DALLAS – Prevention of delirium in hospitalized seniors is a largely untapped opportunity to achieve major improvements in health care–and the blueprint for success already exists in the form of standardized evidence-based approaches such as the Elder Life Program.
“We don't have really convincing evidence that we can cure delirium. Our best hope is to prevent it. And there's data out there to say we can,” said Dr. Robert M. Palmer, head of the section of geriatric medicine at the Cleveland Clinic Foundation.
He cited a seminal yet underappreciated clinical trial published 8 years ago by Dr. Sharon K. Inouye and coworkers at Harvard Medical School, Boston. They assigned 852 patients, who were aged 70 years or older and admitted to a hospital general medicine service, to either a multicomponent risk factor intervention program or usual care. Delirium was assessed daily until discharge.
Delirium developed in 9.9% of the intervention group and in 15.0% of controls, for a highly significant 40% reduction in relative risk. The total number of delirium episodes and total days with delirium were similarly reduced. The effect was seen starting on day 3 and increased throughout the rest of the stay (N. Engl. J. Med. 1999;340:669–76).
The intervention, known as the Elder Life Program, systematically targeted six established modifiable risk factors for delirium: cognitive impairment, sleep deprivation, immobility, dehydration, visual impairment, and hearing impairment.
To prevent cognitive impairment, for example, the protocol called for simple activities that maintain reality orientation. Sleep deprivation was addressed nonpharmacologically via warm bedtime drinks, relaxation tapes, and back massage. For hearing impairment, there was provision of amplifying devices and earwax disimpaction.
“Each of these interventions can be done by any of us if we think of it and have a good nursing staff and a good team to work with,” Dr. Palmer stressed at the annual meeting of the Society of Hospital Medicine.
The program had no significant effect on severity of delirium or on recurrence rates, underscoring that primary prevention is the best approach.
A program like this is a golden opportunity for hospitalists to make a difference at their institutions, he added.
Another potential opportunity was highlighted in a separate study that identified five delirium precipitants that occur with increased frequency within 24 hours before diagnosis of the condition. These precipitants are the addition of more than three medications, malnutrition, use of physical restraints, any iatrogenic event, or use of a bladder catheter.
“The point is, these are things we and our nurses do to patients which are at least associated with the incidence of delirium. For us as hospitalists, maybe if we change the processes of care we can prevent delirium,” he said.
Delirium, a syndrome with multiple etiologies and pathophysiologies, is marked by a unifying theme: acute decline in attention and cognition.
Well-designed prospective observational studies have shown that 10%–15% of medically ill patients older than age 65 years have delirium when they present for hospitalization, whereas another 10%–15% develop new-onset delirium after admission.
Delirium occurs in 30%–50% of elderly patients following hip or knee surgery and in 70%–84% of patients in the intensive care unit.
The clinical consequences of delirium can be considerable. Delirium is consistently associated with increased morbidity and mortality, prolonged length of hospital stay, and nursing home placement, Dr. Palmer said.
The condition is estimated to cost more than $7 billion annually in increased Medicare hospital expenditures.
Although delirium is an acute condition, it is associated with increased long-term mortality.
A Yale University study showed that patients who experienced delirium during hospitalization had a 62% increased risk of mortality during the subsequent year, compared with those without delirium (Arch. Intern. Med. 2005;165:1657–62).
'Our best hope is to prevent [delirium]. And there's data out there to say we can.' DR. PALMER