These scales were used initially in medical or surgical patients in the ICU and later in trauma patients and less extensive in neurosurgical patients. The authors present several challenges of its applicability in patients with cognitive impairment or aphasia, requiring a more in-depth and differentiated evaluation of delirium with other neurological problems. The role of sedation in the use of CAM-ICU and ICDSC may influence the results with false positives (CAM-ICU 10%-89%) and (ICDSC 15%–47%). Awake patients have between 22% to 57% fewer false positive results compared to more sedated patients. ICU outcomes in patients who had positive CAM-ICU during the phase when they were most sedated and then negative results when awake are similar to patients without delirium in terms of time of IMV, SUI and hospital stay, and mortality after 1 year. With the implementation of these scales, between 14% and 92% documented the implementation of strategies for the prevention and management of delirium in the ICU. The routine evaluation of at least one evaluation per shift helps in the effectiveness of the implementation of the strategies. Delirium assessment tools for critically ill adults Not available The most valid and reliable scale in the diagnosis of delirium in critically ill patients is the CAM-ICU and the ICDSC. The routine use of these scales helps nurses and the multidisciplinary team to more efficiently detect delirium in patients. Limitations: studies with samples of less than 30 were excluded. The strategies and measures implemented for delirium are not static and need further development and testing in the ICU. The use of several scales can influence several results that do not may refer to extrapolated to all critically ill patients, especially neurological patients in whom there is cognitive impairment. 8/11
Deng et al. [16] 2020 To compare non-pharmacological measures for the prevention of delirium in the critically ill and find the best treatment regimen The most effective intervention in reducing the incidence of delirium is family participation (94%), followed by physical activity (74%), multi-component interventions (68%), cognitive stimulation (58%), physical environment intervention (26%) and reduction of sedation (18%). In the decrease in hospital mortality, physical activity (97.2%) is the most effective measure, followed by multicomponent interventions (73.2%), cognitive stimulation (35.8%), intervention in the physical environment (34.8%) and reduction of sedation (31.8%). The multi-component intervention was the most effective in reducing days of delirium (78.6%) and length of ICU stay (71.2%). Physical environment intervention, SR, family participation, exercise program, cerebral hemodynamics improving, multi-component studies and usual care Statistical heterogeneity was moderate. Family participation is suggested as the most effective intervention in reducing delirium in relation to the multi-component strategy, although it has not yet been studied. The multi-component strategy is more effective inpatient outcomes taking into account several risk factors and in reducing the incidence of delirium, and in the length of hospital stay. Several bundles of care to prevent delirium include, a coordinated awakening and ventilation, delirium management, early mobilization, and family participation (ABCDEF). The performance of physical exercise has an impact on the reduction of IMV time, length of hospital stay and ICU-associated myopathy, however more research should be carried out in this context. Limitations: not all studies are randomized; some interventions are based on the physical environment that may be limited to its evaluation in RCTs; the heterogeneity of the type of interventions evaluated and the evaluation of outcomes. 8/11
Barr et al. [30] 2013 To describe the methodological approach used in the 2013 PAD guidelines by the American College of Critical Care Medicine The guidelines of PAD They include the psychometric analysis of six behavioral pain scales, ten sedation/agitation scales, and five delirium assessment scales. The most reliable and valid scales used in the assessment of pain in critically ill patients are the Behavioral Pain Scale and the Critical Care Pain Observation Tool. The validated scale for assessing sedation/agitation of critically ill patients is the RASS scale. For the evaluation of delirium in critically ill patients, the Confusion Assessment Method CAM and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable scales. A meta-analysis was performed to evaluate the effects on sedation with the presence or absence of benzodiazepines on the outcomes of critically ill patients in the ICU, confirming that the use of benzodiazepines increases the length of ICU stay and IMV. The ICU PAD bundle serves as a guide to implement the PAD guidelines in the management, evaluation and prevention of pain, agitation, oversedation and delirium in critically ill patients. It also indirectly encompasses ICU interventions such as spontaneous ventilation and spontaneous ventilation tests, early mobilization protocols and management of environmental measures in sleep management, with the aim of achieving further improvements in the outcomes of ICU patients. Pain, Agitation, and Delirium Clinical Practice Guidelines Not available Guidelines for clinical practice are crucial to assist health professionals in making evidence-based decisions in the management of critically ill patients. The PAD 2013 guidelines are consistent with the Institute of Medicine recommendations for the most rigorous and contemporary clinical practice. 8/11
Saritas et al. [39] 2021 To review the non-pharmacological interventions used in the prevention of delirium in ICUs The use of multicomponent strategies is statistically significant in the reduction/prevention of delirium. The interventions used in the prevention of delirium are categorized as multi-component, health education, hormonal intervention, automatic prevention system, daily suspension of sedation and exercise. The difficulty of professionals in distinguishing delirium with other psycho-neurocognitive conditions due to the non-use of tools to assess it. The very episode of hospitalization of the patient in an ICU causes stress, emotional emptiness and social problems, with the use of the multi-component strategy, allows a greater support for patients, which allows greater control over delirium. Non-pharmacological interventions used to prevent delirium at intensive care units: patient education, hormone intervention, physical environment, therapeutic intervention, automated preventive system, quitting daily sedation and exercise Not available The most widely used delirium assessment scale is the CAM-ICU, recommending its use in conjunction with the RASS scale. There are authors who report that they should not be only evaluative methods used, suggesting the use of electroencephalogram for an objective diagnosis, due to the existence of delirium symptoms in encephalopathy. Limitations: the use of a multi-component strategy helps in the prevention of delirium in the ICU and its occurrence. However, mortality was not addressed in the studies analyzed. 7/11
Halpin et al. [48] 2020 The relationship between POD and the use of dexmedetomidine when compared with the use of sedatives/analgesics in the postoperative period of cardiac surgery Dexmedetomidine significantly reduces POD in cardiac surgery patients. However, inconsistency in the evaluation, treatment and administration of therapy may influence this conclusion. The influence of analgesia on the evaluation of delirium in some of the studies it was not possible to conclude its efficacy in its prevention. The use of dexmedetomidine in comparison with commonly used sedatives/analgesics in the postoperative cardiac surgery patient Not available Dexmedetomidine is associated with a reduction in POD in cardiac surgical patients. Limitations: similar tools for the assessment of delirium by trained professionals should be used in future studies. The relationship should be evaluated between the concomitant use of dexmedetomidine and the addition of another sedative or analgesic to check the response. 7/11
