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Non-pharmacological delirium detection and management interventions for informal caregivers of older people at home: A scoping review protocol
Delirium detection and management interventions for informal caregivers: A scoping review protocol
https://orcid.org/0000-0003-0572-3892
Fox Mary T. Conceptualization Methodology Supervision Writing – original draft Writing – review & editing 1 2 *
Maimets Ilo-Katryn Data curation Writing – review & editing 3
Butler Jeffrey I. Formal analysis Project administration Software Writing – review & editing 1 2
Sidani Souraya Methodology Writing – review & editing 1
Godfrey Christina Methodology Writing – review & editing 4
1 School of Nursing, York University, Toronto, Ontario, Canada
2 York University Centre for Aging Research and Education, Toronto, Ontario, Canada
3 Steacie Science and Engineering Library, York University, Toronto, Ontario, Canada
4 Queen’s Collaboration for Health Care Quality: A JBI Centre of Excellence, School of Nursing, Queen’s University, Kingston, Ontario, Canada
Curiati Pedro Kallas Editor
Hospital Sirio-Libanes, BRAZIL
Competing Interests: The authors have declared that no competing interests exist. This scoping review is being supported by a York University Research Support Grant and Library Minor Research Grant, as well as the Research At York (RAY) program.

* E-mail: maryfox@yorku.ca
20 9 2024
2024
19 9 e030888621 6 2024
31 7 2024
© 2024 Fox et al
2024
Fox et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Objective

The objective of this proposed scoping review is to identify and map the available evidence on interventions that aim to help informal caregivers identify and/or manage delirium in an older person at home.

Introduction

Delirium is a neurocognitive condition characterized by acute confusion and is associated with increased risk of morbidity and mortality. Research estimates delirium to be present in 17% of community-dwellers aged 85 and older, increasing proportionally with age to 45% in those aged 90 and older. Delirium often occurs at the onset of an older person’s acute illness or exacerbation of a chronic illness (sometimes while at home) and, because of its protracted nature, usually continues after a hospital stay. Even when an older person’s delirium resolves during hospitalization, they remain at risk of its recurrence after discharge home. Consequently, knowing how to detect and manage delirium is critical for informal caregivers of older people at home. However, there are no reviews focused exclusively on this topic in this setting.

Inclusion criteria

The population of interest includes informal caregivers of a person aged 65+. Concepts of interest include delirium detection and/or management interventions. The context of interest is any setting where informal care is delivered, including the transition from hospital to home, in any geographical area.

Materials and methods

The review will be conducted according to the JBI guidelines for scoping reviews. A three-step search strategy will be used to locate both published and unpublished papers in MEDLINE, Embase, CINAHL, PsycINFO, Web of Science Core Collection, ProQuest Nursing & Allied Health, SCOPUS, LILACS, and SciELO, PQD&T, NDLTD, Google Scholar and Google. No language restrictions will be placed on the review. Papers will be screened for eligibility at the title, abstract, and full text level by two independent reviewers. Data will be extracted by two independent reviewers and managed in Covidence. Any disagreements in screening or data extraction will be resolved by consensus or a third reviewer. Results will be summarised in narrative and tabular formats.

This scoping review is being supported by a York University Research Support Grant and Library Minor Research Grant, as well as the Research At York (RAY) program. https://orcid.org/0000-0003-0572-3892
Fox Mary T. This scoping review is being supported by a York University Research Support Grant and Library Minor Research Grant, as well as the Research At York (RAY) program. NA Dr. Mary T. Fox and Ilo-Katryn Maimets. Data AvailabilityNo datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
Data Availability

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
==== Body
pmcIntroduction

Delirium is a serious neurocognitive syndrome characterized by a sudden and fluctuating disturbance in an individual’s cognition, attention, and awareness [1]. Its diagnosis “requires evidence of an underlying organic cause” [2] (p. 1) which can involve any stressor (e.g., metabolic imbalance, infection) that disrupts the homeostasis of an individual with already diminished physiological reserves [1,2]. Although delirium can present at any age during the onset of an 1) acute illness, 2) acute exacerbation of a chronic condition, or 3) injury, it typically occurs in older people (age 65+) [3].

Although few studies have examined the prevalence of delirium at home in the community, studies estimate it ranges from .5% to 34.5% in the general non-hospital population aged 65+ with higher prevalence rates with increasing age [4]. For example, one study found delirium to be present in 17% of community-dwellers aged 85 and older increasing proportionally with age to 39% in those aged 95 and older [5]. Consequently, informal caregivers (i.e., any family member, friend, neighbor, or volunteer who provides informal, unpaid care at home; hereafter, referred to as caregivers) need to be able to recognize its onset at home in the community. Doing so will allow caregivers to seek medical attention from a primary care provider, which may prevent hospital admission and the worsening of delirium.

