The Prevention Program for Alzheimer's Related Delirium (PREPARED) Trial

Dementia Clinical Trial

— PREPARED  

Official title:

The Prevention Program for Alzheimer's Related Delirium (PREPARED) Cluster Randomized Trial

Clinical Trial Details — Status: Suspended

Administrative data

• NCT number: NCT03718156
• Other study ID #: PT 71435
• Status: Suspended
• Phase: N/A
• Start date: June 23, 2018
• Est. completion date: June 2026

Study information

• Verified date: July 2022
• Source: McGill University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

By the year 2038, over a million Canadians are expected to have Alzheimer's disease, a type of dementia. Dementia increases the risk of nursing home placement among the elderly more than fivefold. Given the exceptionally vulnerable nature of this patient population, there is a pressing need to ensure that the clinical care they receive is evidence-based, tailored specifically for them, and meeting the high standards of quality that would be expected in any other health-care setting. Delirium is a sudden and severe change in brain function that can cause a person to appear confused or disoriented, have memory loss, and have difficulties maintaining focus. It is an urgent care issue facing elderly patients residing in nursing homes, or long-term care (LTC) facilities. Delirium is a significant cause of illness and mortality, affecting between 10%-89% of LTC patients, but little research has focused on delirium prevention in the LTC setting. This study will assess the effectiveness of a LTC multicomponent delirium prevention program (PREPARED Trial intervention). The PREPARED Trial intervention is an intervention provided to nursing staff working in LTC facilities that consists of four components: a decision tree, an instruction manual, a training package, and a toolkit. The feasibility and acceptability of the PREPARED Trial intervention has already been successfully demonstrated; however, a thorough and well-designed large scale study is needed in order to confirm its ability to reduce delirium among LTC residents. In this study, approximately 40-50 LTC facilities will be randomized to either receive the PREPARED Trial intervention or to receive usual care. At the end of the 4-year study period, the investigators will be able to demonstrate the degree to which the PREPARED Trial intervention reduces: 1) the number of new cases of delirium; 2) delirium severity; and 3) the duration of delirium episodes. This study will provide the blueprint of a program that can be transferable to LTC facilities across Canada.

Description:

Overall Goal: To reduce the incidence, severity, duration, and frequency of delirium episodes in cognitively impaired long-term care (LTC) residents at high risk for delirium.

Background: Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and LTC settings. Prevention, founded on a thorough understanding of associated risk factors, is the best approach for dealing with delirium. Several successful multicomponent interventions have been developed to reduce delirium incidence in the acute care setting (30%-73% reduction) by intervening on identified modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTC. As such, co-investigators within the study team employed an integrated knowledge translation strategy to develop a LTC multicomponent delirium prevention program (PREPARED Trial intervention). The feasibility and acceptability of this program has been demonstrated using a participatory approach in two Quebec LTC facilities (LTCFs), and the program has received recognition by the scientific community. Given its large expected impact and high knowledge translation potential, a thorough and well-designed large-scale evaluation is urgently needed in order to demonstrate the effectiveness of the multicomponent delirium prevention program in preventing delirium among high-risk LTC residents.

Primary Objective: To assess efficacy of the PREPARED Trial intervention in reducing delirium incidence, and delirium episode severity, duration, and frequency among cognitively impaired, high-risk LTC residents.

Secondary Objectives: To compare the effect of the PREPARED Trial intervention to that of usual care on the incidence of falls among cognitively impaired LTC residents, to estimate the association between medication use and delirium incidence in LTCFs, to estimate if there is an effect modification by motor subtype of delirium or by dementia subtype, and to measure the prevalence of delirium in participating institutions.

Tertiary Objectives: To compare the effect of the PREPARED Trial intervention on other health outcomes, including: changes in functional autonomy or social engagement, the number of transfers to acute care, consultations with healthcare providers, and mortality rates.

Methods: This 4-year cluster randomized study will involve nursing staff and residents in 40-50 public and semi-private LTC facilities in Quebec, Canada. Institutions within all 5 of the Montreal island Integrated University Health and Social Services networks (CIUSSS) and one private provincial network are currently participating. Approximately 900 LTC residents will be enrolled in the study and followed for 18 weeks only if they are at high risk of delirium and are delirium-free at baseline. The PREPARED Trial intervention is a program consisting of four components: a decision tree, an instruction manual, a training package and a toolkit. Primary study outcomes such as delirium incidence (measured by the Confusion Assessment Method), delirium severity (measured by the Delirium Index), and level of adherence to the PREPARED Trial protocol will be assessed weekly. Functional autonomy levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and institutional transfers will be collected for the duration of the follow-up period. For primary analysis, hazard ratios will be modeled using Cox regression to compare the effect of the PREPARED Trial intervention to that of usual care on the time to first delirium episode. Clustering effects will be taken into account using frailty models, an extension of Cox regression for the addition of random effects.