Balas et al. [25] 2016 It reviews the concept of the chronically critical patient, presents historical perspectives regarding the ABCDEF bundle and addresses controversies and the implications for practice in the application of the same in the provision of care to patients under prolonged IMV in long-term critical care services. Up to about 80% of ventilated patients and up to 50% of non-ventilated patients in the ICU, delirium can be prevented and associated with a number of adverse outcomes. Its occurrence and duration do not influence mortality. Patients with delirium have 6 times more complications, with longer ICU and hospital stays, and about 7 more days of IMV. The evidence proves that its impact extends beyond the period of hospitalization and promotes the decline of cognitive function, a higher risk of rehospitalization and long-term neurocognitive changes. The guidelines of the PAD 2013 state that the systematic evaluation of delirium should be carried out through the CAM-ICU or ICDSC. The professionals report that the diagnosis of Hypoactive delirium may occur in 75% of patients. This assessment should be performed when the patient is most awake. Reversible causes of delirium should always be identified. Non-pharmacological strategies such as reorientation, use of hearing aids, management of the physical environment, early mobilization, help to contribute to the reduction of delirium. Sleep promotion strategies that include the use of tampons also contribute to this reduction. Scheduled administration of antipsychotics to prevent or treat delirium is common (despite the lack of evidence that it prevents or improves delirium-related outcomes). This therapeutic administration of antipsychotics may have an influence on the symptoms associated with delirium; the risk-benefit has not yet been proven. ABCDEF bundle Not available Developing new and improved approaches to manage stressful symptoms in critically ill patients shows high potential in improving the quality of life of critically ill patients in these services. As such, the traditional use of the ABCDEF bundle in this type of patients enables the improvement of multidisciplinary care and outcomes in chronic critically ill patients, with the need to adapt some measures to monitor its safety and efficacy. 4/11
Bingham et al. [27] 2022 To examine existing studies in the management of delirium in adults The use of dexmedetomidine showed benefits in decreasing the incidence and duration of delirium in the ICU; The use of anticonvulsants in the prevention and treatment of delirium was not supported by the evidence presented. The use of the CAM-ICU scale proved to be the gold-standard scale for the assessment of delirium, although its use may be influenced in patients with dementia and result in false positives (20%). The use of antipsychotics (haloperidol and second-generation psychotics) has not been shown to improve the severity or mortality associated with delirium. Multicomponent non-pharmacological interventions which include early mobilization, pain management, infection prevention, use of vision and hearing aids, avoidance of sleep disruption, adequate hydration and nutrition, re-orientation, cognitive stimulation, and review of psychoactive medications Not available The best approach in the management of delirium is the use of a multi-component strategy (non-pharmacological strategies, early mobilization, pain management, infection prevention). Limitations: sample size, bias, various outcomes, assessment instruments, and inadequate description of the use of non-pharmacological measures, benzodiazepines, and physical restriction. Also as limitations, studies generally do not report adverse events or length of hospital stay;, hospital disposition and potential clinically important variable outcomes. Network for Investigation of Delirium: Unifying Scientists is developing a set of patient-centered outcomes and evidence-based instruments for delirium research. The International Federation of Delirium Societies has proposed the structured diagnosis of delirium superimposed on dementia. Ideally, RCTs should include predefined subgroups in order to assess the effectiveness of interventions in patients with dementia. 5/11
Carvalho et al. [32] 2013 To identify scales that can establish a quantitative assessment of Symptoms of delirium in the critically ill patients We obtained six scales capable of quantitatively identifying the symptoms of delirium: delirium detection score is a validity scale that considers eight of the symptoms of delirium and each of these symptoms has a classification of 0, 1, 4 or 7 points, this was created through the modification of an instrument to assess the alcohol withdrawal syndrome); CTD evaluates five items in which each of them receives a score of 0,2,4,6 up to a total of 30 points. There is no subdivision described in the literature that correlates the levels of severity with the respective values, however the lower the CTD value, the worse the prognosis. This scale is able to differentiate delirium from other psychiatric diseases such as dementia, an abbreviated form of this scale has been created, but it has not been validated for use in the ICU; the Memorial Delirium Assessment Scale was initially developed to evaluate delirium in terminally ill cancer patients. It has since been validated for use in the ICU. The scale assesses variables across two major domains—cognition and behavior—allowing clinicians to stratify delirium into different levels of severity; ICDSC is a delirium stratification scale, which can be used for its diagnosis. consists of the observation of 8 variables and a comparison with the evaluation of the previous day, proved to be relevant in the diagnosis of subsyndromic delirium; the Neelon and Champagne confusion scale this scale was created for nurses to assess delirium daily in ICU patients under IMV; Delirium Rating Scale-Revised-98 is the oldest and most traditional scale, whose objective is to measure the degree of delirium, consists of a scale of 16 items (3 of them used only at the time of diagnosis and 13 used for stratification in successive evaluations), each item receives a score from 0 to 2 or from 0 to 3 points and The higher the final score, the greater the severity of the condition; however it is very complex that generates divergent results. Delirium scales: Delirium Detection Score, the Cognitive Test of Delirium, the Memorial Delirium Assessment Scale, the Intensive Care Delirium Screening Checklist, The Neelon and Champagne Confusion Scale and the Delirium Rating Scale-Revised-98 Not available We identified six validity scales (only two for the Portuguese language) with the target population of ICU patients under different levels of sedation. All of them have high efficacy in the stratification of delirium. The most studied scale and the one that is best suited to the ICDC was used in the ICU because it is practical, effective and validated for the Portuguese language. Note: the CAM-ICU was created based on the Diagnostic and Statistical Manual of Mental Disorders-IV delirium diagnostic criteria, with the objective of facilitating the diagnosis of delirium in the ICU and allowing the evaluation of patients under IMV. This scale was not included because it only allowed the diagnosis to be made without establishing a correlation with the severity of the condition. 9 /11
Ho et al. [36] 2020 To evaluate and compare the different delirium rating scales in critically ill patients Studies suggest that ICDSC has a higher sensitivity compared to CAM-ICU for detection of delirium in ICU patients. The high specificity becomes clinically more useful to exclude delirium. However, studies reveal high heterogeneity both in the typology of patients and care practice. These scales (CAM-ICU and ICDSC) are more accurate than other delirium diagnostic scales. CAM-ICU can be used in patients under IMV through visual or auditory assessment methods. The CAM-ICU proves to be easier for healthcare professionals to use, requires less education and training from them, and is faster to be applied during the provision of care to the critically ill. Delirium assessment tool Studies heterogeneity is present. These scales (CAM-ICU and ICDSC) are more accurate than other scales for diagnosing delirium. The CAM-ICU scale proved to be the best option in the evaluation of delirium in critically ill patients, which has less training and is faster in the application in the provision of care to nurses. Limitations: the number of studies is limited. The different meta-analyses compared different delirium rating scales in the same locations, despite the sample size and that of the different types of study. 9/11
Ho et al. [26] 2019 To evaluate and compare the CAM-ICU and the ICDSC in the diagnosis of delirium in critically ill patients The CAM-ICU has a specificity of 95% and sensitivity of 85%, while the ICDSC has a specificity of 91% and a sensitivity of 87%. The impact on the diagnosis of delirium with CAM-ICU was 99% and 65% on ICDSC. Diagnostic performance of the CAM-ICU and the ICDSC in diagnosing delirium in critical ill patients Not available Both the CAM-ICU and the ICDSC are of high precision, good sensitivity and excellent specificity. However, the CAM-ICU has been shown to have a more accurate diagnosis and to be easier to understand and more specific, as a tool for assessing delirium. 5/11

ICU: intensive care unit; PS: pain control; EC: early cognitive stimulation; MP: mobility promotion; CD: cognitive stimulation; AS: assessment; PADIS: Pain, Agitation/Sedation, Delirium, Immobility, and Sleep disruption; POD: postoperative delirium; MMSE: mini-mental status examination; CAM-ICU: Confusion Assessment Method for the ICU; ICDSC: Intensive Care Delirium Screening Checklist; ABCDEF: Assess, Prevent, and Manage Pain; Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; Choice of analgesia and sedation; Delirium: Assess, Prevent, and Manage; Early mobility and Exercise; and Family engagement and empowerment; RCT: randomized controlled trial; PTSD: post-traumatic stress disorder; IMV: invasive mechanical ventilation; PAD: Pain, Agitation, and Delirium; SR: sedation reducing; RASS: Richmond Agitation-Sedation Scale; CTD: Cognitive Test For Delirium.