In the hospital setting, delirium has been found in 10%-30% of older patients upon admission to the emergency department [1], 20 to 23% of older medical inpatients [6,7], up to 50% of older post-operative patients, and 80% of older intensive care patients [8]. Delirium is regarded as reversable when the underlying cause can be resolved [3]. However, because of delirium’s protracted nature, when it is diagnosed in hospital, it usually continues after discharge– 36% of older patients have delirium at the time of hospital discharge [9]. The probability of full recovery is only 4% at 4 weeks and 27% at 24 weeks post-discharge [10]. Consequently, the caregivers of patients discharged with delirium require information on non-pharmacological interventions, such as promoting physical activity and reducing environmental noise, which are needed to promote recovery at home following hospitalization. Yet, many caregivers recognize their lack of knowledge in managing delirium and they find caring for someone with delirium to be very challenging [11].

Even when an older person’s delirium resolves during hospitalization, they remain at risk of experiencing a recurrence after discharge [12]. Because delirium can manifest as decreased psychomotor activity (e.g., listlessness, sleepiness), increased psychomotor activity (e.g., restlessness, agitation) or mixed psychomotor activity (e.g., alternating between listlessness and restlessness) [13], it can be difficult for caregivers to identify and/or manage. For example, when an older person is lethargic and listless, a caregiver may fail to recognize delirium and not seek medical help, thereby putting the older person at risk of experiencing delirium-related complications. Delirium in the post-discharge period is associated with serious complications including functional disability, loss of independence [8], hospital readmission, and death [10]. Indeed, people who manifest their delirium through decreased psychomotor activity have worse outcomes than those who manifest their delirium through increased psychomotor activity–likely due to delayed detection [14]. Caregivers may interpret excessive sleepiness as a person’s need for sleep and inadvertently encourage bed rest. Because ambulation and regulation of the sleep-wake cycle are interventions that promote recovery of delirium and mitigate its negative effects [3], encouraging bed rest may precipitate a new delirium or worsen an existing delirium.

While prior reviews have established the effectiveness of delirium detection [15–17] and/or management [18–20] interventions in improving patient outcomes, most reviews were limited to the hospital setting and did not extend into patients’ homes during the post-discharge period [16–20]. We found only four reviews that included studies conducted with the caregivers of older adults at home. A review by Zhou and colleagues (2023) focused solely on the diagnostic accuracy of tools to detect delirium and did not describe if and how caregivers were taught to use the tool [21], and a 2015 review led by Carbone excluded studies that focused only on the detection of delirium [22]. A review by Lee’s team (2023) described educational interventions for managing delirium but provided a high level, thematic interpretation of the interventions and did not describe their characteristics [23]. Only one review (Bull et al, 2016) attempted to describe the intervention under examination but only addressed dose (e.g., duration, frequency) [15]; moreover, that review was limited to studies examining the effects of educational interventions with experimental, quasi-experimental, and comparative designs. Most studies with these types of designs, particularly in the testing of non-pharmacological interventions, do not adequately describe the interventions being tested [24,25]. It has been our experience that detailed descriptions of interventions, when they do appear, tend to be published in protocols and other descriptive papers [26]. The lack of description of interventions in this clinical area thus likely limits intervention implementation and uptake [27]. For example, knowing whether an intervention initiated in hospital was in fact continued into the post-discharge period is critical to optimizing its use in the community.

Furthermore, the four available reviews restricted inclusion to studies published in English [15,21–23] or Chinese [21]. Delirium, however, is an important global issue as many countries are experiencing population aging [28]. There is likely untapped knowledge published in other languages that could enhance understanding of how to help caregivers detect and manage delirium. Yet, to the best of our knowledge, this information has not yet been synthesized to facilitate its widespread adoption.

Lastly, the four reviews that we found lacked comprehensiveness in their selection of databases. Bramer et al, 2017 recommends that, at a minimum, Medline and Embase should be searched along with Web of Science Core Collection, Google Scholar and specialized databases that are relevant to the topic [29]. In the case of searching for delirium detection and management interventions, CINAHL and PsycINFO should be included [29]. Likewise, any search in these databases should include a combination of index terms and keywords; only two reviews indicated that index terms and keywords were used to develop the search strategy [15,21].

This proposed scoping review will differ from prior reviews in several ways. First, the review will not be limited to only the hospital setting and will include interventions initiated in the hospital and extended into the home. Second, this review will also include studies that initiated the interventions in the non-hospital setting. Third, unlike prior reviews, this review will provide comprehensive, in-depth descriptions of the interventions. Fourth, the search strategy will undergo peer review and will be as comprehensive as possible. Lastly, there will be no limitations on the language of papers.

