Decreasing Delirium Through Music

A Randomized Pilot Trial

Sikandar H. Khan, DO, MS; Chenjia Xu, PhD; Russell Purpura, MD; Sana Durrani, MBBS; Heidi Lindroth, PhD, RN; Sophia Wang, MD; Sujuan Gao, PhD; Annie Heiderscheit, PhD, MT-BC, LMFT; Linda Chlan, PhD, RN; Malaz Boustani, MD, MPH; Babar A. Khan, MD, MS

Disclosures

Am J Crit Care. 2020;29(2):e31-e38. 

In This Article

Abstract and Introduction

Abstract

Background: Management of delirium in intensive care units is challenging because effective therapies are lacking. Music is a promising nonpharmacological intervention.

Objectives: To determine the feasibility and acceptability of personalized music (PM), slow-tempo music (STM), and attention control (AC) in patients receiving mechanical ventilation in an intensive care unit, and to estimate the effect of music on delirium.

Methods: A randomized controlled trial was performed in an academic medical-surgical intensive care unit. After particular inclusion and exclusion criteria were applied, patients were randomized to groups listening to PM, relaxing STM, or an audiobook (AC group). Sessions lasted 1 hour and were given twice daily for up to 7 days. Patients wore noise-canceling headphones and used mp3 players to listen to their music/audiobook. Delirium and delirium severity were assessed twice daily by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the CAM-ICU-7, respectively.

Results: Of the 1589 patients screened, 117 (7.4%) were eligible. Of those, 52 (44.4%) were randomized, with a recruitment rate of 5 patients per month. Adherence was higher in the groups listening to music (80% in the PM and STM groups vs 30% in the AC group; P = .01), and 80% of patients surveyed rated the music as enjoyable. The median number (interquartile range) of delirium/coma-free days by day 7 was 2 (1–6) for PM, 3 (1–6) for STM, and 2 (0–3) for AC (P = .32). Median delirium severity was 5.5 (1–7) for PM, 3.5 (0–7) for STM, and 4 (1–6.5) for AC (P = .78).

Conclusions: Music delivery is acceptable to patients and is feasible in intensive care units. Further research testing use of this promising intervention to reduce delirium is warranted.

Introduction

Patients receiving mechanical ventilation are at high risk for delirium, a syndrome of acute brain failure associated with prolonged stays in an intensive care unit (ICU), high health care costs, and high mortality.[1–6] An intubated patient also experiences pain, anxiety, and physiological stress, which are usually treated with sedatives—themselves risk factors for delirium. This creates a perpetuating cycle of pain, anxiety, sedation, and delirium.

Efforts to prevent and manage delirium in the ICU have had mixed results: pharmacological interventions have not changed delirium outcomes, whereas bundled protocols emphasizing judicious pain control, avoidance of oversedation, delirium monitoring, daily ventilator liberation trials, mobility, and family involvement have reduced delirium.[7–11] These multicomponent protocols are limited by low adherence; greater adherence was associated with increased patient-reported pain.[11] Scalable, low-burden, and effective interventions are clearly needed to manage patients' symptoms and reduce the burden of delirium.

Effective nonpharmacological interventions to prevent and treat delirium are needed.

Music may be an ideal nonpharmacological intervention that could begin to address this gap. In hospitals, listening to music has been associated with lower heart rates, blood pressures, and serum cortisol levels, and less anxiety, postoperative pain, and sedative exposure.[12–19] Patients undergoing mechanical ventilation who listened to slow-tempo music (STM) in a patient-directed music intervention had less anxiety and received fewer doses of sedative than did patients receiving usual care.[13] Despite these findings, few studies have examined the effect of music on delirium in the ICU. Furthermore, prior studies limited enrollment to alert, stable patients receiving spontaneous mechanical ventilation in order to obtain the patients' music preferences.

Providing a personalized music intervention for critically ill patients poses unique logistical challenges, but the comparative efficacy of nonpersonalized STM has not been tested. Therefore, we designed our study to test the feasibility of, adherence to, and acceptability of 2 types of music intervention and attention control in complex, critically ill patients, and to estimate the effect of music on delirium outcomes.

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