Maria Reyna, MD

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.

Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?

Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.

Study design: Prospective, observational study.

Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.

Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).

Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.

These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.

Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.

Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.

Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?

Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.

Study design: Prospective, observational study.

Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.

Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).

Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.

These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.

Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.

Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.

Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?

Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.

Study design: Prospective, observational study.

Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.

Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).

Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.

These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.

Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.

Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.