The proposed review addresses an immense gap in synthesized knowledge. In our preliminary search of PROSPERO, MEDLINE, Pilot and Feasibility Studies, the Cochrane Database of Systematic Reviews, Epistemonikos, and the JBI Evidence Synthesis, we identified no current or underway systematic or scoping reviews on this specific topic. Furthermore, this search identified four unique articles that were not included in the four prior reviews that included studies conducted with the caregivers of older adults at home [15,21–23]. The objective of this proposed scoping review is to identify and map the available evidence on interventions that aim to help caregivers identify and/or manage delirium in an older person at home.

Review questions

What non-pharmacological interventions that aim to help caregivers detect and/or manage delirium of an older non-institutionalized person at home have been studied? What outcomes have been examined (e.g., improvement in caregivers’ knowledge of delirium, ability to recognize delirium, ability to manage delirium, burden, and stress)?

How were outcomes measured?

What results were reported?

What were the characteristics of the interventions that have been studied? What were the goals of the interventions (e.g., detect delirium, know what to do if delirium is detected)?

What were the components and activities of the interventions (e.g., educational with teachback, behavioral with demonstration of a skill)?

What materials were used in the interventions (e.g., educational pamphlets, videos)?

What were the doses of the interventions (e.g., length, duration, frequency of intervention sessions)?

What was the context of implementing those interventions? In what setting were the interventions initiated (e.g., hospital, home, primary care clinic)?

Who provided the interventions to caregivers (e.g., nurses, social workers)?

What modes of providing the interventions to caregivers have been used (e.g., in-person, online)?

What were the characteristics of the caregivers that were included in the studies? What were the living arrangements of the caregivers (e.g., living with the patient)?

What was the level of literacy of the caregivers (e.g., health and digital literacy, reading level)?

Materials and methods

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews [30] and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [31]. A scoping review is “a type of evidence synthesis that aims to systematically identify and map the breadth of evidence available on a particular topic, field, concept, or issue, often irrespective of source (i.e., primary research, reviews, non-empirical evidence) within or across particular contexts” (page 1) [32]. Because we could not locate any existing reviews that provide an in-depth description of interventions that aim to help caregivers identify and/or manage delirium in an older person at home, we determined that a scoping review to identify and map this body of literature, rather than a systematic review, was most appropriate to meet our review objective. The protocol is registered with AsPredicted, Registration #160678 (https://aspredicted.org/WNW_QFS).

Inclusion criteria

Participants

This review will include papers that targeted informal, unpaid caregivers who are family members, friends, volunteers, or neighbours providing care or support to an older person (aged 65+) at home. Providing care or support is defined as any type of assistance in basic or instrumental activities of daily living of any duration or frequency and need not be provided by live-in caregivers. Caregivers may be providing care and support to older people who:

received hospital care for various medical conditions and/or injuries and developed delirium and was discharged home;

received hospital care for various medical conditions and/or injuries and was at risk of developing delirium in the post-discharge period; and/or

are living at home and are at risk of developing delirium.

Papers will be excluded if informal caregiver data cannot be separated from those of patients and/or healthcare professionals.

Concept

The review will consider non-pharmacological interventions that aim to help caregivers detect and/or manage delirium. Interventions that exclusively aimed to help caregivers prevent delirium will be excluded.

Context

The context for the review is any setting where informal care is delivered, however, we will consider papers examining interventions that were initiated in the hospital (including the emergency department) provided they were continued at home after hospital discharge. All geographical areas will be eligible for inclusion. Papers written since 1980, the year that delirium became a diagnostic entity in the DSM-III, will be considered for inclusion [33]. Papers that focused exclusively on institutional settings such as nursing homes or settings staffed with full-time formal healthcare workers will not be eligible.

Types of sources

There will be two types of sources of evidence in this review: 1) papers reporting on the effectiveness of interventions that aim to help caregivers detect and/or manage delirium, and 2) papers describing those interventions. For the first type of source, we will consider studies that evaluated interventions, using any research design (e.g., randomized and non-randomized trials). For the second type of source, we will consider qualitative study designs, including qualitative descriptive, phenomenology, action research, grounded theory, ethnography, and mixed-method study designs. We will also include protocols, commentaries, abstracts, editorials, text, opinion, conceptual, clinical, and empirical papers describing the interventions; eligibility will be confirmed when the paper cites an intervention reported in an effectiveness study or the included effectiveness study cites the paper as providing additional information about the intervention, or when the study author(s) confirm that the paper describes the intervention. Papers focused exclusively on delirium prevention interventions or psychometric testing of delirium detection tools will be excluded, as will diagnostic studies.

