Yale School of Medicine "Elder Life Program" Shown Successful In Preventing Delirium in Hospitalized Older Patients

A program designed to reduce six risk factors for delirium in hospitalized patients 70 years old or older successfully reduced the number of patients who developed symptoms by 40 percent compared to a control group, a Yale study has shown.

Published in the March 4 issue of the New England Journal of Medicine, the study measured the effectiveness of the first major clinical program designed to prevent rather than treat delirium, which can be a major obstacle to recovery in older hospitalized patients.

“It’s not unusual for active, independent older people to start a downward spiral, both mentally and physically, during a routine hospital stay. As a result, they may require long-term home care after hospitalization, or even a transfer to a rehabilitation center or nursing home,” said Sharon Inouye, M.D., associate professor of medicine and geriatrics at the Yale University School of Medicine and the study’s leader. “We wanted to see if some common-sense steps to reduce well-known risk factors for delirium would help prevent that downward spiral from starting.”

The result was the Elder Life Program, which focuses on reducing six risk factors for delirium – vision loss, hearing impairment, dehydration, sleep deprivation, cognitive impairment, and immobility from prolonged bed rest. The program was tested in a study of 852 patients between the ages of 70 and 97 treated at Yale-New Haven Hospital from March 1995 through March 1998. So successful were the results that the program was adopted recently by the hospital’s board as a permanent program and now serves more than 800 elderly patients a year, Inouye said.

In the Yale study, patients showed significantly less disorientation with the help of trained volunteers and various memory aids, such as a bedside bulletin board with a daily schedule of tests and activities, along with doctors’ and nurses’ names. The volunteers helped patients fight the effects of immobility by taking them for walks three times a day; reduced their need for sleep sedatives by giving them warm milk, back rubs and relaxation audiotapes at night; and played word games and talked about current events with them to keep them mentally active.

The 40 volunteers, each of whom spent 16 hours in classroom training and an additional 16 hours observing an experienced volunteer, provided 20-30 minutes, three times daily, of volunteer help for each patient. An interdisciplinary team that included specially trained elder life specialists, a nurse specialist, a geriatric physician, rehabilitation specialists, a geriatric chaplain, a dietician and a pharmacist also worked with patients to reduce dehydration, restore muscle strength, avoid over-medication and reduce anxiety.

Nurses joined in the program with unit-wide noise reduction at night to enhance sleep. They used silent pill crushers and vibrating beepers, monitored hallway noise, and adjusted the nightly medication routine and taking of vital signs to reduce sleep interruption.

In addition to Inouye, other members of the research team were Doctors Sidney T. Bogardus Jr. and Leo M. Cooney Jr.; biostatistician Theodore R. Holford; data analysts Peter A. Charpentier and Linda Leo-Summers; and project manager Denise Acampora.

Preventing delirium

Delirium developed in only 9.9 percent of the intervention group, compared with 15 percent of the control group receiving routine care – a 40 percent lower rate in matched analyses. (Each patient in the intervention group was matched with a patient in the control group of similar age, gender and delirium risk, yielding matched-odds ratios. The matched design of this study is an important innovation, providing a much-needed alternative when randomization to study groups is not possible, Inouye said.)

The final study included 426 matched pairs (852 subjects). None of the patients showed delirium upon admission, although they were categorized at either intermediate or high risk for developing delirium. Average hospital stay was 7 days for the intervention group and 6.5 days for the control group. All assessments were carried out by research staff who had no role in the intervention and who were blinded to the nature of the study and the patients’ group assignments. Screening for delirium included such tests as the Mini-Mental State Examination and the Confusion Assessment Method. A family member was interviewed at admission to establish the patient’s baseline cognitive function.

Significantly lower rates for the intervention group also were found in total delirium days (105 days vs. 161 days) and number of delirium episodes (62 vs. 90). “The intervention program was most effective in patients at intermediate risk for delirium,” Inouye said. “Once delirium occurs, however, the cat’s more or less out of the bag. The intervention has no significant effect on severity or recurrence, showing that prevention of delirium is much more effective than treatment.”

Incidence on the rise

Each year, delirium complicates hospital stays for more than 2.3 million older persons, involving more than 17.5 million inpatient days and accounting for more than $4 billion (1994 dollars) of Medicare expenditures, according to a 1996 U.S. Bureau of the Census statistical abstract. Overall, patients over age 65 account for 13 percent of the population but 44 percent of all hospital care, 40 percent of all visits to physicians and one-third of the nation’s health care expenditures, the American Association of Retired People reported in 1995. The incidence of delirium is expected to increase with the aging of the population in coming years as baby boomers retire.

The Elder Life Program significantly reduced the total number of targeted risk factors for delirium in hospitalized patients. Improvements were significant in cognitive impairment and reduction of sedative drugs for sleep, while immobility, vision and hearing revealed trends toward improvement, Inouye said.

Total cost for the program was $139,506, or $327 per patient in the intervention group. Because there were 22 fewer cases of delirium in the intervention group, the cost per delirium case prevented was $6,341, Inouye said. That compares favorably with costs for other prevention programs, such as falls prevented ($7,727-$11,834 per case), and heart attacks prevented ($19,800-$42,900 per case).

“While most studies have focused on treating symptoms of delirium after they appear, the Elder Life Program is the first major clinical program with the goal of preventing delirium. The practical, real-world nature of the interventions is a major strength of this study,” Inouye said. “We need further evaluation to determine cost-effectiveness and the impact of the program on mortality, rehospitalization, institutionalization, home health care and long-term cognitive function. But the early results are extremely promising.”

This research was funded by the National Institute on Aging, the Commonwealth Fund, The Retirement Research Foundation, the Community Foundation for Greater New Haven, and The Patrick and Catherine Weldon Donaghue Medical Research Foundation.