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Article history:
Received 27 June 2015
Received in revised form
7 December 2015
Accepted 14 December 2015
Available online xxx
The purpose of this study was to determine the effect of range of motion exercises on preventing
delirium and shortening the duration of delirium among patients in the intensive care unit who are aged
65 and over. The study was conducted in the intensive care unit on patients with non-invasive mechanical ventilation. The sample size included 47 patients from the intervention group and 47 from the
control group. The incidence of delirium was 8.5% in the intervention group and 21.3% in the control
group. The duration of delirium was 15 h for patients in the intervention group and 38 h for those in the
control group. Although delirium incidence and duration decreased by 2.5-fold in the intervention group
compared to the control group; there was no signicant relationship between the intervention and
control groups. In conclusion, as the decreases in delirium occurrence and duration were not statistically
signicant, the effect of range of motion exercises was limited.
2015 Elsevier Inc. All rights reserved.
Keywords:
Intensive care
Mobility
Range of motion
Delirium
Geriatrics
Introduction
Delirium, as an acute state of confusion, is a severe geriatric
syndrome common among older patients in the intensive care unit
(ICU) that is caused by a decrease in functional, metabolic and
cognitive activities.1,2 Delirium is a complicated clinical syndrome
affected by patients physiological parameters and their health
conditions. These parameters are utilized to develop a model to
predict delirium. Inouye et al.s model to predict delirium includes
four risk factors for delirium: the presence of cognitive and vision
impairment, an Acute Physiology and Chronic Health Assessment II
(APACHE II) score of 16 or above, and a bloodeurea nitrogen (BUN)/
serum creatinine ratio of 18 or above.3 Delirium occurs at a high
incidence in patients with ventilation support. In invasive mechanic ventilation (IMV), the patient is supported via an endotracheal tube that provides positive pressure from a ventilator.4 In
non-invasive mechanic ventilation (NIMV), the patient is supported
by a face mask that provides positive pressure from a ventilator.
NIMV has certain advantages, such as a decreased need for sedation, a reduced use of physical restraints, a decreased number of
tubes, low anxiety levels due to the patients speaking ability,
Being on IMV
(n = 13)
Amputated
extremity
(n = 1)
Having a cognitive
disorder (n = 6)
Patients included in
the sample
(n = 94)
Randomization of patients
included in the sample
Control (n:47)
- Daily CAM-ICU assessment
-RASS assessment
-Routine clinical procedures
Having delirium
(n = 5)
Active GIS**
bleeding
(n = 2)
Refused to participate in
the study
(n = 3)
Intervention (n:47)
- Daily CAM-ICU assessment
-RASS assessment
-Routine clinical procedures
- Performing ROMs
using the RASS and the CAM-ICU Scales. The control group received
no intervention apart from routine clinical practice. In the intervention group, after the daily RASS and CAM-ICU assessments, ROM
exercises were performed once a day until the patients were discharged. Passive, assisted-active or active ROM exercises were
performed based on the patients ability to respond to verbal
commands. ROM exercises were performed for the four extremities
in the supine position with 10 repetitions for approximately 30 min.
If the patient was unable to tolerate the intervention, the exercise
ceased and the intervention continued the next day. The parameters indicating that the exercise was not tolerated were as follows:
average arterial pressure 65 mm Hg, systolic blood pressure
200 mm Hg and above, pulse rate 40 or 130, saturation 88%,
breathing rate 5 or 40 per minute, and arrhythmia.
Data analysis
The data were analyzed using the IBM SPSS Statistics 22 program. Percentages, means and medians were used for the
descriptive and medical patient characteristics, and the characteristics of patients experiencing delirium and ROM intervention
traits. The Chi-square test was used to assess the delirium incidence
and vision impairment homogeneity, the ManneWhitney U test
was used to assess the delirium duration, the independent sample t
test was used to assess the BUN/creatinine ratio, and the APACHE II
score was used to assess homogeneity.
Ethical consideration
This study was approved by the Ethical Committee of the Turgut
Ozal University Faculty of Medicine (Reference no.99950699/340).
The researcher explained the study to the patients and their proxy
decision maker prior to the study. Informed consent was obtained
from the patient or the proxy decision maker. If patients were
unable to provide informed consent, due to their level of consciousness, including confusion or lethargy, informed consent was
obtained from their proxy decision maker, and the patients were
later informed when they re-gained consciousness. Three patients
had a 2 score (light sedation) from the RASS Scale at the
beginning of the study, so their informed consent was given by
their proxy decision maker, and the other 91 patients provided
consent.
Results
Descriptive, medical, and ROM exercises characteristics of patients
The mean age of patients from the intervention group was
75 7.5 years, and 48.9% of them were female. The mean age of the
patients in the control group was 72.6 6.8 years, and 57.4% of
them were female. In both groups, 51.1% of the patients stayed in
the ICU for less than 9 days. All of the patients in the intervention
group had chronic diseases, and the average number of chronic
diseases was 4.04 1.2. The current number of medications was
11.44 1.4, and H2 receptor antagonists were frequently used
(46.8%) in the intervention group. In the control group, 95.7% of the
patients had chronic diseases, and the average number of chronic
diseases was 4.0 3.9. The current number of medications was
11.14 3.7, and H2 receptor antagonist group medication was
frequently used in the control group.
