nicheprogram.org • 2016 annual niche conference • care ...listening+for... · synthesizer...
Post on 24-Feb-2018
212 Views
Preview:
TRANSCRIPT
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum1
Music Intervention to Prevent Delirium Among Older
Patients Admitted to a Trauma Intensive Care Unit and a
Trauma Orthopedic Unit
Kari Johnson
PhD, RN, ACNS-BC, Hartford Scholar
Introduction
• Delirium is a neurobehavioral syndrome characterized by
alterations in consciousness, attention, cognition, and
perception.1,2
• Hospitalized older adults have the highest rate of delirium.3
• Age related changes in the brain that contribute to delirium:
o Neurotransmitter imbalance
o Inflammation
o Physiologic stressors.4,5
Significance
• Neurotransmitter Imbalance
o Age related changes in the brain alter neurotransmission.
o Neurotransmitters serotonin (5HT), dopamine (DA),
norepinephrine (NE), acetylcholine (ACh), and gamma
aminobutyric Acid (GABA) are involved in delirium.7
o Iatrogenic factors with medications (sedatives, hypnotics,
anticholinergics) contribute to delirium.4
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum2
Significance
• Inflammationo Age related changes:
o Low grade inflammation with chronic neurodegenerative
changes in the brain.7
oCauses a more severe CNS response increasing
pro-inflammatory cytokines at areas of existing
inflammation, resulting in delirium.9
Significance
• Stressor
o Stress hormones are released due to a stress response
from surgery, pain, trauma, and systemic inflammation,
causing and prolonging delirium.7, 10,11
o Hospitalized older adults experience acute stress from
sensory impairment, medications, immobilization, physical
restraints, noise stimuli, and sleep deprivation.6
Significance• Music:
o A non-pharmacologic approach for delirium prevention.
o Addresses pathophysiologic mechanisms that contribute to
delirium.4
o Music can regulate stress and emotions through reflexive
brainstem responses caused by slow tempo, low pitch, and
simple repetitive rhythms.13
o Reflexive brainstem responses found to alter physiological
responses include decreased systolic blood pressure (SBP),
heart rate (HR), and respiratory rate (RR).13-16
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum3
Purpose
• Evaluate the feasibility of a music intervention for
delirium prevention among older adults in a Trauma
Intensive Care Unit (TICU) and a Trauma Orthopedic
Unit (TOU).
Specific Aim 1
• Specific Aim 1: Examine acceptability, demand, and
implementation of a music intervention among older patients in a
TICU and TOU setting.
o 1a. Acceptability: Participant evaluation of intervention
protocol and delivery mechanisms.
o 1b. Demand: Participant attrition rates and dose of music
intervention sessions.
o 1c. Implementation: Index of Procedural Consistency.
Specific Aim 2
• Specific Aim 2: Evaluate effects of a music intervention in
decreasing physiologic parameters (SBP, DBP, HR, RR), and
delirium prevention among older patients.
o 2a. Music listening (ML) group will demonstrate a decrease
in SBP,DBP,HR, and RR compared with usual care (UC)
group.
o 2b. ML group will demonstrate less delirium post-admission
compared with UC group.
