This qualitative thematic analysis (TA) study sought to identify key features of rehabilitation strategies relevant to recovery after an episode of delirium in older adults. The findings validate and build upon our previous understanding of the domains and facilitators of delirium recovery, as outlined in a rapid realist review that included a broad search strategy but was not specific to post-acute delirium rehabilitation [28]. This TA extends the earlier review by incorporating a social dimension into the previously identified emotional component of delirium recovery, offering a more nuanced understanding of the complexities of social reintegration. Specifically, it highlights the role of relationship continuity with professional carers in facilitating this process, addressing a significant challenge in hospital settings: staff turnover, which can negatively impact recovery from delirium, a condition marked by confusion and cognitive impairments. Continuity of care is crucial for mitigating the adverse effects of staff disruptions on patients’ recovery trajectories.
Additionally, this analysis uncovers a critical gap not identified in the preliminary programme theory—the need for delirium-specific education. The study highlights that the lack of knowledge and support during and after discharge contributes to heightened anxiety and fear regarding home-based recovery. Furthermore, it extends our understanding of tailoring and personalisation, emphasising that interventions must be fundamentally person-centred. The findings also reinforce the importance of promoting a healthy lifestyle and treating underlying causes as essential components of delirium recovery.
Social contact and engagement emerged as key components of emotional recovery in the study. Structured activities that promote social interaction were viewed as beneficial for delirium recovery and for rebuilding confidence in functional tasks. Previous research has linked strong social networks to better cognitive function, a lower risk of functional decline, and reduced likelihood of postoperative delirium, emphasising the risks of social isolation [40,41,42,43]. In our study, restoring social connections was an important aspect of post-discharge rehabilitation. However, some individuals may face challenges in resuming their social lives. Long-term care plans should address personal preferences, needs, and barriers to social reintegration. To enhance clinical applicability, social contact could be actively supported through structured peer support groups or community-based activities designed to reduce isolation and promote emotional recovery. Moreover, the interpersonal relationship between a professional carer and a person with delirium can build confidence in social interactions. Relationship continuity could be facilitated by assigning a consistent care coordinator or single point of contact throughout the intervention, fostering trust and sustained engagement. Integrating these elements into service delivery models would address key psychosocial needs and enhance the effectiveness of post-delirium rehabilitation.
Strong evidence supports an educational component to inform and address the increased fear, anxiety, and loss of confidence experienced after delirium. Educational interventions for delirium have been shown to moderately increase confidence and competence, particularly in decision-making [44]. One study found that a low-cost educational intervention reduced delirium incidence and improved function in older medical patients [45]. Other studies have explored psychoeducation as part of multicomponent delirium interventions for carers [46]. A review of family involvement in delirium care suggested that enhancing carers’ understanding of delirium and its care has value, calling for more research into best practices for achieving this goal and evaluating their effectiveness [47].
Finally, the importance of maintaining a healthy lifestyle and addressing underlying medical conditions in the treatment of delirium is well established, both during episodes and in acute settings [20, 48,49,50]. We emphasise their ongoing relevance beyond acute care, particularly as components of community-based rehabilitation care plans, since many individuals experience persistent health complications following hospital discharge.
Implications for practice
This study shifts the primary focus from preventing delirium incidence to rehabilitation outcomes such as enabling independence, functional recovery and autonomy and preventing further decline. There is currently no precedent for utilising multicomponent rehabilitation in post-acute delirium care. The novelty lies in the recommendation that the strategies identified in this research are all necessary, if not sufficient, and must be offered as part of an integrated, holistic care pathway, as opposed to being aimed at addressing symptoms in isolation or out of context.
