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The Impact of Environmental Risk Factors on Delirium and Benefits of Noise and Light Modifications

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The Impact of Environmental Risk Factors on Delirium and Benefits of Noise and Light Modifications F1000Research 2020, 9:1183 Last updated: 22 JUL 2021 SYSTEMATIC REVIEW The impact of environmental risk factors on delirium and benefits of noise and light modifications: a scoping review [version 1; peer review: 2 approved with reservations] Haleh Hashemighouchani 1,2, Julie Cupka1,2, Jessica Lipori1,2, Matthew M. Ruppert1,2, Elizabeth Ingersent1,2, Tezcan Ozrazgat-Baslanti1,2, Parisa Rashidi 2,3, Azra Bihorac 1,2 1Department of Medicine, University of Florida, Gainesville, Florida, 32608, USA 2Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, 32608, USA 3Department of Biomedical Engineering, University of Florida, Gainesville, Florida, 32608, USA v1 First published: 29 Sep 2020, 9:1183 Open Peer Review https://doi.org/10.12688/f1000research.25901.1 Latest published: 29 Sep 2020, 9:1183 https://doi.org/10.12688/f1000research.25901.1 Reviewer Status Invited Reviewers Abstract Background: To explore existing literature on the association 1 2 between environmental risk factors and delirium, and to investigate the effectiveness of environmental modifications on prevention or version 1 management of delirium. 29 Sep 2020 report report Methods: This is a scoping review of peer-reviewed studies in PubMed and the reference lists of reviewed articles. Observational studies 1. Ari Ercole , University of Cambridge, reporting the effect of noise, light, and circadian rhythm on delirium and interventional studies assessing delirium in modified Cambridge, UK environments were reviewed. Results: 37 studies were included, 21 of which evaluated the impact of 2. Annmarie Hosie , The University of Notre environment on delirium and 16 studied possible solutions to mitigate Dame Australia, School of Nursing and those impacts. Mixed findings of the reviewed studies yielded Midwifery, Darlinghurst, Australia inconclusive results; a clearly delineated association between high noise levels, abnormal amounts of light exposure, and sleep St Vincent's Health Network , Sydney, disruption with delirium could not be established. The environmental Australia interventions targeted reducing noise exposure, improving daytime and mitigating night-time light exposure to follow circadian rhythm, Any reports and responses or comments on the and promoting sleep. The overall evidence supporting effectiveness of article can be found at the end of the article. environmental interventions was also of a low confidence; however, quiet-time protocols, earplugs, and bright light therapy showed a benefit for prevention or management of delirium. Conclusions: Environmental modifications are non-invasive, risk-free, and low-cost strategies that may be beneficial in preventing and managing delirium, especially when used as part of a multi- component plan. However, given the limited evidence-based conclusions, further high-quality and larger studies focusing on environmental modifications and delirium outcomes are strongly Page 1 of 42 F1000Research 2020, 9:1183 Last updated: 22 JUL 2021 recommended. Keywords delirium, environmental intervention, noise, light, circadian, scoping review Corresponding author: Azra Bihorac ([email protected]) Author roles: Hashemighouchani H: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Cupka J: Data Curation, Formal Analysis, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Lipori J: Formal Analysis, Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Ruppert MM: Visualization, Writing – Review & Editing; Ingersent E: Investigation, Writing – Review & Editing; Ozrazgat-Baslanti T: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Resources, Supervision, Validation, Visualization, Writing – Review & Editing; Rashidi P: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing; Bihorac A: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Competing interests: No competing interests were disclosed. Grant information: AB, TOB, and PR were supported by the National Institute of General Medical Sciences [R01 GM110240]. AB and TOB were supported by a Sepsis and Critical Illness Research Center Award from the National Institute of General Medical Sciences [P50 GM- 111152]. AB and MR were supported by Davis Foundation – University of Florida. PR was supported by the National Science Foundation CAREER [1750192] and National Institute of Health/National Institute of Biomedical Imaging and Bioengineering [1R21EB027344] grants. TOB received a grant supported by the National Center for Advancing Translational Sciences of the National Institutes of Health [UL1TR001427] and received a grant from Gatorade Trust, University of Florida [127900]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2020 Hashemighouchani H et al. 