Delirium - the sudden onset of confusion frequently seen in older patients - can increase a person's risk of falls, lead to prolonged hospital stays and may contribute to over $164 billion in healthcare costs. A new study led by researchers at Brigham and Women's Hospital (BWH) and Hebrew SeniorLife's Institute for Aging Research suggests that delirium is also preventable, and that non-medication strategies can reduce risk and improve outcomes. This meta-analysis of 14 studies involving multi-component non-pharmacologic interventions is published this week in JAMA Internal Medicine.
"Delirium is a major problem at many hospitals and preventing its downstream consequences, including falls, is a priority," said Tammy Hshieh, MD, of BWH's Division of Aging and the Aging Brain Center in Hebrew SeniorLife's Institute for Aging Research. "Delirium can be the source of anxiety for many patients and their families and often they wish that there was a pill that would make the patient's symptoms go away. Our study demonstrates that there are effective strategies for preventing delirium and treating patients that don't rely on medications."
Researchers analyzed studies that had examined six interventions that targeted delirium risk factors, guided by principles derived from the original delirium prevention study, the Hospital Elder Life Program (HELP). Interventions included strategies to improve a person's nutrition and hydration and to ensure uninterrupted sleep; daily exercise and therapeutic activities to improve cognition; and "re-orientation" or telling patients where they are and the date and time every day. The studies were conducted at 12 hospital sites from all over the world.
"These preventive approaches provide evidence-based models to improve processes of care for older hospitalized persons. The fact that these approaches are so effective for prevention of delirium, falls and institutionalization provides strong support for their importance in the setting of accountable, cost-effective care. We hope this study will bring to attention these important models for hospital administrators and policymakers," said Sharon K. Inouye, MD, MPH, director of the Aging Brain Center at the Institute for Aging Research at Hebrew SeniorLife and the senior author on the paper.
The researchers found that older patients who received non-medication based interventions were at decreased risk of both delirium and falls, and found trends toward decreased length of hospital stay and institutionalization. Based on their results, they estimated that each year, approximately one million cases of delirium could be prevented using non-medication based interventions, resulting in a Medicare cost savings of $10 billion per year.
Delirium is a disorder with a constellation and range of symptoms - patients can exhibit agitation and confusion or they may be non-responsive. It is estimated that 29 to 64 percent of hospitalized elderly patients suffer from delirium, although it is likely under-diagnosed.
"Delirium is sometimes difficult to recognize but given its complications, it deserves more national and international attention," said Hshieh. "If we can prevent delirium, we can do a lot of good for patients in the long run. It's important for both families and healthcare providers to be aware of these beneficial non-medical strategies."
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In addition to Hshieh and Inouye, study coauthors include Jirong Yue, MD of West China Hospital, Sichuan University; Esther Oh, MD of Johns Hopkins School of Medicine; Sarah Dowal, MSW, MPH and Thomas Travison, PhD of the Aging Brain Center, Hebrew SeniorLife.
This study was supported in part by Grant K07AG041835 from the National Institute on Aging. Dr. Hshieh is supported by T32 Training Grant (AG000158) from the National Institute on Aging. Dr. Inouye holds the Milton and Shirley F. Levy Family Chair. The funding sources had no role in the design, conduct or reporting of this study.
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in New England and employs nearly 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Biomedical Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $650 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative. For more information and resources, please visit BWH's online newsroom.
Journal
JAMA Internal Medicine