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum4
Environmental
Stimuli
Focal
Contextual
Management
of stimuli17
Coping
Process
Regulator
Cognator
Modes of
Adaptation
Physiologic
Mode
Roy Adaptation Model
Intervention Components of a Music InterventionTheory
of the Problem
Critical
Inputs
Process
Variables
Expected
Outcomes
Extraneous
Factors
Implementation
Issues
Neuro-
Transmitter
Imbalance
Inflammation
Physiologic
Stressor
Regulator:
ML
(1) Slow
tempo
(2) Simple
repetitive
rhythm
Cognator:
(1) Self
selected
music
Adaptive
Physiologic
Response to
Focal
Stimuli:
(1) SBP
(2) DBP
(3) HR
(4) RR
Adaptive
response:
Prevent
delirium
Noise
Stimuli
Bright
lights
Interruption
from care
ICU setting
intervention
Delivery
intervener
Research Design and Methods
• Design
o Randomized
o Sample
o N = 40 older adults
oML group (n = 20)
o UC group (n = 20)
• Setting
o TICU: 22 bed trauma intensive care unit
o TOU: 37 bed trauma orthopedic unit
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum5
Sample • Inclusion criteria:
o 55 years and older
o Oriented on admission
o Confusion Assessment Method (CAM-ICU)
negative on admission
o Hearing intact
o Provide consent
o Not intubated
Methods: Music Intervention Protocol
• Self-selection of music
o Slow tempo – 60-80 beats per minute
o Simple repetitive rhythm
• Delivered with iPod and headphones
• Dose: 60 minutes twice a day (2 p.m. and 8 p.m.)x 3
days
Music SelectionsStyle Selection Tape or CD Artist
Synthesizer Selection #1 Comfort Zone Steven Halpern
Harp Gnossienne #2 Fresh Impression Georgia Kelly
Piano Gigi #3 Nadia’s Theme Roger Williams
Orchestra Symphony #4 Beethoven Cleveland
Orchestra
Jazz When Joanna
Loved Me #5
Easy Living Paul Desmond
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum6
Variables and Measurement• Acceptability
o Intervention of Acceptability Questionnaire
• Demand
o Study attendance/Attrition rates
• Implementation
o Index of Procedural Consistency
• Physiologic Parameters
o SBP, DBP, HR, RR
• CAM-ICU score
Data Management and Analysis
• Specific Aim 1
o Means and SD for continuous variables
o Frequencies and percentages
• Specific Aim 2
o Descriptive statistics
o Repeated Measures ANOVA
o Post Hoc Analysis
o Pairwise Comparisons
Demographic Characteristics UC Group (n=20) ML Group (n=20) Total
Age : Range 58-87 58-86 58-87
Race: White Caucasian 16(80%) 18(90%) 34(85%)
Gender: Female 17(85%) 17(85%) 34(85%)
Widowed 8(40%) 9(45%) 17(42%)
Married 6(30%) 7(35%) 13(32%)
Adm. Dx. Respiratory 5(25%) 5(25%) 10(25%)
Adm. Dx. Gastro- intestinal 4(20%) 6(30%) 10(25%)
Adm. Dx. Cardiovascular 4(20%) 4(20%) 8(20%)
Adm. Dx. Bone 5(25%) 3(15%) 8(20%)
Medication: Analgesic 14(70%) 15(75%) 29(72.5%)
Medication: Cardiovascular 11(55%) 12(60%) 23(57.5%)
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum7
Results: Intervention of Acceptability Questionnaire
Variable n % Variable n % Variable n %
Overall ML was
helpful
ML helped with anxious
thoughts
Satisfied with number &
length of sessions
Strongly Agree 3 15 Strongly Agree 2 10 Agree 7 35
Agree 17 85 Agree 8 40 Disagree 11 55
ML helped me relax Would recommend ML
to others
Wearing headphones
was comfortable
Strongly Agree 2 10 Agree 14 74 Agree 12 60
Agree 18 90 Disagree 7 35
Satisfied with ML ML helped me feel
more like myself
Using ML equipment was
easy
Strongly Agree 2 10 Agree 7 35 Agree 10 50
Agree 18 90 Neutral 7 35 Disagree 5 25
____________________________________________________________
Means and Standard Deviations for ML in Minutes by Session
________________________________________________________
n Minimum Maximum Mean SD
________________________________________________________
D1T1 20 53.00 60.00 1.400 .8826
D1T2 18 35.00 60.00 1.056 .2357
D2T1 17 60.00 60.00 1.000 .0000
D2T2 14 30.00 60.00 1.286 1.069
D3T1 6 45.00 60.00 1.333 .8165
D3T2 4 40.00 60.00 2.250 2.500