The median duration of the ROM exercises in the intervention
group was 5 days (range: 1e16 days). Active ROM exercises were
administered to 63.8% of the patients, followed by assisted-active
ROM exercises (34.1%) and passive ROM exercises (2.1%).
Table 1
The relationship between the CAM-ICU items by group.
Characteristics
Discussion
When we examined the effect of ROM exercises on delirium
occurrence, the difference between the two groups was not statistically signicant (p > 0.05); however, the delirium incidence
was 8.5% in the intervention group and 21.3% in the control group.
There is no consensus regarding the responses to ROM exercises in
ICU patients with delirium. Accordingly, there are different results
in the literature related to the effect of ROM exercises on the
development of delirium. A study using a delirium prevention
protocol including early mobility in the ICU, showed no signicant
effect on the incidence of delirium.25 Nydahl et al also asserted that
there is a consensus decit regarding early mobilization of
100%
90%
80%
70%
37
60%
50%
43
40%
30%
20%
10
10%
0%
4
Intervenon
Control
Delirium occured
Control
Chi-square
1.099
0.294
1.983
0.159
24 h
2.014
0.156
2.286
0.131
3.005
0.083
2.286
0.131
2.712
0.100
a
Item 3: Disorganized thinking, Item 4: Altered level of consciousness. If the
other items meet the delirium criteria, the existence of one of these two items is
enough for diagnosis; therefore, they are indicated together in the table.
Duration (h)
(med minemax)
28
>28
Occurrence time
Night
Morning
Type
Hyperactive
Hypoactive
Mixed
Treatment procedure
Pharmacologica
Non-pharmacologicb
Pharmacologic
non-pharmacologic
No procedure
Total
a
Fig. 2. The distribution of delirium incidence in the intervention and control groups.
Intervention
Intervention
(n 4)
Control (n 10)
15 (3e144)
38 (9e120)
3
1
75
25
5
5
50
50
4
0
100
0
7
3
70
30
1
1
2
25
25
50
4
6
0
40
60
0
0
1
1
0
25
25
1
1
3
10
10
30
2
4
50
100
5
10
50
100
to the ROM exercises. The patients suffered from delirium just after
an infection due to an acid-base imbalance and renal function
disorder in the intervention group. Such complications and serious
diseases provide potential reasons why not all of the participants
responded to the ROM exercises. When we compared the length of
stay in the ICU (4.5 days) with exercise duration (2 days) in the
patients with delirium, we found fewer ROM exercise days due to
the development of respiratory instability and intracranial arterial
conditions. This limited exercise duration and the severe medical
conditions in the intervention group may have reduced the effectiveness of the ROM exercises and contributed to the development
of delirium.
We found no statistically signicant difference between the
intervention and control groups in terms of the duration of
delirium (p > 0.05). However, the median delirium duration was
15 h in the intervention group and 38 h in the control group. In
agreement with this result, a randomized-controlled study
administering a progressive exercise and resistance program reported that the decrease in the delirium duration did not reach
statistically signicant level (intervention: 2.4 days, control: 2.1
days).28 Additionally, according to a meta-analysis examining the
effect of randomized-controlled interventions on delirium duration, delirium duration changed with a wide range, results from
little impact to signicant reduction.29 Within the context of this
meta-analysis, early physical and occupational therapy signicantly
decreased delirium duration.20
The literature recommends assessing the delirium scale items
during delirium screening because of their effect on patient outcomes.30e33 Therefore, scale items were examined in our study.
Although there was no statistically signicant relationship between
the CAM-ICU Scale items in the intervention and control groups,
the incidence rates of all the scale items were lower in the intervention group. In a study conducted by Meagher et al on 133 participants, 56.3% of patients were not diagnosed with delirium
according to the CAM-ICU.33 However, 96% of patients were positive for at least one of the scale items, and 13.2% were positive for at
least two scale items (n 41). In our study, the highest improvement in the intervention group was observed in the item, difculty
in maintaining or shifting attention, compared to the control group
(intervention n 7, control n 14). Considering that attention
disorder is the most common issue in patients with delirium, the
clinical importance of this item is evident.
In conclusion, although a decrease of approximately 2.5-fold
was observed in delirium development and duration, there was
no statistically signicant difference in patients using ROM exercises. The effect of ROM exercises on delirium development and
duration was limited in critically ill elderly patients. Therefore,
instead of offering only one type of mobility choice, such as ROM
exercises, an individualized exercise therapy from passive ROM to
active mobility, according to patient tolerance, could be more
promising for preventing delirium development and shortening
the duration of delirium. Furthermore, considering the multifactorial nature of delirium, certain precautions, such as controlling
infection, maintaining hydration, establishing a multidisciplinary
team approach, and accurately implementing the ABCDE bundle
may be benecial for strengthening the effect of ROM exercises on
combating delirium symptoms.
Limitation of study
The current study was limited to the patients aged 65 and over
in a medical ICU with the non-invasive mechanical ventilation. The
sample size of the study was totally 94 patients. This was another
limitation for our study.
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