Search strategy

The search strategy will be conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses literature search extension (PRISMA-S) [34]. A three-step search strategy will be used to locate both published and unpublished papers. Step 1: One of us (IM), an academic librarian with expertise in teaching and conducting reviews, will conduct an initial scoping search of MEDLINE (OVID) using only MeSH terms where feasible, to locate a set of relevant papers which will then be searched in PubMed for the purpose of harvesting additional MeSH terms and keywords from relevant results and gathering additional relevant papers from the “Similar articles” and “Cited by" lists. MeSH terms will also be searched in CINAHL to locate additional CINAHL-specific index terms and additional keywords from relevant articles. The final vocabulary selection will be done in consultation with team members with clinical expertise on the topic (see S1 Appendix). The final search strategy, including all identified keywords and index terms, will be submitted for peer-review to colleagues who, while not blinded, nevertheless will adhere closely to the Peer Review of Electronic Search Strategies (PRESS) guidelines for reviews [35]. Step 2: The search strategy will then be translated into the syntax of additional included databases, preserving strict fidelity to the original strategy so that index terms are translated individually to find the counterparts in the target databases, and the keyword strategy will be transferred as unchanged as possible taking database constraints and idiosyncrasies into account. Given the limitations of some of the grey literature databases and search engines, simplified keyword strategies (S1 Appendix) will be used to search various online sources such as Networked Digital Library of Theses and Dissertations (NDLTD) and Google that do not support more sophisticated search techniques. Advanced Search features of search engines and databases will be used where available. Step 3: Once articles, reports, and other grey literature information sources have been screened and identified for inclusion at the full text stage, their reference lists will be examined for any additional relevant papers that may meet the inclusion criteria for the review. All search strategies, as they are run in each database, will be reported in the scoping review.

To cast a broad net and capture articles from other cultures and jurisdictions, the databases to be searched will include MEDLINE (OVID), Embase (OVID), CINAHL (EBSCOhost), PsycINFO (OVID), Web of Science Collection, ProQuest Nursing & Allied Health, SCOPUS, LILACS, and SciELO and Google Scholar. A search for unpublished papers will be conducted in ProQuest Dissertation and Theses (ProQuest), NDLTD, and Google. Google search algorithms are not transparent and adapt themselves to the user; to avoid this adaptation by Google, the searchers will log off their Google account prior to searching [36]. The first 100 entries of the Google searches will be scanned for relevant results. No language restrictions will be placed on the review. Papers not published in English will be translated using DeepL.

Source of evidence selection

Following the search, all identified citations will be collated and uploaded into Covidence and duplicates removed. After training and pilot testing of the screening process, titles and abstracts will be screened independently by two or more reviewers for assessment against the inclusion criteria for the review. The full text of selected citations will be retrieved and assessed in detail against the inclusion criteria by two or more independent reviewers. Reasons for exclusion of sources of evidence at full text will be recorded and reported in the scoping review. Any disagreements between the reviewers at any stage of the screening process will be resolved through discussion, or with an additional reviewer. The results of the search and the review process will be reported in full in the final scoping review and presented in a PRISMA flow diagram [37]. Papers not published in English will be translated using DeepL.

Data extraction

Data will be extracted from papers included in the scoping review by using a data extraction tool developed by the reviewers, based on the Template for Intervention Description and Replication (TIDieR) [27] (S2 Appendix). Teams of two independent reviewers will pilot test the tool for ease of use, redundancy, clarity, and comprehensiveness of data extracted, and time for completion; we will perform the pilot test on two to three items for each type of evidence source (i.e., papers reporting on the effectiveness of the interventions and papers describing those interventions) [38]. Following the pilot test, we will modify the tool accordingly. Any modifications, and their rationale, made at this stage or throughout the scoping review (e.g., data items not initially considered but identified and determined by our team as relevant) [38] will be reported in the scoping review publication. Extracted data will include specific details about the participants, concept, context, study methods, and key findings relevant to the review questions and sub-questions. Any disagreements on the data extracted will be resolved through discussion or with an additional reviewer. We will contact authors of the papers to request any missing or additional data, where required.

Data analysis and presentation

Data analysis will involve descriptive statistics including frequencies, counts, and measures of central tendency and variation (e.g., medians and ranges for duration of the intervention). Textual data will be subjected to conventional content analysis. Data presentation is planned to be in tabular format. A narrative summary will accompany tabulated and/or charted results and will describe how the results relate to the review objective, questions, and sub-questions. Covidence (Veritas Health Innovation) will be used to manage the references, abstracts, and full-text articles included in the scoping review.

