Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia

A Randomized Controlled Trial

Ann Kolanowski, PhD; Donna Fick, PhD; Mark Litaker, PhD; Paula Mulhall, RN; Linda Clare, PhD; Nikki Hill, PhD; Jacqueline Mogle, PhD; Malaz Boustani, MD; David Gill, MD; Andrea Yevchak-Sillner, PhD


J Am Geriatr Soc. 2016;64(12):2424-2432. 

In This Article

Abstract and Introduction


Objective: To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care.

Design: Single-blind randomized clinical trial.

Setting: Eight post-acute care (PAC) facilities.

Participants: Community-dwelling older adults with dementia and delirium (N = 283).

Intervention: Research staff provided cognitively stimulating activities daily for up to 30 days.

Measurements: Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index).

Results: Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6–70.1; control: 68.7%, 95% CI = 63.9–73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0–39: intervention: 10.77, 95% CI = 10.10–11.45; control: 11.15, 95% CI = 10.50–11.80; difference 0.37, 95% CI = 0.56–1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0–15): intervention: 6.58, 95% CI = 6.12–7.04; control: 5.89, 95% CI = 5.45–6.33; difference −0.69, 95% CI = 1.33 to −0.06, P = .03; constructional praxis (range 0–15): intervention: 8.84, 95% CI = 8.83–9.34; control: 7.53, 95% CI = 7.04–8.01; difference −1.31, 95% CI = 2.01 to −0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression).

Conclusion: Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.


Delirium is a state of confusion characterized by acute decline in cognitive function.[1] It is common and can be deadly in older adults with dementia.[2] The effects of delirium persist long after hospitalization[3,4] and manifest as worsening global cognition.[5] Discharges to postacute care (PAC) facilities after a hospitalization have risen sharply in recent years. Because people generally enter PAC after a hospitalization for a medical illness, many people with dementia have delirium on admission to PAC facilities that, if unresolved, reduces the potential for rehabilitation,[6] increases medical costs,[7] and predicts new institutionalization.[8] It is important to determine whether interventions for delirium in PAC settings can improve clinical outcomes for individuals at highest risk of poor outcomes—those with delirium superimposed on dementia (DSD).[3]

There is no standard treatment for delirium. Current practice is to manage symptoms using antipsychotic or sedative medications.[1] These medications increase the risk of adverse outcomes in individuals with dementia and may actually prolong the duration of delirium.[1] Multicomponent nonpharmacological interventions that modify delirium risk factors are efficacious for prevention,[9] but evidence of their efficacy for treatment is lacking,[10] although they are recommended in current guidelines.[11] With few exceptions, there is no indication that the individual components of these interventions were implemented in a consistent fashion or in a "dose" that was likely to produce an effect. Because there is no widely accepted intervention for delirium,[12] the goal of the current study was to determine whether a theoretically based, nonpharmacological intervention would be effective at managing symptoms of DSD. Because delirium resolution may be independent of improvements in specific cognitive domains,[13] these outcomes were also examined.

The intervention uses individualized cognitively stimulating activities to restore the disrupted cognitive function that individuals with delirium experience regardless of precipitating cause.[14] Several lines of evidence support a strong relationship between delirium and dementia;[1,15] interventions that improve symptoms in one of these conditions may also improve symptoms of the other. For example, cognitive stimulation therapy can improve cognitive function in individuals with dementia.[16] Pilot work showed that individuals with DSD in PAC who engaged in cognitively stimulating activities daily had less decline in global cognition and physical function than controls.[17] Cognitive stimulation is often a component of efficacious delirium prevention protocols, although its independent effects are not know, and much of this research did not include individuals with dementia.[9] In a recent clinical trial, an intervention of combined cognition-focused and physical therapy improved executive function and instrumental activities of daily living in cognitively impaired survivors of critical illness better than physical therapy only.[18]

It was hypothesized that individualized cognitively stimulating activities would reduce the duration and severity of delirium and improve cognitive and physical function in individuals with DSD in PAC more than usual care.