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        Nursing delirium management to promoting critically ill patients’ safety: an umbrella review
        Acute Crit Care. 2025;40(3):373-392.   Published online August 29, 2025
        DOI: https://doi.org/10.4266/acc.005221
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      Nursing delirium management to promoting critically ill patients’ safety: an umbrella review
      Image Image Image
      Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram.
      Figure 2. Nursing interventions according to Meyer and Lavin [12]. SP: sleep promotion; CE: cognitive stimulation; EM: early mobilization; PM: pain management and control; SA: systematic evaluation; RO: reorientation; ES: sensory stimulation; CAM-ICU: Confusion Assessment Method for the intensive care unit.
      Graphical abstract

      Figure 1.

      Figure 2.

      Graphical abstract

      Nursing delirium management to promoting critically ill patients’ safety: an umbrella review
      Study Year Objective Result and implication for clinical practice Nursing intervention Heterogeneity Conclusion and limitation Quality
      Matsuura et al. [42] 2022 To evaluate the efficacy of non-pharmacological interventions and to determine which combinations of them are effective in preventing delirium in ICU patients Significant effects were observed in the % occurrence of delirium with the use of multi-component non-pharmacological strategies (sleep promotion, cognitive stimulation, early mobilization, pain control, assessment) used in the prevention of delirium in critically ill patients. In this study they observed that two bundles (PS, EC, MP, CD, AS) and (PS, EC) were effective in reducing the incidence of delirium. According to the PADIS guidelines, in addition to the strategies described above for the prevention of delirium, optimization of vision and hearing in critically ill patients. Despite multi-component non-pharmacological strategies (sleep promotion, cognitive stimulation, early mobilization, pain management, assessment) if prove effective in preventing the incidence of delirium, there are barriers in its application such as lack of time, high workload and the high complexity of the applicability of all components in the ICU environment. It has been suggested that neurologically delirium is developed due to changes in the prefrontal and anterior cortex, parietal lobes, basal ganglia, superior colliculi, and thalamic pulvinar nucleus as they are entirely linked with the cholinergic response that is associated with cognitive function. Implications for practice: this review incorporated sleep promotion, with strategies such as reducing noise and luminosity and optimizing night care interventions. (1) The combination of sleep promotion, cognitive stimulation, early mobilization, pain control, and AS Significant heterogeneity as either I2 more than 50% or P<0.1 for Cochran Q test. If the synthesized data were heterogenous. In this study they observed that two bundles (PS, EC, MP, CD, AS) and (PS, CE) were effective in reducing the incidence of delirium. The second bundle has a greater impact on reducing the incidence of delirium (76%). The first bundle should have a multidisciplinary approach (nursing, medicine, pharmaceutical, physiotherapy). Limitations: this study included several types of interventions, types of studies and characteristics of the participants, being these critically ill surgical or trauma. 10/11
      (2) Combination of sleep promotion and cognitive stimulation
      Bannon et al. [41] 2019 To evaluate the effect of non-pharmacological interventions vs. standard care on the incidence and duration of delirium in critically ill patients The evaluation of the efficacy of non-pharmacological interventions when compared with standard care or pharmacological interventions in the incidence and duration of delirium, hospital mortality, sleep quality, cognitive function, quality of life or adverse events in critically ill patients has been shown to have very variable outcomes but that only one or several non-pharmacological interventions have not been shown to have a significant effect on incidence or duration of delirium. A pilot study revealed that a multi-component intensive occupational therapy intervention significantly reduces the incidence of delirium, in its duration and cognitive function, but when studied in meta-analysis this effect disappeared. Interventions should be more personalized with the existing type of patients (cardiac, medical, surgical). Four interventions of the multicomponent strategy seem to contribute positively to the outcomes of patients, such as the use of white light and earplugs (improves sleep quality), physiotherapy for 6 months (standard rehabilitation), hospital mortality (multicomponent strategy). (1) Multicomponent physical therapy Statistical heterogeneity was evaluated using the chi-square test (P<0.1, significant heterogeneity) and I2 statistic (I2 >50%, significant heterogeneity). There is poor-quality evidence to suggest that one or more non-pharmacological interventions are effective in reducing the incidence and duration of delirium in critically ill patients. Delirium has a multifactorial etiology; multicomponent strategies seem to be more useful. Limitations: heterogeneity of the interventions studied; how interventions are carried out; and the measurement of outcomes; The duration of delirium has been reported in several ways. 9/11
      (2) Bright light therapy
      (3) Earplugs
      (4) Occupational therapy
      (5) Multicomponent orientation and cognitive stimulation
      (6) Protocolized sedation with daily sedation interruption
      (7) Multicomponent targeting risk factors
      (8) Structured mirrors
      (9) Range of motion exercises
      Chen et al. [33] 2022 To compare the effects of non-pharmacological interventions by directly and indirectly combining the evidence regarding the incidence and duration of delirium in ICUs Incidence of delirium in the ICU: the use of a multi-component strategy (81.5%) significantly reduced the incidence of delirium when compared to standard care. Then health education (57.4%), family participation (57.1%), environmental management (50.1%), relaxing measures (44.8%), clinical adjustment (43.4%), physical activity (42.3%) and standard care (23.4%); the use of multi-component strategies that includes physical activity interventions, family participation, cognitive stimulation, reorientation, sensory stimulation, environmental management and adjustment of Clinical interventions significantly reduce the risk of incidence of delirium (87.4%) when compared to standard care. However, the effects of the combination of health education, reorientation, effective communication, management of the environment and adjustment of clinical interventions, relaxing measures and early mobilization when compared with the effects of standard care there is no significant difference in their impact. Duration of delirium in the ICU: no single intervention contributes to the decrease in the duration of delirium. However, the combination of the multi-component strategy contributed more effectively to the reduction of the duration of delirium when compared to the implementation of non-pharmacological measures. (1) Early mobilization The Cochrane Q test with a statistical significance of P< 0.1 and I2 statistics with the values of > 50% were used. An approach of a set of non-pharmacological strategies is the most effective in the prevention of delirium, but not in its duration. To optimize the quality of care provided, multiple interventions such as early mobilization and family participation should be incorporated into the delivery of critically ill patients care in the ICU. 8/11
      (2) Family participation
      (3) Multicomponent intervention
      (4) Environmental control
      (5) Physical activity
      (6) Reorientation
      (7) Clinical adjustment
      (8) Health education
      (9) Relaxion
