Award Title: Developing a multi-component intervention for the prevention and management of delirium in hospice in-patient units: a targeted behaviour change approach.
Funder: Department of Health and Social Care

Abstract: Background Delirium is a distressing condition which is commonly experienced by patients in hospices. Prevalence in palliative care in-patient settings ranges from 13 to 42% on admission and 58 to 88% in the last weeks of life2. It is characterised by disturbances in attention, awareness and cognition which have a rapid onset and fluctuating course3. Delirium is associated with serious adverse outcomes and for hospice patients it can result in the loss of decision-making capacity and prevent meaningful communication at a critical time4, 5. Multiple risk factors have been identified for delirium in patients admitted to hospitals (as distinct from hospices) including sleep deprivation, dehydration and use of psychoactive drugs6, 7. There is strong evidence that the use of multi-component interventions (MCIs) which address modifiable risk factors in hospitalised patients can significantly reduce new onset delirium 8. Strategies to address risk factors are used both to prevent delirium and to treat established episodes. People who have been admitted to a hospice are at particular risk of delirium because of the advanced nature of their illness, but there is little evidence on effective prevention and management of delirium in this setting. The risk factors for delirium among hospice patients may vary from those in other settings and different approaches to its prevention and management may be appropriate for patients nearing the end of life.5, 9 There is a need for research to develop and test an intervention to prevent and manage delirium which is tailored to the hospice setting. Aim To develop a multi-component intervention for the prevention and management of delirium in hospice in-patient units. Plan of Investigation Workstream 1: To identify risk factors for delirium and strategies for addressing delirium that are relevant to palliative care. A systematic review of risk factors for delirium in palliative care will be conducted. An expert panel of palliative care and delirium academics and clinicians will draw upon evidence and clinical guidelines to agree a list of risk factors for delirium, and a list of staff behaviours to address delirium, that are relevant to hospices. Workstream 2: To explore hospice staff's current practice in addressing delirium and barriers and enablers to improving practice. Qualitative observations and interviews will be conducted in two hospices. The qualitative data collection and analysis will be structured using a behaviour change framework10, and the lists of relevant factors identified by the expert panel. Workstream 3: To design a targeted behaviour change intervention to improve care of delirium by hospice staff. Drawing upon the qualitative findings, the expert panel will agree target behaviours of hospice staff that are priorities for change to improve delirium care. A modified version of nominal group technique will be used to reach consensus. The 'Behaviour Change Wheel'10 framework will be used to support the design of an intervention to prevent and manage delirium in hospices which focuses on these target behaviours. A hospice working group will be engaged in this process. Workstream 4: To implement components of the intervention and evaluate their feasibility and acceptability. Components of the intervention will be implemented and a process evaluation will be carried out with a focus on feasibility and acceptability. The intervention design will be refined on the basis of this. An intervention manual and protocol will be produced for use in a future pilot study and eventual testing of the intervention's effectiveness in a cluster randomised controlled trial. Potential benefits of this research This project will make significant progress towards improving the prevention and management of delirium in hospice patients and reducing associated adverse outcomes, including the distress it causes to patients, their families and staff.

Lay Abstract: Improving care of delirium in hospices What is the problem to be addressed? Delirium is a condition in which people become confused over a short time due to causes including infection, medication, dehydration and sleep problems. Several of these may occur at the same time. People with delirium may find it hard to think clearly, pay attention and remember things. They may become restless and agitated or withdrawn and sleepy. They may lose the ability to make decisions about their care and to have meaningful communication with family and friends. Delirium is distressing for patients, their families and people caring for them. People who have been admitted to a hospice are at particular risk of delirium because of the advanced nature of their illness, but little is known about how to prevent or manage this frightening condition in hospices. There is strong evidence that delirium can be prevented in hospitals using 'multi-component interventions' aimed at the potential causes of delirium. These include: ensuring patients have enough to drink; changes in routines to encourage good sleep patterns; reviewing medication and investigating infections. This approach may be useful in hospices, but there may also be important differences in how delirium should be cared for. For example, the understanding and knowledge of staff; patient risk factors and approaches to treatment may differ from those in hospitals or other settings. Delirium is very common among people admitted to hospices and its effect on patient's ability to communicate and make decisions may be particularly distressing for patients and their loved ones at this critical time. It is important to develop an approach to preventing and managing delirium that is tailored to hospice care. Aim: To develop an approach to prevent people admitted to hospices from developing delirium and to improve the care of those who experience delirium. What will I do? Review previous research and guidelines to draw up a list of causes of delirium and of staff skills and behaviours that are important for delirium care in hospices. An expert panel of delirium and palliative care researchers and hospice staff will discuss and agree the list. Carry out a study in two hospices to observe the ways that hospice staff work to prevent and manage delirium. I will also interview staff members to explore their understanding of delirium care and what would help or hinder improvements in practice. The expert panel will use this information to prioritise a number of aspects of staff care which, if changed, should improve delirium care in hospices. Design an approach which will focus upon these target aspects of care (known as 'behaviours'), using a tool called 'The Behaviour Change Wheel' to find the best ways to help hospice staff change these behaviours. A hospice working group, including staff, patients and relatives, will work with me to develop the approach. Staff will try out these ways of working to check if they are practical to carry out and acceptable to staff and patients. Produce a manual which will describe this approach to improve delirium care in hospices. In future studies this could be put into practice to see if it makes hospice care better for patients and their families.I will involve patients and carers who have experience of palliative care or delirium throughout this project. They will advise on aims; study design; the research summary and other documents; sensitive approaches to carrying out research in hospices; developing the approach and sharing the results. The research results will be shared with many different people and groups including hospice patients and carers; researchers and health professionals working with delirium or in palliative care; health services and charities. This will involve publishing them in academic journals, newsletters and online and carrying out presentations, talks and workshops. I expect this project to be an important step forward in improving delirium prevention and care in hospices and reducing the difficulties and distress that delirium can cause patients and their families.

Research Activity Codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;7.2 END OF LIFE CARE;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: MENTAL HEALTH