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 work is properly cited. How to cite this article: Hashemighouchani H, Cupka J, Lipori J et al. The impact of environmental risk factors on delirium and benefits of noise and light modifications: a scoping review [version 1; peer review: 2 approved with reservations] F1000Research 2020, 9:1183 https://doi.org/10.12688/f1000research.25901.1 First published: 29 Sep 2020, 9:1183 https://doi.org/10.12688/f1000research.25901.1 Page 2 of 42 F1000Research 2020, 9:1183 Last updated: 22 JUL 2021 Introduction environmental noise, light, and disrupted circadian rhythms Delirium is a multifactorial, acute, confusional state charac- affect delirium?” and “How do existing environmental inter- terized by disturbance of consciousness and cognition; it is ventions such as noise reduction, light modifications, and sleep particularly common in the intensive care unit (ICU) with inci- promotion help prevent or manage delirium?” dence of 19 to 87% with higher rates in mechanically ven- tilated patients1–3. ICU delirium is associated with adverse Methods outcomes, including prolonged mechanical ventilation, This review was conducted according to the methods of increased risk of long-term cognitive dysfunction, prolonged Arksey and O’Malley26 and Levac et al.27, and reported follow- hospitalization, higher cost of care, and increased mortality4–7. ing the Preferred Reporting Items for Systematic Reviews and While the pathophysiology of delirium is poorly understood, Meta-Analyses (PRISMA) Extension for Scoping Reviews there are multiple factors associated with increased risk of (extended data)28,29. The aim of this review is to map existing delirium including age, education, pre-existing conditions such literature identifying modifiable environmental risk factors for as hypertension, neurological or psychological disorders, illness delirium, and assess the role of non-pharmacological noise, severity, Acute Physiology and Chronic Health Evaluation II light, and circadian rhythm interventions for delirium prevention (APACHE II) score, sensory impairment, and use of analge- and management. sics, sedatives, and polypharmacy8–12. The ICU environment may be a modifiable risk factor for delirium. Decreased natural Search strategy and data charting daylight, night-time light exposure, excessive noise, immo- Studies were identified by searching PubMed for articles relat- bilization, and isolation are potential delirium risk factors in ing to our questions. Search results were restricted to the English ICU13–15. language and peer-reviewed studies, with no restriction on year of publication. The search was last executed on November 20, ICU noise levels are above the World Health Organization’s 2019 in order to cover recent publications. Search queries (WHO) recommendations, which suggest 30 A-weighted deci- were generated using the following combination of keywords: bels (dBA) for background noise, a maximum of 35 dBA for [“delirium” AND “noise OR sound OR light OR circadian”]. treatment and observation areas, and a maximum of 40 dBA The search was applied with no field tags to maximize results. at night16–18. Patients interviewed post-ICU discharge report noise as an overall stressor and contributor to loss of sleep19,20. After compiling research results and removing duplicates, Another common environmental disturbance for ICUs is non- HH and JL screened titles and abstracts to retrieve articles for cycling light sources. Disruptions in normal amounts of blue eligibility. Articles on pediatric populations, animal subjects, case light (460–480 nm) hitting the retina affect neurological proc- reports, or where the full-text was unavailable were excluded. esses responsible for melatonin release15. Constant delivery of Additional studies were identified through hand-searches and these wavelengths may cause abnormal suppression of melatonin, searching the reference list of reviewed articles. Disagree- altering circadian cycles15. Although the ICU does not lend itself ments on study eligibility were resolved by involving a third to quietude, it is feasible to employ noise-reducing techniques reviewer and a discussion between the
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