      Kim et al. [38] 2020 To create a hierarchy based on the efficacy and tolerance of pharmacological interventions to prevent and treat delirium Dexmedetomidine significantly reduces the duration of delirium and length of hospital stay, but it causes hemodynamic changes such as bradycardia and hypotension. Regarding antipsychotics, only second-generation drugs (quetiapine and risperidone) showed benefits in the prevention and treatment of delirium, unlike haloperidol. Ramelteon is the most effective therapeutic agent in the prevention of delirium, as it is safer and more convenient to administer. The use of lorazepam has been shown to be a risk factor for the development of delirium. Pharmacotherapy on delirium (quetiapine, morphine, dexmedetomidine, dexmedetomidine, risperidone, ramelteon) I2 not available The ethology of delirium is complex and multifactorial as such its prevention and treatment should be taken into consideration. Dexmedetomidine is the best agent in the prevention and treatment of delirium in the ICU. The evidence does not suggest the routine use of antipsychotics due to their low efficacy and tolerance. For the critically ill, oral ramelteon may be convenient and safe as an alternative to antipsychotics. 8/11
      Tao et al. [46] 2018 To determine the pharmacological effect of agents used in the prevention of POD after heart surgery The pharmacological agents reported in the studies are: risperidone, dexmedetomidine, ketamine, rivastigmine, clonidine, propofol, dexamethasone, methylprednisolone. Incidence of POD: there was a reduction in the incidence of POD after cardiac surgery after the use of pharmacological strategies, the most significant being dexmedetomidine; Severity of POD: this was only reported as outcome in only one study that used the delirium detection score to measure its severity, in which only the use of clonidine was associated with lower severity of POD; Cognitive disorders in POD: this type of disorders is inherent in delirium. The use of the MMSE was used to assess the cognitive function of patients with delirium. The use of dexamethasone seemed to increase the MMSE score on the 1st and 2nd postoperative days. In another study, rivastigmine did not seem to influence MMSE in the first 6 postoperative days; Duration of the POD: there was a significant reduction in the duration of the delirium with the use of prophylactic pharmacological agents, the most significant being dexmedetomidine (rivastigmine, dexamethasone and risperidone have not been shown to be significant). Length of stay in ICU and hospital: no agent seemed to be significant in reducing this outcome. Use of pharmacologic agents (1), and specifically dexmedetomidine (2), or dexamethasone (3) Pharmacological interventions:I2=66%; It is demonstrated in this meta-analysis that the use of pharmacological agents for the prevention of the development of POD in patients undergoing cardiac surgery. Limited evidence also demonstrates that this pharmacological prevention may reduce the duration of POD. However, no benefits were found in short-term mortality, length of ICU stay, or length of hospital stay. Limitations: the limitations of this study were not described, only that they exist. 8/11
      Dexmedetomidine: I2=38%;
      Dexamethasone: I2=44%
      Kappen et al. [45] 2022 To evaluate the evidence in the field of diagnosis, incidence, risk factors and health outcomes in patients with delirium The incidence of delirium in neurosurgical patients is about 19%; however, the diagnostic method used was quite variable in the studies presented. It was not possible to investigate which scale is best suited for the evaluation of delirium due to the impossibility of the existence of a standard for this type of population, despite everything, the CAM-ICU proved to be the most used because it is the most reliable in surgical patients, second to the ICDSC (sensitivity 80% and specificity 96% to CAM-ICU, and 74% and 82% to ICDSC) which explains the incidence using CAM-ICU 19% and 15% to ICDSC): the authors suggest that in later studies the scales should be validated according to the symptoms of neurosurgical patients. Future studies should include multiple evaluations throughout the day due to the existing fluctuation in delirium throughout the day, as it was found that the daily or bidaily evaluation increases the incidence (20 to 36%); however, surprisingly when evaluated 3 times a day, it reduced about 5%. The use of sedatives can apparently reduce the incidence of delirium, due to induced coma that does not allow the evaluation of the same. The highest incidence of delirium occurred in surgical neurovascular patients (42%), which can be explained by cerebral ischemia, hypoxia, oxidative stress induced by clipping and bypass techniques, which are described as mechanisms pathophysiology of delirium; concomitantly, these patients have longer sedation time and IMV. No correlation was found between age groups and the presence of delirium. Delirium scales I2=95% Delirium is often an adverse effect in neurosurgical patients. Future studies should include scales valid for the neurosurgical population and define the impact of delirium on the prognosis of patients. Limitations: some of the studies used non-validated scales, which did not allow the diagnosis of hypoactive delirium that constitutes about 26%–58% of the diagnosis of delirium in the population studied. 10/11
      Sosnowski et al. [47] 2023 To systematize the synthesis of evidence of the efficacy of the ABCDEF bundle in the approach to delirium, function and quality of life of critically ill patients in ICU Incidence and duration of delirium: with the use of the ABCDEF bundle in relation to the provision of standard care, there was a reduction in the incidence and duration of delirium in the ICU; outcomes of functionality: mobility that includes sitting in bed, standing next to the bed or walking significantly improved patients' functionality when compared to standard care. These interventions improved patients' physical capacity after ICU discharge and hospital discharge; Quality of life: improvement in scores 90 days after hospital discharge were reported with an improvement in physical and mental capacity in patients who were cared for with the ABCDEF bundle. Facilitating factors and barriers: as facilitating factors to the implementation of the ABCDEF bundle were the involvement and participation of the family, the collaboration of members of the multidisciplinary team with their education and training, discussion of the applicability of the bundle in the passage of shift by the multidisciplinary team, the early introduction of early mobilization in the implemented interventions, focus on non-pharmacological strategies in the approach to delirium, fully dedicated rehabilitation professionals; adaptation of protocols and procedures; as barriers, the existence of ventilatory or hemodynamic instability of patients; tests or procedures, the fatigue of the patient, the presence of agitation or delirium, deep sedation, patient refusal, lack of auxiliary prostheses of patients, patients on dialysis, lack of knowledge or communication by the multidisciplinary team, lack of nursing resources and teams of physiotherapists, limited time and the presence of light and noise. ABCDE/ABCDEF bundle I2=96% The current evidence for the effect of ABCDEF bundles in ICU patients is low. However, positive outcomes such as reduced incidence and duration of delirium were demonstrated in this study. The ABCDEF bundle includes multicomponent interventions that are applied daily in ICUs. The idea that this bundle should be applied to both ventilated and non-ventilated patients is supported. Limitations: the heterogeneity of the included studies calls into question the reliability of the conclusions of this study. Many of the studies were only focused on one type of participants as ventilated or unventilated with a low severity of critical illness. Standard care was not always addressed in most outcomes. The heterogeneity of the outcomes evaluated prevented an extensive meta-analysis from being performed. And only the approach of articles in English may have prevented the inclusion of relevant studies from other countries. 10/11