Supporting information

S1 Appendix Search strategy.

(DOCX)

S2 Appendix Draft data extraction instrument.

(DOCX)

S3 Appendix PRISMA-P 2015 checklist.

(DOCX)

The authors would like to thank York University undergraduate students Shannon Gordon and Madison Clancy for their help in reviewing the literature.

10.1371/journal.pone.0308886.r001
Decision Letter 0
Curiati Pedro Kallas Academic Editor
© 2024 Pedro Kallas Curiati
2024
Pedro Kallas Curiati
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
23 Jul 2024

PONE-D-24-24285Non-pharmacological delirium detection and management interventions for informal caregivers of older people at home: a scoping review protocolPLOS ONE

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #1: This proposal addresses a highly relevant topic, particularly due to the universally high incidence of delirium. The methodology appears to be suitable and interesting; however, the authors' assertion that “no reviews have identified and mapped the available evidence on interventions that aim to help informal caregivers identify and/or manage delirium in an older person at home.” requires further clarification. For illustrative examples, please refer to the attached articles.

Young, J., Inouye, S. K., & Marcantonio, E. R. (2015). Delirium in older people. BMJ (Clinical research ed.), 350, h279.

We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

Patnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, Lin JS. Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Feb. Report No.: 19-05257-EF-1. PMID: 32129963.

Caregiver and caregiver-patient dyad interventions including psychoeducation for the caregiver and care and case management interventions, reported in 88 trials (n=14,880), resulted in a consistent benefit on caregiver burden and depression outcomes. Effect sizes were mostly small, however, and were of unclear clinical significance. Little harm was evident in the few nonpharmacologic intervention trials that reported harms.

Reviewer #2: Review comments

Thank you for your protocol on a scoping review which will address an important, and under-researched topic. A few comments

1. Your introduction is written very much from the perspective of interventions that informal carers may continue at home, after a delirium in hospital. However, you also state that you will include papers for interventions commenced at home, where a person has developed delirium but not been admitted to hospital. I think the latter is potentially a very interesting area to explore, as interventions by informal carers may prevent hospital admission, and thus worsening of delirium. If you wish to include this scenario in your review, I suggest reframing your introduction.

2. In your introduction you write that there have been no reviews conducted on this topic but then say in an initial search you identified four studies which had not been included in previous reviews. Please clarify what these previous reviews were on, as it is not clear.

3. In outcomes (1) I would also include carers’ burden or stress, as this is likely to be a barrier to implementation of such interventions.

4. In outcomes (3) I would also include a question about what the characteristics of the caregivers were, if reported. i.e. is the intervention only feasible if the informal caregiver lives with the patient. Do they need a certain level of literacy / digital literacy.

5. Types of sources – this needs a little clarification and would read better if split up into individual statements, rather than use of multiple semicolons. You state that eligibility will be confirmed when the paper cites an intervention reported in an effectiveness study or the included effectiveness study cites the paper as providing additional information about the intervention, or when the study author(s) confirm that the paper describes the interventionyou will first search for any study which evaluates an intervention and then search for studies or grey literature which describes the intervention. Does the citation requirement refer just to the grey literature or also to qualitative studies as well? This will clearly narrow your inclusion criteria if so. Please then justify this in your methods.

6. Please describe where data will be available when the study is complete

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Reviewer #1: No

Reviewer #2: Yes: Dr Anna Seeley

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10.1371/journal.pone.0308886.r002
Author response to Decision Letter 0
Submission Version1
30 Jul 2024

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Response: We have ensured the ‘Funding Information’ and ‘Financial Disclosure’ sections match. The financial support provided did not include specific grant numbers.

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Response: We have provided a complete Data Availability Statement in the submission form. Given that this is a protocol and does not report results, we selected

“N/A” – No results are reported. We also indicate “No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.”

Reviewer 1

Comment: This proposal addresses a highly relevant topic, particularly due to the universally high incidence of delirium. The methodology appears to be suitable and interesting; however, the authors' assertion that “no reviews have identified and mapped the available evidence on interventions that aim to help informal caregivers identify and/or manage delirium in an older person at home.” requires further clarification. For illustrative examples, please refer to the attached articles.

Young, J., Inouye, S. K., & Marcantonio, E. R. (2015). Delirium in older people. BMJ (Clinical research ed.), 350, h279.

We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

Patnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, Lin JS. Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Feb. Report No.: 19-05257-EF-1. PMID: 32129963.

