Stimulated by Levy et al 2021.
TEAS – transcutaneous electrical acupoint stimulationkey to acronyms
TENS – transcutaneous electrical nerve stimulation
4AT – 4 A’s test, a rapid screening test for delirium
CAM – Confusion Assessment Method
m-RASS – modified Richmond Agitation and Sedation Scale
CAM-S – Confusion Assessment Method Severity
NNT – number needed to treat (to achieve one positive outcome)
NNH – number needed to harm (to suffer one adverse event)
This week I have chosen a trial on delirium in hospitalised older adults. It caught my attention because I remember being asked about this topic on a course some time ago and at the time I could not recall having seen any trial evidence, nor had I even thought about acupuncture as a possible intervention. My interlocutor impressed on me how troublesome delirium could be, especially in more elderly patients admitted to hospital, and I remembered this.
This could be the first trial. There are only 7 citations on PubMed with both delirium and acup* in the title, and of the two other trials, one involved TEAS, or TENS to acupuncture sites, and the other concerned emergence delirium after anaesthesia in children undergoing myringotomy.
Levy et al studied 81 older adults (older than 65 years) who were hospitalised in an internal medicine ward and diagnosed with delirium. They tell us in the abstract that 50 were randomised to standard care plus acupuncture and 31 to standard care only. I immediately wondered what sort of process could achieve this uneven distribution randomly. It would be possible on coin toss, but highly unlikely. The methods section revealed the answer. Patients were allocated to acupuncture only on the days that there was an acupuncturist available ie on a Sunday, Monday, Wednesday or Thursday. Strictly speaking this is not random; however, it is also unlikely to result in any selection bias, so I won’t complain further, apart from saying that as an editor I might have pressed to call it pseudo-randomisation.
The patients had a TCM pattern diagnosis and then a set of points that varied with the specific pattern identified. All sets included points in the arms and legs, and the patterns appear to have been allocated to the western medicine delirium classifications, and then based on pulse diagnosis and clinical observation. In neurophysiological terms the treatments would all have fallen into the category of generating general effects.
Treatment was performed on the day of admission and then daily for a maximum of 5 days. Needle retention time was 15 to 20 minutes, but if the patient was severely agitated a shorter form was used called ‘quick needle acupuncture’.
Patients were screened daily using a validated rapid screening test for delirium and cognitive impairment called the 4 A’s test or 4AT for short. Those found to be positive on 4AT were assessed with the much older Confusion Assessment Method (CAM) tool, which was first described over 30 years ago. The CAM tool is intended for non-psychiatric clinicians and can be applied in around 5 minutes apparently. Finally, alertness was measured on 3 separate occasions on the screening day using the modified Richmond Agitation and Sedation Scale (m-RASS). That all resulted in patients being categories as hyperactive, hypoactive or mixed-type delirium. Severity was measured with CAM-S – exactly the same as the CAM tool but with numbers added.
Time to first delirium remission was significantly shorter in the acupuncture group and an NNT of 3 was calculated for first delirium remission. That is a pretty good number for an NNT, and the opposite (NNH) was not calculated since there were no adverse events recorded from the acupuncture.
Delirium severity was substantially reduced in the acupuncture group, and the median delirium free days over the 7-day trial was 5.5 in the acupuncture group and 0 in the standard care group.
The authors suggest further research to investigate the pathophysiology of the acupuncture effect, and they also mention that it could all be context related, which led them to propose a sham controlled trial. Personally, I don’t think either is necessary when you have an intervention that seems to work so well and has no measurable risk in this application. Sham controlled trials are all about ensuring your intervention does more good than harm. If you can measure no harm, surely there is no need! Of course, we know there are theoretical risks with acupuncture, but since they didn’t use any risky points and serious infection secondary to acupuncture is astonishingly rare, why wait to role this out?
1 Levy I, Gavrieli S, Hefer T, et al. Acupuncture Treatment of Delirium in Older Adults Hospitalized in Internal Medicine Departments: An Open-Label Pragmatic Randomized-Controlled Trial. J Geriatr Psychiatry Neurol Published Online First: 9 March 2021. doi:10.1177/0891988721996804
2 Gao F, Zhang Q, Li Y, et al. Transcutaneous electrical acupoint stimulation for prevention of postoperative delirium in geriatric patients with silent lacunar infarction: a preliminary study. Clin Interv Aging 2018;13:2127–34. doi:10.2147/CIA.S183698
3 Martin CS, Yanez ND, Treggiari MM, et al. Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement. Minerva Anestesiol 2020;86:141–9. doi:10.23736/S0375-9393.19.13591-2
4 Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014;43:496–502. doi:10.1093/ageing/afu021
5 Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8. doi:10.7326/0003-4819-113-12-941
6 Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med 2014;160:526–33. doi:10.7326/M13-1927