      Flannery et al. [34] 2016 To evaluate which interventions, promote sleep in the ICU and that, in association decrease delirium. Secondary outcomes include duration of delirium and length of ICU stay. Interventions for the promotion of sleep seem to improve the neurocognitive outcomes of the critically ill, common to the noticeable decrease in the rate of occurrence and duration of delirium. In the studies in which pharmacological strategies for sleep promotion were addressed; in about 12 to 43% (in the RCT) and 16 to 20% (in the pre-post-studies), there was a decrease in the rate of presence of delirium. However, there were numerous biases such as the heterogeneity of populations and interventions, the quality of the articles included (only one was strong). Sleep intervention (nonpharmacologic or pharmacologic) Not available: the heterogeneity of the existing body of literature (in terms of patient populations and concomitant interventions that confound results) and quality of data (only one study rated strong) makes the evidence base for this conclusion weak at best and precludes quantitative pooling in a meta-analysis. Although the studies evaluated the interventions directed to the promotion of sleep in the ICU, which include sleep bundles, earplugs, white light therapy and pharmacological interventions look promising, however, the methodologies are different, and a moderately significant bias exists. Limitations: although interventions related to sleep promotion improve outcomes related to delirium, studies have limitations such as the use of several methodologies, multiple biases that make the evidence limited. It is intended that there is a systematic approach to evaluate the relationship between sleep promotion interventions and delirium. recommendations for future studies: the relationship between sleep promotion interventions and outcomes should be objectively demonstrated; prospective studies of sleep promotion interventions should be conducted in settings that use recommended practices and guidelines in the prevention and treatment of delirium that allow testing of the only intervention with an impact on delirium; The assessment of delirium should be performed using validated scales; critical patient populations should be studied and should be less comprehensive in order to minimize existing bias. 10/11
      Hu et al. [37] 2015 To verify the efficacy of non-pharmacological interventions for the promotion of sleep in critically ill patients in the ICU. Establish whether non-pharmacological interventions are safe and clinically effective in improving sleep quality and reducing the length of ICU stay of critically ill patients, as well as their cost effectiveness (1) In the non-pharmacological strategies for the promotion of sleep in ICU patients described: (a) The impact of the optimization of the ventilatory mode and type was not possible to evaluate by the heterogeneity of reporting of the outcomes, however it seems to be able to improve the quality of sleep and ventilatory asynchrony; (b) The use of earplugs and/or eye masks could not validate its improvement in sleep promotion due to the low quality of the evidence, however, it seems to increase the amount of hours of sleep by 2.19 hours in relation to standard care; (c) Music intervention was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (d) Relaxation techniques with and without relaxing music: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (e) Foot massage or foot washing: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (f) Other interventions: no studies addressed the use of valerian acupressure, aromatherapy, sound mask, or nursing/social interventions; (2) in the reduction of the length of stay in the ICU, none of the non-pharmacological interventions seemed to have an impact on it; (3) mortality none of the studies addressed mortality; (4) adverse events: it was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained; (5) delirium was not possible to evaluate its efficacy due to the inconsistency and low quality of the evidence obtained, however two studies reported a decrease in the incidence of delirium when using earplugs and/or eye masks; (6) PTSD none of the studies addressed the presence of this syndrome. Non-pharmacological interventions for sleep promotion in critically ill adults I2 greater than 50% IMV is an important contributing factor to sleep deprivation. However, several studies have investigated the effects of ventilatory modes on sleep outcomes, failing to conclude their improvement. Some suggest that pressure-controlled, or assisted, mode ventilation or proportional assisted ventilation may improve the quality and quantity of sleep when compared to pressure-controlled ventilation. The use of non-pharmacological strategies such as tampons and/or eye masks seems to promote benefits in the sleep pattern and potentiate a decrease in the risk of incidence of delirium. 10/11
      Burry et al. [31] 2021 To compare the effects of delirium prevention interventions with their presence in critically ill patients Occurrence of delirium: only alpha-agonists 2 seem to decrease the occurrence of delirium (dexmedetomidine); The comparison between the use of benzodiazepines, dexmedetomidine, the interruption of sedation, the use of opioids and benzodiazepines and the sedation protocol may decrease the occurrence of delirium, but the evidence is not concrete; The use of environmental management measures or multi-component interventions has no differences in the provision of standard care. Duration of mechanical ventilation: no intervention reduced the time of IMV; Compared with the use of benzodiazepines, dexmedetomidine appears to reduce IMV time; Length of stay: the use of alpha-agonists 2 (dexmedetomidine - except in one study) seems to decrease the length of ICU stay when compared to antipsychotics. Non-pharmacological interventions individually or together do not seem to differentiate the outcome with the use of standard care. Similar results were found related to the length of hospital stay, the only intervention that seems to have a positive impact on reducing the length of hospital stay is early mobilization through other therapists; Mortality: no pharmacological or non-pharmacological intervention reduces the mortality rate; Other outcomes: for the duration of delirium there is insufficient evidence to indicate that its use reduces it (whether pharmacological or non-pharmacological measures or standard care). The evidence was insufficient to compare interventions comparing days of absence of delirium and absence of coma, severity of delirium, incidence of subsyndromic delirium, outcomes in long-term cognition, time to discharge, and health and quality of life; Adverse events: the presence of adverse events goes through the removal of medical devices, reintubation, arrhythmias, tracheostomy and extrapyramidal effects. Except in arrhythmias (in which no intervention increases their occurrence), there is not enough evidence to make a comparison. Implications for practice: dexmedetomidine probably reduces the occurrence of delirium; The use of dexmedetomidine in comparison with the use of benzodiazepines, favoring analgesia, the existence of sedoanalgesia protocols and the daily interruption of sedation, may reduce the occurrence of delirium; The use of dexmedetomidine seems to be the only intervention that reduces the length of stay in the ICU and at the hospital level, if antipsychotics are additionally introduced, opioids, sedation strategies, there is not enough evidence to confirm it; No non-pharmacological intervention influenced mortality or the presence of arrhythmias and did not differ from standard care. The pharmacological properties of dexmedetomidine, of minimal impact at the respiratory level, with some analgesic properties, makes the use more attractive than benzodiazepines, because they increase the prevalence of delirium, alter the sleep architecture and suppress the respiratory drive; Other strategies that reduce exposure to sedation are to favor the use of analgesia or not to use sedation, the existence of sedation protocols and the daily interruption of sedation; Evidence is scarce regarding the use of antipsychotics in the occurrence and duration of delirium, duration of ventilation, length of ICU stay or mortality. Pharmacological sedation intervention (Benzodiazepines, Dexmedetomidine, sedation-minimization strategy) Not available There are no interventions to treat delirium and its high incidence in the ICU, the review provides health professionals with evidence on pharmacological measures, sedation management and non-pharmacological strategies to prevent delirium in the ICU. Compared to benzodiazepine or placebo, dexmedetomidine probably prevents delirium; The strategy of the minimum effective sedation dose that reduces exposure to sedatives can prevent delirium and antipsychotics do not. Limitations: it was not possible to compare non-pharmacological strategies with pharmacological strategies because of the number of studies that report several interventions and do not allow the connection between them. Although no effects of non-pharmacological strategies were found, further studies should be conducted to illustrate their common applicability. Future studies should include the severity of delirium, as well as the time to its resolution, patients' quality of life, and emotional stress that are not normally reported. 9/11