Caregiver and caregiver-patient dyad interventions including psychoeducation for the caregiver and care and case management interventions, reported in 88 trials (n=14,880), resulted in a consistent benefit on caregiver burden and depression outcomes. Effect sizes were mostly small, however, and were of unclear clinical significance. Little harm was evident in the few nonpharmacologic intervention trials that reported harms.

Response: We were unable to locate the recommended article by Young et al (2015). We believe that there may have been an error in the citation. However, we found the passage in a review article by Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: advances in diagnosis and treatment. Jama. 2017 Sep 26;318(12):1161-74.The Oh et al, 2017 review article restricted studies to RCTs which would have precluded the retrieval of descriptive studies which our review attempts to overcome. Also, the review article restricted studies to those published in English in the 6-year period prior to 2017 – which are major limitations given that delirium is a global issue and there is likely untapped knowledge published in other languages that could enhance understanding of how to help caregivers detect and manage delirium. Lastly, this review article was not focused on studies aiming to help informal caregivers detect and manage delirium. Consequently, this lack of focus likely precluded finding this body of knowledge.

Thank you for drawing our attention to the Patnode et al (2020) review. However, the review questions and findings pertained to dementia and mild cognitive impairment, not delirium. Here is a passage that provides evidence of this (page 26): “We identified 224 trials representing more than 50,000 patients and or caregivers and three cohort studies with more than 190,000 patients that address the treatment or management of MCI or mild to moderate dementia”.

Reviewer 2

Comment: Your introduction is written very much from the perspective of interventions that informal carers may continue at home, after a delirium in hospital. However, you also state that you will include papers for interventions commenced at home, where a person has developed delirium but not been admitted to hospital. I think the latter is potentially a very interesting area to explore, as interventions by informal carers may prevent hospital admission, and thus worsening of delirium. If you wish to include this scenario in your review, I suggest reframing your introduction.

Response: We have reframed the introduction by providing more information about the prevalence of delirium in the community-dwelling non-hospital population and its increasing prevalence with advancing age. We also explain that delirium often occurs at the onset of an older person’s acute illness or exacerbation of a chronic illness which may occur at home. We propose that caregivers need to be aware of the signs of delirium so that they can seek medical attention from their primary care providers which may prevent hospital admission and the worsening of delirium.

Comment: In your introduction you write that there have been no reviews conducted on this topic but then say in an initial search you identified four studies which had not been included in previous reviews. Please clarify what these previous reviews were on, as it is not clear.

Response: We now clarify that this search identified four unique articles that were not included in the four prior reviews that included studies conducted with the caregivers of older adults at home.

Comment: In outcomes (1) I would also include carers’ burden or stress, as this is likely to be a barrier to implementation of such interventions.

Response: We plan to synthesize the evidence on all caregiver outcomes including burden or stress. We have clarified this by including burden and stress as examples in the types of outcomes that may possibly be reported in studies.

a) What outcomes have been examined (e.g., improvement in caregivers’ knowledge of delirium, ability to recognize delirium, ability to manage delirium, burden, and stress)?

Comment: In outcomes (3) I would also include a question about what the characteristics of the caregivers were, if reported. i.e. is the intervention only feasible if the informal caregiver lives with the patient. Do they need a certain level of literacy / digital literacy.

Response: In the section on review questions, we now include:

4. What were the characteristics of the caregivers that were included in the studies?

a) What were the living arrangements of the caregivers (e.g., living with the patient)?

b) What was the level of literacy of the caregivers (e.g., health and digital literacy, reading level)?

We opted not to locate this question in the outcomes to ensure conceptual clarity.

Comment: Types of sources – this needs a little clarification and would read better if split up into individual statements, rather than use of multiple semicolons. You state that eligibility will be confirmed when the paper cites an intervention reported in an effectiveness study or the included effectiveness study cites the paper as providing additional information about the intervention, or when the study author(s) confirm that the paper describes the intervention you will first search for any study which evaluates an intervention and then search for studies or grey literature which describes the intervention. Does the citation requirement refer just to the grey literature or also to qualitative studies as well? This will clearly narrow your inclusion criteria if so. Please then justify this in your methods.

Response: We have removed the semi-colon and have split the sentence up to enhance its readability. There is no citation requirement. We now number the criteria so that readers can clearly see that any one criterion can be met for the paper to be eligible. We now state “The eligibility of these descriptive papers will be confirmed when 1) the paper cites an intervention reported in an effectiveness study, 2) the included effectiveness study cites the paper as providing additional information about the intervention, or 3) the study author(s) confirm that the paper describes the intervention.

Comment: Please describe where data will be available when the study is complete

Response: We now explain that the data will be available from the first author upon request.

