Efforts to Prevent Delirium in Hospitalized Older Patients Show Promise
In this issue of Clinical Geriatrics, Angela Botts, MD, has written an article on delirium that I believe presents information of great value to anyone caring for older hospitalized patients. Delirium is a common and serious problem that affects as many as 70% of older persons admitted to critical care units and between 6% and 50% of older persons admitted to general medical and surgical floors, based on a composite of numerous studies that have examined this serious and growing problem. It is associated with an approximate 35% 1-year mortality, and is thought to result in as many as 17.5 million inpatient days annually. It has been referred to as “The beginning of the end,”1 and is considered by many to be one of the leading causes of “preventable” injury in persons over the age of 65 years.
We have come a long way in reaching uniformity in the way we diagnose delirium with the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the ICU (CAM-ICU), which are currently universally accepted as appropriate diagnostic tools. Although we know what can increase a person’s chances of developing delirium, even under the best of circumstances we are often helpless in preventing it. Infections, electrolyte disturbances, constipation, and drug toxicities are at the top of everyone’s list when delirium is being considered; unfortunately, many forget the more basic issues that are at the very foundation of proper geriatric care. These are frequent and potentially preventable causes of delirium and must not be overlooked.
This past May, Sharon K. Inouye, MD, MPH, was recognized at the annual meeting of the American Geriatrics Society for her cutting-edge work on delirium in the elderly. In 1999, Dr. Inouye and colleagues developed a multicomponent intervention to prevent delirium in hospitalized older patients.2 This program focuses on areas of cognitive impairment, sleep deprivation, immobilization, vision impairment, hearing impairment, and dehydration. Many hospitals and long-term care institutions have already implemented programs that focus on these areas or are planning to do so in an attempt to prevent delirium in their hospitalized patients. Although this is exciting news and holds great promise, it is important to note that the interventions studied failed to affect delirium severity or the recurrence rate once delirium occurred. In addition, the intervention was most effective in the group assessed as being at “intermediate risk” for delirium. In the “high-risk” group, there was no statistically significant difference in the reduction of incident delirium. Some have also questioned the methodology used, as well as whether the findings were applicable to specific populations of older persons, such as those who suffered from traumatic injury. Clearly, additional research is essential; new strategies will undoubtedly continue to be developed and tested.
One outcome of Dr. Inouye’s study has been the Hospital Elder Life Program, or HELP; this is being increasingly accepted as a model of care designed to prevent functional and cognitive decline in older persons during a hospitalization.3 This program uses an interdisciplinary team and a trained and supervised group of volunteers to target the six specific areas of concern listed earlier (ie, cognitive impairment, sleep deprivation, immobilization, vision impairment, hearing impairment, and dehydration). Once again, this program has not been shown to be universally beneficial in preventing delirium, as so many other causative factors exist. Given the time-intensive nature of the interventions, careful consideration should be given as to how best to use this approach in order to have the greatest chance of success. Clearly, attention to all of the aforementioned aspects of care constitute good medicine and should be a guiding principle in the care of all older hospitalized patients, whether one’s institution has a specific delirium prevention program or not. From a cost-effective point of view, however, there remains skepticism among many healthcare administrators as to the role that this program may have in the care of hospitalized elderly patients, especially those who are critically ill and suffering from complex medical conditions. As with all areas of medicine, decisions must be made as to how best to allocate scarce resources based on cost benefit potential. I, for one, believe that programs such as HELP can be an invaluable tool if used appropriately and in carefully selected groups of elderly patients. Failure to implement aspects of this program correctly, however, may create a negative impression that these efforts are not effective, which may lead to a quick demise of what could, in my opinion, be an invaluable benefit to many older persons in the hospital.
Given the heterogeneity of elderly persons in the hospital and the limited resources available to care for them, additional research is clearly needed to better define what works to prevent delirium and in whom. While we are all aware that proper nutrition, skin care, and other tangible manpower-dependent provisions are essential to the care of the older hospitalized person, we now have additional factors that must be considered and in some way incorporated into our care plans, whether part of a formal implementation program or based on specific patient needs and staffing ability. The final answer as to how best to prevent delirium in all older persons has not been found. Despite this, we have taken a major step in raising the level of awareness of this major problem and in introducing programs that will undoubtedly improve the care of many older persons. As always, we welcome your comments.
Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
References
1. Leslie DL, Zhang Y, Holford TR, Bogardus ST, Leo-Summers LS, Inouye SK. Premature death associated with delirium at 1-year follow-up. Arch Intern Med 2005;165(14):1657-1662.
2. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340(9):669-676.
3. Inouye SK, Bogardus ST Jr, Baker DI, Leo-Summers L, Cooney LM Jr; Hospital Elder Life Program. The Hospital Elder Life Program: A model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc 2000;48(12):1697-1706.