Expected Outcomes and Significance: This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale. In addition to reducing delirium in this frail population, deliverables include validation of this prevention program, as well as the transferring of its components (including bilingual video training modules for LTC staff) to relevant knowledge users across Canada.

Recruitment information / eligibility

• Status: Suspended
• Enrollment: 800
• Est. completion date: June 2026
• Est. primary completion date: June 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 65 Years and older

Eligibility

Inclusion Criteria:

• has dementia and/or cognitive impairment (as determined by discussions with the nursing staff and chart abstraction);

• a minimum length of stay in the LTC institution of at least two weeks prior to the start of the baseline assessments;

• at high risk of delirium, as indicated by a score of 3 or higher on a validated 5-item delirium risk screening tool;

• delirium-free at baseline, as assessed by the Confusion Assessment Method (CAM), the Delirium Index (DI) and a brief chart review over a screening period of two consecutive weeks.

Exclusion Criteria:

• unable to communicate verbally in English or French (as determined by either the nursing staff or two consecutive 0-score administrations of the composite cognitive interview at screening);

• has a history of specific psychiatric conditions (bipolar disorder, depression with signs of psychosis, and psychotic disorders) or intellectual disability;

• is receiving comfort/end-of-life care.

Related Conditions & MeSH terms

• Delirium
• Dementia

Intervention

Other:
• PREPARED Trial Intervention
Nursing staff members will be trained to adjust the therapeutic nursing plans (TNP) for residents enrolled in the study, as follows: 1) by providing optimal stimulation (surveying the use of eyeglasses and hearing aids, the room lighting and space organization; orienting the resident to time and space; and stimulating the resident using familiar objects, photos, and life histories); and 2) by assessing the presence of 4 modifiable delirium risk factors (antipsychotic use, sensory impairment, restraint use, and dehydration) and taking specific actions once a given risk factor is identified. For instance, if physical restraints are used, the TNP will require that they are to be removed during care when a caregiver is present (nail care, feeding, and wound care).

Locations

Country	Name	City	State
Canada	Association des établissements privés conventionnés	Montréal
Canada	Integrated University Health and Social Services Centre for East Montreal	Montréal
Canada	Integrated University Health and Social Services Centre for North Montreal	Montréal
Canada	Integrated University Health and Social Services Centre for South-Central Montreal	Montréal
Canada	Integrated University Health and Social Services Centre for West Montreal	Montréal
Canada	Integrated University Health and Social Services Centre for West-Central Montreal	Montréal

Sponsors (1)

Lead Sponsor	Collaborator
McGill University

Country where clinical trial is conducted

Canada, 

References & Publications (22)

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Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):375-80. doi: 10.7326/0003-4819-158-5-201303051-00003. Review. — View Citation

Rockwood K. Making delirium prevention acceptable in nursing homes. J Am Med Dir Assoc. 2014 Jan;15(1):6-7. doi: 10.1016/j.jamda.2013.09.002. Epub 2013 Oct 8. — View Citation

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Vidán MT, Sánchez E, Alonso M, Montero B, Ortiz J, Serra JA. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc. 2009 Nov;57(11):2029-36. doi: 10.1111/j.1532-5415.2009.02485.x. Epub 2009 Sep 15. — View Citation

Voyer P, McCusker J, Cole MG, Monette J, Champoux N, Vu M, Ciampi A, Sanche S, Richard S, de Raad M. Feasibility and acceptability of a delirium prevention program for cognitively impaired long term care residents: a participatory approach. J Am Med Dir Assoc. 2014 Jan;15(1):77.e1-9. doi: 10.1016/j.jamda.2013.08.013. Epub 2013 Oct 2. — View Citation

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* Note: There are 22 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Incidence of delirium	Confusion Assessment Method (CAM) scores	over the 18 week follow-up period
Primary	Delirium severity	Delirium Index scores (0-21)	over the 18 week follow-up period
Primary	Delirium episode duration	the total number of days that a given resident experiences active episode(s) of delirium	over the 18 week follow-up period
Primary	Number of delirium episodes	count of delirium episodes	over the 18 week follow-up period
Secondary	Delirium motoric subtype	Delirium Motor Subtype Scale scores	over the 18 week follow-up period
Secondary	Number of falls	count of falls and fall-related injuries, as documented in medical charts	over the 18 week follow-up period
Secondary	Time to first fall	days to first reported fall	over the 18 week follow-up period
Secondary	Change in functional autonomy	Barthel Index (Shah version) scores	over the study period (18 weeks)
Secondary	Change in cognitive functioning	Hierarchic Dementia Scale scores	over the study period (18 weeks)
Secondary	Change in level of social engagement	Revised Index of Social Engagement in Long-Term Care Facilities scores	over the study period (18 weeks)