      Zhang et al. [9] 2021 To evaluate the impact of the bundle of interventions on the prevalence of delirium in the ICU, its duration and other adverse outcomes Prevalence of delirium in the ICU: the use of bundle of interventions decreased the probability of prevalence by 8% or were not significant; duration of Delirium in ICU: no differences were identified in the duration of delirium in the ICU or in the group in which the bundle of interventions and the standard care group was implemented. Proportion of days in relation to comatose patients: patients in whom the bundle of interventions was applied, decreased the time of induced coma; Mechanical ventilation and days without ventilation: with the application of the bundle of interventions there was a statistically insignificant decrease in relation to the control group, as well as the days without ventilation; ICU admission: ICU admission days were 1.08 times lower in the group in which the bundle of interventions was implemented compared to the control group; Length of hospital stay: there was a decrease in about 1.47 days of hospitalization in the group of ICU patients in which the bundle of interventions was implemented; Mortality: studies show that the use of the bundle of interventions did not decrease mortality in the ICU, nor was it significant in mortality at the hospital level. Mortality at the 28th day showed to be decreased by about 18% with the use of the bundle of interventions in ICU patients. Bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes I2=93% This study did not prove the effects of the bundle of interventions in reducing the prevalence or duration of delirium in the ICU. However, there is evidence that refers to the effectiveness of these interventions in reducing the number of days of coma, hospitalization and mortality at the 28th day in ICU patients. Limitations: modifiable risk factors were not fully addressed in the studies presented, which may limit the efficacy of the bundle of interventions in the prevalence and duration of delirium. In future studies, the effects of the bundle of interventions on the prevalence and duration of delirium in the ICU should be considered, as well as other adverse outcomes. 9/11
      Trogrlić et al. [40] 2015 To summarize the types of strategies that have improved the ability to efficiency identify, prevent and treat delirium and evaluate the effects of these strategies on outcomes. Implementation of strategies: the strategies implemented that aimed to change the behavior of health professionals (professional-oriented strategies: distribution of educational material (81%) or educational sessions (100%) and organizational strategies (change in the structure of care delivery) were the most implemented strategies. The strategies implemented oriented to the intervention to the patient, such as the evaluation of delirium with the CAM-ICU (86%); Length of stay in the ICU: after the implementation of PAD or ABCDE bundle strategies, there was a significant reduction in the length of stay in the ICU. Mortality: there was a reduction of about 2.9 to 12% in mortality (this being defined either by mortality in the ICU, in the hospital or at 30 days). The risk of mortality was significantly reduced in studies in which a greater number of implementation strategies were used. In the studies that were used, the PAD or ABCDE bundle guidelines reduced mortality by a higher % compared to studies that applied implementation strategies. Note: implementation strategies: professional (distribution of educational materials; training sessions; local consensus; visits; patient-mediated intervention; audits and feedbacks; reminders; marketing; mass media) organizational (provider-oriented interventions; patient-oriented interventions; structural interventions) financial (patient or caregiver interventions) regulatory (changes in medical practice; management of patient complaints; by the literature). Interventions to assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes Not available, but the Systematic Review has “strong heterogeneity”. The use of measures that include the evaluation, prevention and management of delirium in the ICU proved to be effective in changing adherence to the evaluation of delirium and knowledge on the same, targeting not only the use by health professionals as well as the results at the level of the organization. With the use of these bundles in delirium management that integrate pain and agitation management, coordinated waking and ventilation and early mobilization, there was an improvement in outcomes. However, to confirm this benefit more study is needed of more effective implementation strategies and the importance of focusing on delirium as the form of organ failure. 8/11
      Gélinas et al. [35] 2018 To analyze the development and psychometric properties of delirium rating scales in critically ill patients. The CAM-ICU and the ICDSC are the most valid and reliable tools for the evaluation of delirium in critically ill patients in the ICU. The CAM-ICU and the ICDSC are the most sensitive scales (74 to 80% in both scales), and the CAM-ICU is the most specific with 95%, when compared to the 5 delirium assessment scales. These scales were used initially in medical or surgical patients in the ICU and later in trauma patients and less extensive in neurosurgical patients. The authors present several challenges of its applicability in patients with cognitive impairment or aphasia, requiring a more in-depth and differentiated evaluation of delirium with other neurological problems. The role of sedation in the use of CAM-ICU and ICDSC may influence the results with false positives (CAM-ICU 10%-89%) and (ICDSC 15%–47%). Awake patients have between 22% to 57% fewer false positive results compared to more sedated patients. ICU outcomes in patients who had positive CAM-ICU during the phase when they were most sedated and then negative results when awake are similar to patients without delirium in terms of time of IMV, SUI and hospital stay, and mortality after 1 year. With the implementation of these scales, between 14% and 92% documented the implementation of strategies for the prevention and management of delirium in the ICU. The routine evaluation of at least one evaluation per shift helps in the effectiveness of the implementation of the strategies. Delirium assessment tools for critically ill adults Not available The most valid and reliable scale in the diagnosis of delirium in critically ill patients is the CAM-ICU and the ICDSC. The routine use of these scales helps nurses and the multidisciplinary team to more efficiently detect delirium in patients. Limitations: studies with samples of less than 30 were excluded. The strategies and measures implemented for delirium are not static and need further development and testing in the ICU. The use of several scales can influence several results that do not may refer to extrapolated to all critically ill patients, especially neurological patients in whom there is cognitive impairment. 8/11