Importantly, there is no evidence for effective rehabilitative interventions for delirium in the community setting. Once discharged, older people need support that is goal-oriented, is based on shared decision-making and aims at functional recovery in addition to symptom management. The professional participants in this study highlighted the benefits of home-based care for people with delirium, and the patient and carer participants shared their preferences for rehabilitation and recovery at home. It is unclear whether recovery is quicker or better after an episode of delirium at home than in the hospital. However, research has documented the high incidence and prevalence of delirium in intensive care unit patients, which is attributable to their exposure to a range of risk factors in acute settings [51]. Discharge to the home is also significantly associated with a reduced incidence of delirium [52], which suggests that home-based care could be better for recovery from and after delirium. This study highlighted inconsistencies in care pathways for patients with delirium, and there are risks associated with home-based care. Therefore, it is recommended that a well-planned and appropriately administered intervention can ensure that people can recover safely at home.
The study also highlighted training and knowledge gaps in delirium care, which has a knock-on effect on patients and carers. We found that delirium can often be missed, misdiagnosed, or managed poorly in the community. Supporting all healthcare staff with appropriate training, supervision and support with delirium management both in hospitals and in the community is crucial for supporting persons with delirium and their carers.
Strengths and limitations
This study was conducted during the SARS-CoV-2 pandemic, which significantly limited recruitment, particularly of older people with delirium. The final patient-participant sample was smaller than intended, due to health, cognitive or communicative impairments that affected interview participation. Consequently, we relied more heavily on proxy view of carers, which may have excluded patients’ own perspectives.
The small interview cohort may also have introduced sampling bias by potentially excluding frailer individuals, those discharged to care facilities or those unable to participate due to cognitive or physical limitations, whose experiences and recovery needs may differ significantly.
The study may be subject to recall bias, as interviews were conducted four weeks after discharge, potentially affecting the accuracy of participants’ recollections; additionally, attrition bias may have influenced the findings, given that nine patients who initially consented did not complete the study.
The patient-participant sample included only individuals of White-British ethnicity. Minority ethnic groups remain underrepresented in healthcare research, and the exclusion of diverse voices limits our understanding of how cultural factors may influence healthcare use and responses to rehabilitation interventions [53, 54].
Furthermore, all participant groups were recruited from a single NHS organisation in Southwest England, where the demographics of older people may differ from those in other parts of the UK. As a result, certain themes related to delirium rehabilitation strategies may remain undiscovered due to the ethnic and geographic homogeneity of the sample.
Patient participants were recruited at admission or diagnosis, with interviews conducted four weeks post-discharge. As a result, the sample included individuals who had fully recovered by the time of interview and others who continued to experience symptoms, which highlights the difficulty of differentiating between recovery from delirium and recovery after delirium within this project [28]. Additionally, some participants were discharged home while others were transferred to care homes, which likely influenced the services they could access. These differences may have led to a conflation of diverse experiences of delirium presentation, symptomatology, and health status within a single theory of recovery.
The key strength of this study is its exploration of people’s perceptions of what is needed to affect recovery after delirium in post-acute settings. This study builds on our previous understanding of the mechanisms of recovery from delirium by investigating experiential accounts of delirium and what is needed for recovery after discharge. The themes constructed from these data bridge the gap between what is known about delirium rehabilitation in general and what additional features of rehabilitation are needed when planning a multicomponent home care plan for older people. This is a crucial step in the project’s overall realist approach to develop a programme theory of delirium rehabilitation in the community.
While the generalisability of our findings is limited by the single-site recruitment and specific patient profile, the theoretical depth achieved through thematic analysis and the development of programme theory, guided by a realist review, enhances the transferability of the findings.
In terms of reflexivity, the research team comprised individuals from mixed professional backgrounds, including three non-clinicians and two Research Fellows (SR and AM) with expertise in health services research and complex interventions. This mix of perspectives contributed to a more nuanced interpretation of the data by encouraging critical reflection and helping to mitigate individual biases. The involvement of non-clinical researchers also supported a broader consideration of psychosocial and contextual influences, ensuring that interpretations were not solely shaped by clinical perspectives.
Future directions for research
This study aims to augment our limited understanding of the support and rehabilitation needs of older people with delirium after discharge from the hospital in the community setting. These findings contributed to the development of a programme theory, which served as the theoretical foundation for a novel, community-based delirium rehabilitation intervention [29]. This novel intervention addresses a lack of research on delirium treatment and management in post-acute settings.
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