______________________________________________
___________
Reasons For Missed Scheduled Doses
0 2 4 6 8 10 12 14 16 18
D1T1
D1T2
D2T1
D2T2
D3T1
D3T2
D1T1 D1T2 D2T1 D2T2 D3T1 D3T2
Family Visits 0 0 1 0 1 1
Medication Request 0 0 0 0 1 3
Procedures 0 0 0 2 1 1
Transfers 0 1 1 0 8 2
Discharge Planning 0 1 1 4 3 9
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum8
Results: Index of Procedural Consistency
D1T1 D2T2
Achieved Very Well 12(60%) Achieved Very Well 6(43%)
Achieved 4(20%) Achieved 5(36%)
D1T2 D3T1
Achieved Very Well 13(72%) Achieved Very Well 3(50%)
Achieved 1(6%) Achieved 2(33%)
D2T1 D3T2
Achieved Very Well 12(70%) Achieved Very Well 3(75%)
Achieved 4(24%) Achieved 1(25%)
Repeated Measures ANOVA for Variable D1T2SBPpreML and
D1T2SBPpostML
____________________________________________________
Variable df1 F p
____________________________________________________
D1T2SBPpreML
and D1T2SBPpostML 1 10.44 .003
____________________________________________________
__________________________________________________
Means and Standard Deviations for variables
D1T2SBPpreML and D1T2SBPpostML
________________________________________________
Variable M SD
_________________________________________________
D1T2SBPpreML 136.37 18.48
D1T2SBPpostML 132.71 17.80
_________________________________________________
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum9
130
131
132
133
134
135
136
137
D1SBPpre2 D1SBPpost2
Mean score of D1T2SBPpreML, D1T2SBPpost ML
Mean
_____________________________________________
Repeated Measures ANOVA for Heart Rate (HR) ML
_____________________________________________
HR ML df1 F p
_____________________________________________
D1T1HRpreML,
D1T1HRpostML,
D1T2HRpostML,
D2T1HRpostML,
D2T2HRpostML 4 4.75 .001
______________________________________________
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum10
_____________________________________________________
Means and Standard Deviations for variables D1T1HRpreML,
D1T1HRpostML, D1T2HRpostML, D2T1HRpostML, D2T2HRpostML
_____________________________________________________
HR ML M SD
____________________________________________________
D1T1HRpreML 80.18 14.13
D1T1HRpostML 80.92 13.73
D1T2HRpostML 77.21 13.67
D2T1HRpostML 73.73 11.46
D2T2HRpostML 75.11 12.92
_____________________________________________________
70
72
74
76
78
80
82
D1HRpre1 D1HRpost1 D1HRpost2 D2HRpost1 D2HRpost2
Mean scores: D1T1HRpreML, D1T1HRpostML, D1T2HRpostML, D2T1HRpostML, and D2T2HRpostML
Mean
___________________________________________________________
Mean and SD for CAM-ICU scores T2, T3, and T4 for ML and UC group
_____________________________________________________________
ML = 1 UC = 0 N M SD
_____________________________________________________________
CAM Negative: ML
T2 19 2.00 .000
T3 17 2.00 .000
T4 4 2.00 .000
CAM Negative: UC
T2 19 2.00 .000
T3 14 2.00 .000
T4 7 2.00 .000
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum11
• “I am not sure if I was anxious, but the music did help me relax.”
• “I was not anxious, but I did feel nervous not knowing.”
• “It was a nice distraction and overall I found it very calming.”
• “The headsets did not completely block out noise, I could hear my
neighbor talking on phone.”
• “I do not like headsets with my oxygen.”
• “I would like a music player at my bedside so I can listen when I am
feeling anxious.”
• “I would have preferred to listen when I wanted to, company or the Dr.
may be here during scheduled times.”
• “Your choices were calming, but I like my music that I have at home.”
Summary• Strengths:
o Randomized design
o Use of a theory based intervention
o Innovative use of an established intervention with a
different patient population.
• Limitations:
o Increase in missed intervention sessions over time.
Results• Support for ML among older adults admitted to a TICU and TOU
setting.