      Deng et al. [16] 2020 To compare non-pharmacological measures for the prevention of delirium in the critically ill and find the best treatment regimen The most effective intervention in reducing the incidence of delirium is family participation (94%), followed by physical activity (74%), multi-component interventions (68%), cognitive stimulation (58%), physical environment intervention (26%) and reduction of sedation (18%). In the decrease in hospital mortality, physical activity (97.2%) is the most effective measure, followed by multicomponent interventions (73.2%), cognitive stimulation (35.8%), intervention in the physical environment (34.8%) and reduction of sedation (31.8%). The multi-component intervention was the most effective in reducing days of delirium (78.6%) and length of ICU stay (71.2%). Physical environment intervention, SR, family participation, exercise program, cerebral hemodynamics improving, multi-component studies and usual care Statistical heterogeneity was moderate. Family participation is suggested as the most effective intervention in reducing delirium in relation to the multi-component strategy, although it has not yet been studied. The multi-component strategy is more effective inpatient outcomes taking into account several risk factors and in reducing the incidence of delirium, and in the length of hospital stay. Several bundles of care to prevent delirium include, a coordinated awakening and ventilation, delirium management, early mobilization, and family participation (ABCDEF). The performance of physical exercise has an impact on the reduction of IMV time, length of hospital stay and ICU-associated myopathy, however more research should be carried out in this context. Limitations: not all studies are randomized; some interventions are based on the physical environment that may be limited to its evaluation in RCTs; the heterogeneity of the type of interventions evaluated and the evaluation of outcomes. 8/11
      Barr et al. [30] 2013 To describe the methodological approach used in the 2013 PAD guidelines by the American College of Critical Care Medicine The guidelines of PAD They include the psychometric analysis of six behavioral pain scales, ten sedation/agitation scales, and five delirium assessment scales. The most reliable and valid scales used in the assessment of pain in critically ill patients are the Behavioral Pain Scale and the Critical Care Pain Observation Tool. The validated scale for assessing sedation/agitation of critically ill patients is the RASS scale. For the evaluation of delirium in critically ill patients, the Confusion Assessment Method CAM and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable scales. A meta-analysis was performed to evaluate the effects on sedation with the presence or absence of benzodiazepines on the outcomes of critically ill patients in the ICU, confirming that the use of benzodiazepines increases the length of ICU stay and IMV. The ICU PAD bundle serves as a guide to implement the PAD guidelines in the management, evaluation and prevention of pain, agitation, oversedation and delirium in critically ill patients. It also indirectly encompasses ICU interventions such as spontaneous ventilation and spontaneous ventilation tests, early mobilization protocols and management of environmental measures in sleep management, with the aim of achieving further improvements in the outcomes of ICU patients. Pain, Agitation, and Delirium Clinical Practice Guidelines Not available Guidelines for clinical practice are crucial to assist health professionals in making evidence-based decisions in the management of critically ill patients. The PAD 2013 guidelines are consistent with the Institute of Medicine recommendations for the most rigorous and contemporary clinical practice. 8/11
      Saritas et al. [39] 2021 To review the non-pharmacological interventions used in the prevention of delirium in ICUs The use of multicomponent strategies is statistically significant in the reduction/prevention of delirium. The interventions used in the prevention of delirium are categorized as multi-component, health education, hormonal intervention, automatic prevention system, daily suspension of sedation and exercise. The difficulty of professionals in distinguishing delirium with other psycho-neurocognitive conditions due to the non-use of tools to assess it. The very episode of hospitalization of the patient in an ICU causes stress, emotional emptiness and social problems, with the use of the multi-component strategy, allows a greater support for patients, which allows greater control over delirium. Non-pharmacological interventions used to prevent delirium at intensive care units: patient education, hormone intervention, physical environment, therapeutic intervention, automated preventive system, quitting daily sedation and exercise Not available The most widely used delirium assessment scale is the CAM-ICU, recommending its use in conjunction with the RASS scale. There are authors who report that they should not be only evaluative methods used, suggesting the use of electroencephalogram for an objective diagnosis, due to the existence of delirium symptoms in encephalopathy. Limitations: the use of a multi-component strategy helps in the prevention of delirium in the ICU and its occurrence. However, mortality was not addressed in the studies analyzed. 7/11
      Halpin et al. [48] 2020 The relationship between POD and the use of dexmedetomidine when compared with the use of sedatives/analgesics in the postoperative period of cardiac surgery Dexmedetomidine significantly reduces POD in cardiac surgery patients. However, inconsistency in the evaluation, treatment and administration of therapy may influence this conclusion. The influence of analgesia on the evaluation of delirium in some of the studies it was not possible to conclude its efficacy in its prevention. The use of dexmedetomidine in comparison with commonly used sedatives/analgesics in the postoperative cardiac surgery patient Not available Dexmedetomidine is associated with a reduction in POD in cardiac surgical patients. Limitations: similar tools for the assessment of delirium by trained professionals should be used in future studies. The relationship should be evaluated between the concomitant use of dexmedetomidine and the addition of another sedative or analgesic to check the response. 7/11
      Balas et al. [25] 2016 It reviews the concept of the chronically critical patient, presents historical perspectives regarding the ABCDEF bundle and addresses controversies and the implications for practice in the application of the same in the provision of care to patients under prolonged IMV in long-term critical care services. Up to about 80% of ventilated patients and up to 50% of non-ventilated patients in the ICU, delirium can be prevented and associated with a number of adverse outcomes. Its occurrence and duration do not influence mortality. Patients with delirium have 6 times more complications, with longer ICU and hospital stays, and about 7 more days of IMV. The evidence proves that its impact extends beyond the period of hospitalization and promotes the decline of cognitive function, a higher risk of rehospitalization and long-term neurocognitive changes. The guidelines of the PAD 2013 state that the systematic evaluation of delirium should be carried out through the CAM-ICU or ICDSC. The professionals report that the diagnosis of Hypoactive delirium may occur in 75% of patients. This assessment should be performed when the patient is most awake. Reversible causes of delirium should always be identified. Non-pharmacological strategies such as reorientation, use of hearing aids, management of the physical environment, early mobilization, help to contribute to the reduction of delirium. Sleep promotion strategies that include the use of tampons also contribute to this reduction. Scheduled administration of antipsychotics to prevent or treat delirium is common (despite the lack of evidence that it prevents or improves delirium-related outcomes). This therapeutic administration of antipsychotics may have an influence on the symptoms associated with delirium; the risk-benefit has not yet been proven. ABCDEF bundle Not available Developing new and improved approaches to manage stressful symptoms in critically ill patients shows high potential in improving the quality of life of critically ill patients in these services. As such, the traditional use of the ABCDEF bundle in this type of patients enables the improvement of multidisciplinary care and outcomes in chronic critically ill patients, with the need to adapt some measures to monitor its safety and efficacy. 4/11
