February 13, 2019

EJRC - A systematic review and meta-analysis

The use of non-pharmacological interventions for reduction of delirium incidence and duration in critically ill patients is currently not supported by evidence


Up to 80% of mechanically ventilated ICU patients may get delirium, and this can lead to longer duration of mechanical ventilation, longer ICU stay, cognitive impairments, long-term psychological problems, and increased mortality.  Delirium is often managed medically, but non-pharmacological interventions such as early mobility, bright light therapy, and family voice reorientation are also used.

The aim of the review was to evaluate the effect of non-pharmacological interventions versus standard care on delirium in critically ill patients.

The primary outcomes were incidence and duration of delirium. Secondary outcomes were hospital mortality, sleep quality, cognitive functions, quality of life and adverse events.

The Cochrane review methodology was used to search MEDLINE, EMBASE, CINAHL, Web of Science, PsykINFO, AMED and Cochrane, and the inclusion criterion was RCTs evaluating effectiveness of non-pharmacological interventions targeting prevention or treatment of delirium. Meta-analysis was performed if outcomes from two or more studies with similar interventions were available.

A total of 15 studies were included, representing 2,812 adult participants. Nine of the studies reported incidence and eight studies duration of delirium. Regarding incidence, pooled data from four studies of bright light therapy did not show any effect; neither did seven studies of individual interventions such as using ear plugs or protocolised sedation with a daily wake-up call.

Regarding duration, pooled data from two studies using physio therapy showed no effect. One study evaluating family voice reorientation showed a favourable effect, five studies with other interventions showed no effect. Likewise, no effects were found for the secondary outcomes.  For all included studies, the certainty of the evidence was low or very low.

Delirium probably has multiple causes, and therefore multicomponent interventions may be the way forward. This should be the target for future research.



Strengths of the study include high quality screening, data extraction and quality assessment independently by two reviewers.

Limitations include considerable heterogeneity in interventions and outcome measures in the included studies.



So far, the evidence base for using either single or multicomponent non-pharmacological interventions for reduction of delirium in the ICU is limited and of low quality.


This article review was prepared and submitted by Associate Professor Hanne Irene Jensen, member of the ESICM Ethics Section on behalf of the ESICM Journal Review Club.


1) Bannon L et al. The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis. Intensive Care med 2019; 45:1-12


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