• Over time statistically significant differences in HR with ML group
compared to UC group.
• Statistically significant differences in SBP with ML group compared to
UC group.
• All participants (ML and UC) remained CAM-ICU negative.
• Evaluation of Intervention Acceptability:
o 85% agreed or strongly agreed that ML was helpful in the hospital.
o 90% helped participants relax
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum12
Implications for Further Research
• Setting Implications
• Dose and Delivery
• Sensitivity of outcome measures
• Emerging characteristics of delirium
• Patient acuity
References1. Mattar, I., Chan, M. F., & Childs, C. (2013). Risk factors for acute delirium in critically ill adult
patients: A systematic review. ISRN Critical Care.
2. Kalaria, R. N., & Mukaetova-Ladinska, E. B. (2012). Delirium, dementia and senility. Brain,
135(9), 2582-2584.
3. Inouye, S. K., (2006) Delirium in older persons. New England Journal of Medicine, 354(11),
1157-1165.
4. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly
people. The Lancet, 383(9920), 911-922.
5. Gangrade, A. (2012). The effect of music on the production of neurotransmitters, hormones,
cytokines, and peptides a review. Music and Medicine, 4(1), 40-43.
6. Fong, T. G., Tulebaey, S. R., & Inouye, S. K. (2009) Delirium in elderly adults: Diagnosis,
prevention and treatment. National Review Neurology, 5(4), 210–220.
7. Mora, F., Segovia, G., del Arco, A., de Blas, M., & Garrido, P. (2012). Stress,
neurotransmitters, corticosterone and body–brain integration. Brain Research, 476, 71-85.
References8. Hipp, D.M., & Ely, E. W. (2012). Pharmacological and non-pharmacological management of
delirium in critically ill patients. Neurotherapeutics, 24(9), 158-175.
9. MacLullich, A. M., Ferguson, K. J., Miller, T., de Rooij, S. E., & Cunningham, C. (2008).
Unraveling the pathophysiology of delirium: A focus on the role of aberrant stress responses.
Journal of Psychosomatic Research, 65(3),229-238.
10. MacLullich, A. M., Anand, A., Davis, D. H., Jackson, T., Barugh, A. J., Hall, R. J., ... &
Cunningham, C. (2013). New horizons in the pathogenesis, assessment and management of
delirium. Age and Ageing,42(6), 667-674.
11. Krout, R. E. (2007). Music listening to facilitate relaxation and promote wellness: Integrated
aspects of our neuro physiological responses to music. The Arts in Psychotherapy,
34(2), 134-141.
12. Hunter, P. G., Schellenberg, E. G., & Schimmack, U. (2010). Feelings and Perceptions of
happiness and sadness induced by music: Similarities, differences, and mixed emotions.
Psychology of Aesthetics, Creativity, and the Arts, 4(1), 47-56.
nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum13
References13. Chanda, M. L., & Levitin, D. J. (2013). The neurochemistry of music. Trends in Cognitive
Sciences, 17(4), 179-193.
14. To, W., T., Bertolo, T., Dinh, V., Jichici, D., & Hamielec, C. M. (2013). Mozart piano sonatas as
a nonpharmacological adjunct to facilitate sedation vacation in critically ill patients. Music and
Medicine, 5(2), 119-127.
15. Lin, S. T., Yang, P., Lai, C. Y., Su, Y. Y., Yeh, Y. C., Huang, M. F., & Chen, C. C. (2011).
Mental health implications of music: insight from neuroscientific and clinical studies. Harvard
Review of Psychiatry, 19(1),34-46.
16. Nightingale, C. L., Rodriguez, C., & Carnaby, G. (2013). The impact of music interventions on
anxiety for adult cancer patients: A meta-analysis and systematic Review. Integrative Cancer
Therapies, 12(5), 393-403.
17. Roy, C. (1988). An explication of the philosophical assumptions of the Roy Adaptation Model.
Nursing Science Quarterly, 1(1), 26-34.
top related