      Bingham et al. [27] 2022 To examine existing studies in the management of delirium in adults The use of dexmedetomidine showed benefits in decreasing the incidence and duration of delirium in the ICU; The use of anticonvulsants in the prevention and treatment of delirium was not supported by the evidence presented. The use of the CAM-ICU scale proved to be the gold-standard scale for the assessment of delirium, although its use may be influenced in patients with dementia and result in false positives (20%). The use of antipsychotics (haloperidol and second-generation psychotics) has not been shown to improve the severity or mortality associated with delirium. Multicomponent non-pharmacological interventions which include early mobilization, pain management, infection prevention, use of vision and hearing aids, avoidance of sleep disruption, adequate hydration and nutrition, re-orientation, cognitive stimulation, and review of psychoactive medications Not available The best approach in the management of delirium is the use of a multi-component strategy (non-pharmacological strategies, early mobilization, pain management, infection prevention). Limitations: sample size, bias, various outcomes, assessment instruments, and inadequate description of the use of non-pharmacological measures, benzodiazepines, and physical restriction. Also as limitations, studies generally do not report adverse events or length of hospital stay;, hospital disposition and potential clinically important variable outcomes. Network for Investigation of Delirium: Unifying Scientists is developing a set of patient-centered outcomes and evidence-based instruments for delirium research. The International Federation of Delirium Societies has proposed the structured diagnosis of delirium superimposed on dementia. Ideally, RCTs should include predefined subgroups in order to assess the effectiveness of interventions in patients with dementia. 5/11
      Carvalho et al. [32] 2013 To identify scales that can establish a quantitative assessment of Symptoms of delirium in the critically ill patients We obtained six scales capable of quantitatively identifying the symptoms of delirium: delirium detection score is a validity scale that considers eight of the symptoms of delirium and each of these symptoms has a classification of 0, 1, 4 or 7 points, this was created through the modification of an instrument to assess the alcohol withdrawal syndrome); CTD evaluates five items in which each of them receives a score of 0,2,4,6 up to a total of 30 points. There is no subdivision described in the literature that correlates the levels of severity with the respective values, however the lower the CTD value, the worse the prognosis. This scale is able to differentiate delirium from other psychiatric diseases such as dementia, an abbreviated form of this scale has been created, but it has not been validated for use in the ICU; the Memorial Delirium Assessment Scale was initially developed to evaluate delirium in terminally ill cancer patients. It has since been validated for use in the ICU. The scale assesses variables across two major domains—cognition and behavior—allowing clinicians to stratify delirium into different levels of severity; ICDSC is a delirium stratification scale, which can be used for its diagnosis. consists of the observation of 8 variables and a comparison with the evaluation of the previous day, proved to be relevant in the diagnosis of subsyndromic delirium; the Neelon and Champagne confusion scale this scale was created for nurses to assess delirium daily in ICU patients under IMV; Delirium Rating Scale-Revised-98 is the oldest and most traditional scale, whose objective is to measure the degree of delirium, consists of a scale of 16 items (3 of them used only at the time of diagnosis and 13 used for stratification in successive evaluations), each item receives a score from 0 to 2 or from 0 to 3 points and The higher the final score, the greater the severity of the condition; however it is very complex that generates divergent results. Delirium scales: Delirium Detection Score, the Cognitive Test of Delirium, the Memorial Delirium Assessment Scale, the Intensive Care Delirium Screening Checklist, The Neelon and Champagne Confusion Scale and the Delirium Rating Scale-Revised-98 Not available We identified six validity scales (only two for the Portuguese language) with the target population of ICU patients under different levels of sedation. All of them have high efficacy in the stratification of delirium. The most studied scale and the one that is best suited to the ICDC was used in the ICU because it is practical, effective and validated for the Portuguese language. Note: the CAM-ICU was created based on the Diagnostic and Statistical Manual of Mental Disorders-IV delirium diagnostic criteria, with the objective of facilitating the diagnosis of delirium in the ICU and allowing the evaluation of patients under IMV. This scale was not included because it only allowed the diagnosis to be made without establishing a correlation with the severity of the condition. 9 /11
      Ho et al. [36] 2020 To evaluate and compare the different delirium rating scales in critically ill patients Studies suggest that ICDSC has a higher sensitivity compared to CAM-ICU for detection of delirium in ICU patients. The high specificity becomes clinically more useful to exclude delirium. However, studies reveal high heterogeneity both in the typology of patients and care practice. These scales (CAM-ICU and ICDSC) are more accurate than other delirium diagnostic scales. CAM-ICU can be used in patients under IMV through visual or auditory assessment methods. The CAM-ICU proves to be easier for healthcare professionals to use, requires less education and training from them, and is faster to be applied during the provision of care to the critically ill. Delirium assessment tool Studies heterogeneity is present. These scales (CAM-ICU and ICDSC) are more accurate than other scales for diagnosing delirium. The CAM-ICU scale proved to be the best option in the evaluation of delirium in critically ill patients, which has less training and is faster in the application in the provision of care to nurses. Limitations: the number of studies is limited. The different meta-analyses compared different delirium rating scales in the same locations, despite the sample size and that of the different types of study. 9/11
      Ho et al. [26] 2019 To evaluate and compare the CAM-ICU and the ICDSC in the diagnosis of delirium in critically ill patients The CAM-ICU has a specificity of 95% and sensitivity of 85%, while the ICDSC has a specificity of 91% and a sensitivity of 87%. The impact on the diagnosis of delirium with CAM-ICU was 99% and 65% on ICDSC. Diagnostic performance of the CAM-ICU and the ICDSC in diagnosing delirium in critical ill patients Not available Both the CAM-ICU and the ICDSC are of high precision, good sensitivity and excellent specificity. However, the CAM-ICU has been shown to have a more accurate diagnosis and to be easier to understand and more specific, as a tool for assessing delirium. 5/11
      Table 1. Characteristics of included studies

      ICU: intensive care unit; PS: pain control; EC: early cognitive stimulation; MP: mobility promotion; CD: cognitive stimulation; AS: assessment; PADIS: Pain, Agitation/Sedation, Delirium, Immobility, and Sleep disruption; POD: postoperative delirium; MMSE: mini-mental status examination; CAM-ICU: Confusion Assessment Method for the ICU; ICDSC: Intensive Care Delirium Screening Checklist; ABCDEF: Assess, Prevent, and Manage Pain; Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; Choice of analgesia and sedation; Delirium: Assess, Prevent, and Manage; Early mobility and Exercise; and Family engagement and empowerment; RCT: randomized controlled trial; PTSD: post-traumatic stress disorder; IMV: invasive mechanical ventilation; PAD: Pain, Agitation, and Delirium; SR: sedation reducing; RASS: Richmond Agitation-Sedation Scale; CTD: Cognitive Test For Delirium.

      Table 1.

      ACC : Acute and Critical Care
      © The Korean Society of Critical Care Medicine.
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