Attachment Submitted filename: Delirium SR_Response to Reviewers_30_july2024.docx

10.1371/journal.pone.0308886.r003
Decision Letter 1
Curiati Pedro Kallas Academic Editor
© 2024 Pedro Kallas Curiati
2024
Pedro Kallas Curiati
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
1 Aug 2024

Non-pharmacological delirium detection and management interventions for informal caregivers of older people at home: a scoping review protocol

PONE-D-24-24285R1

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Reviewers' comments:

10.1371/journal.pone.0308886.r004
Acceptance letter
Curiati Pedro Kallas Academic Editor
© 2024 Pedro Kallas Curiati
2024
Pedro Kallas Curiati
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
12 Sep 2024

PONE-D-24-24285R1

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References

1 American Psychiatric Association D-TF. Diagnostic and statistical manual of mental disorders: DSM-5™ 5th ed: American Psychiatric Publishing, Inc.; 2013.
2 Marcantonio ER . Delirium in Hospitalized Older Adults. N Engl J Med. 2017 Oct 12;377 (15 ):1456–66. doi: 10.1056/NEJMcp1605501 29020579
3 Wilson JE , Mart MF , Cunningham C et al . Delirium. Nature Reviews Disease Primers. 2020 2020/11/12;6 (1 ):90. doi: 10.1038/s41572-020-00223-4 33184265
4 de Lange E , Verhaak PF , van der Meer K . Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. Int J Geriatr Psychiatry. 2013 Feb;28 (2 ):127–34. doi: 10.1002/gps.3814 22513757
5 Mathillas J , Olofsson B , Lövheim H et al . Thirty-day prevalence of delirium among very old people: a population-based study of very old people living at home and in institutions. Arch Gerontol Geriatr. 2013 Nov-Dec;57 (3 ):298–304. doi: 10.1016/j.archger.2013.04.012 23711428
6 Gibb K , Seeley A , Quinn T et al . The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Age Ageing. 2020 Apr 27;49 (3 ):352–60. doi: 10.1093/ageing/afaa040 32239173
7 Yam KK , Shea YF , Chan TC et al . Prevalence and risk factors of delirium and subsyndromal delirium in Chinese older adults. Geriatr Gerontol Int. 2018 Dec;18 (12 ):1625–8. doi: 10.1111/ggi.13545 30311332
8 Pereira JV , Aung Thein MZ , Nitchingham A et al . Delirium in older adults is associated with development of new dementia: a systematic review and meta-analysis. International journal of geriatric psychiatry. 2021 2021 . doi: 10.1002/gps.5508 33638566
9 Whitby J , Nitchingham A , Caplan G et al . Persistent delirium in older hospital patients: an updated systematic review and meta-analysis. Delirium (Bielef). 2022 Aug 9;1 :36822. doi: 10.56392/001c.36822 36936539
10 Cole MG , McCusker J , Bailey R et al . Partial and no recovery from delirium after hospital discharge predict increased adverse events. Age and Ageing. 2016;46 (1 ):90–5.
11 Shrestha P , Fick DM . Family caregiver’s experience of caring for an older adult with delirium: A systematic review. International journal of older people nursing. 2020 2020;15 (4 ):e12321. doi: 10.1111/opn.12321 32374518
12 Kalish VB , Gillham JE , Unwin BK . Delirium in older persons: evaluation and management. Am Fam Physician. 2014 Aug 1;90 (3 ):150–8. 25077720
13 Lipowski ZJ . Delirium: acute confusional states. New York: Oxford Press; 1990.
14 Hayhurst CJ , Marra A , Han JH et al . Association of Hypoactive and Hyperactive Delirium With Cognitive Function After Critical Illness. Crit Care Med. 2020 Jun;48 (6 ):e480–e8. doi: 10.1097/CCM.0000000000004313 32317589
15 Bull MJ , Boaz L , Jermé M . Educating Family Caregivers for Older Adults About Delirium: A Systematic Review. Worldviews on evidence-based nursing / Sigma Theta Tau International, Honor Society of Nursing. 2016 2016;13 (3 ):232–40. doi: 10.1111/wvn.12154 26970229
16 Lange S , Mędrzycka-Dąbrowska W , Friganovic A et al . Non-Pharmacological Nursing Interventions to Prevent Delirium in ICU Patients-An Umbrella Review with Implications for Evidence-Based Practice. J Pers Med. 2022 May 7;12 (5 ). doi: 10.3390/jpm12050760 35629183
17 Pabón-Martínez BA , Rodríguez-Pulido LI , Henao-Castaño AM . The family in preventing delirium in the intensive care unit: Scoping review. Enfermeria intensiva. 2022 2022 . doi: 10.1016/j.enfie.2021.01.003 35144905
18 Lin L , Peng Y , Zhang H et al . Family-centred care interventions to reduce the delirium prevalence in critically ill patients: A systematic review and meta-analysis. Nursing open. 2022 2022 . doi: 10.1002/nop2.1214 35434971
19 McKenzie J , Joy A . Family intervention improves outcomes for patients with delirium: Systematic review and meta-analysis. Australasian journal on ageing. 2020 2020;39 (1 ):21–30. doi: 10.1111/ajag.12688 31250961
20 Qin M , Gao Y , Guo S et al . Family intervention for delirium for patients in the intensive care unit: A systematic meta-analysis. Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia. 2022 2022;96 :114–9. doi: 10.1016/j.jocn.2021.11.011 34838428
21 Zhou C , Wang H , Wang L et al . Diagnostic accuracy of the Family Confusion Assessment Method for delirium detection: A systematic review and meta-analysis. J Am Geriatr Soc. 2023 Nov 29. doi: 10.1111/jgs.18692 38018490
22 Carbone MK , Gugliucci MR . Delirium and the Family Caregiver: The Need for Evidence-based Education Interventions. Gerontologist. 2015 Jun;55 (3 ):345–52. doi: 10.1093/geront/gnu035 24847844
23 Lee J , Yeom I , Yoo S et al . Educational intervention for family caregivers of older adults with delirium: An integrative review. Journal of clinical nursing. 2023 2023. doi: 10.1111/jocn.16816 37370251
24 Hariohm K , Jeyanthi S , Kumar JS et al . Description of interventions is under-reported in physical therapy clinical trials. Brazilian Journal of Physical Therapy. 2017 2017/07/01/;21 (4 ):281–6. doi: 10.1016/j.bjpt.2017.05.006 28579012
25 Hoffmann TC , Erueti C , Glasziou PP . Poor description of non-pharmacological interventions: analysis of consecutive sample of randomised trials. Bmj. 2013 Sep 10;347 :f3755. doi: 10.1136/bmj.f3755 24021722
26 Fox MT , Sidani S , Persaud M et al . Acute care for elders components of acute geriatric unit care: systematic descriptive review. J Am Geriatr Soc. 2013 Jun;61 (6 ):939–46. doi: 10.1111/jgs.12282 23692509
27 Hoffmann TC , Glasziou PP , Boutron I et al . Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. Bmj. 2014 Mar 7;348 :g1687. doi: 10.1136/bmj.g1687 24609605
28 World Health Organization. Ageing and Health. 2022 Available at https://www.who.int/news-room/fact-sheets/detail/ageing-and-health Accessed January 29 2024
29 Bramer WM , Rethlefsen ML , Kleijnen J et al . Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev. 2017 Dec 6;6 (1 ):245. doi: 10.1186/s13643-017-0644-y 29208034
30 Peters MDJ , Godfrey C , McInerney P et al . Scoping Reviews. In: Aromataris E , Munn Z , editors. JBI Manual for Evidence Synthesis 2020.
31 Tricco AC , Lillie E , Zarin W et al . PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018 Oct 2;169 (7 ):467–73. doi: 10.7326/M18-0850 30178033
32 Munn Z , Pollock D , Khalil H et al . What are scoping reviews? Providing a formal definition of scoping reviews as a type of evidence synthesis. JBI Evid Synth. 2022 Apr 1;20 (4 ):950–2. doi: 10.11124/JBIES-21-00483 35249995
33 van Munster BC , de Rooij SE . Delirium: a synthesis of current knowledge. Clin Med (Lond). 2014 Apr;14 (2 ):192–5. doi: 10.7861/clinmedicine.14-2-192 24715133
34 Rethlefsen ML , Kirtley S , Waffenschmidt S et al . PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews. Syst Rev. 2021 Jan 26;10 (1 ):39. doi: 10.1186/s13643-020-01542-z 33499930
35 McGowan J , Sampson M , Salzwedel DM et al . PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol. 2016 Jul;75 :40–6.27005575
36 Piasecki J , Waligora M , Dranseika V . Google Search as an Additional Source in Systematic Reviews. Sci Eng Ethics. 2018 Apr;24 (2 ):809–10. doi: 10.1007/s11948-017-0010-4 29249022
37 Page MJ , McKenzie JE , Bossuyt PM et al . The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372 :n71. doi: 10.1136/bmj.n71 33782057
38 Pollock D , Peters MDJ , Khalil H et al . Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth. 2023 Mar 1;21 (3 ):520–32. doi: 10.11124/JBIES-22-00123 36081365
