Making Delirium Prevention Acceptable in Nursing Homes

Impaired Arousal in Older Adults Is Associated With Prolonged Hospital Stay and Discharge to Skilled Nursing Facility

BACKGROUND

Poor cognitive function is associated with negative consequences across settings of care, but research instruments are arduous for routine clinical implementation. This study examined the association between impaired arousal, as measured using an ultra-brief screen, and risk of 2 adverse clinical outcomes: hospital length of stay and discharge to a skilled nursing facility (SNF).

DESIGN, SETTING, AND PARTICIPANTS

A secondary data analysis was conducted using 2 separate groups of medical ward patients: a Veterans Affairs medical center in the northeast (N = 1487, between 2010 and 2012) 60 years and older and a large tertiary care, university-based medical center (N = 669, between 2007 and 2013) 65 years and older in the southeastern United States.

MEASUREMENTS

The impact of impaired arousal, defined by the Richmond Agitation Sedation Scale as anything other than "awake and alert," was determined using Cox Proportional Hazard Regression for time to hospital discharge and logistic regression for discharge to a SNF. Hazard ratios (HRs) and odds ratios (OR) with their 95% confidence intervals (CI) are reported, respectively. Both models were adjusted age, sex, and dementia.

RESULTS

The 2156 total patients included in these groups had a mean age of 76 years, of whom 16.4% in group 1 and 28.5% in group 2 had impaired arousal. In the first group, patients with normal arousal spent an average of 5.9 days (standard deviation 6.2) in the hospital, while those with impaired arousal spent 8.5 days (9.2). On any given day, patients with impaired arousal had 27% lower chance of being discharged (adjusted HR 0.73 (95% CI 0.63-0.84). In the second group, individuals with normal arousal spent 3.8 (4.1) days in the hospital compared with 4.7 (4.6) for those with impaired arousal; indicating a 21% lower chance of being discharged [adjusted HR 0.79 (95% CI 0.66-0.95). With regard to risk of discharge to SNF, those with impaired arousal in group 1 had a 65% higher risk than those without impaired arousal [adjusted OR 1.65 (95% CI 1.21-2.25)], and those in group 2 had a nonsignificant 27% higher risk [adjusted OR 1.27 (0.80-2.03)]. Because of the quality improvement nature, this analysis did not control for comorbidities, which is a significant limitation.

CONCLUSIONS

In this study of over 2000 older hospitalized patients, the simple observation of an abnormal arousal level may be an independent predictor of a longer hospital stay and discharge to SNF.

A delirium risk modification program is associated with hospital outcomes

BACKGROUND

Delirium has been associated with negative health consequences, which can potentially be improved by delirium risk modification. This study sought to determine if a quality improvement project to identify and modify delirium risk and discharge to rehabilitation is associated with improved outcomes for patients and health care systems.

METHODS

In older veterans admitted to a tertiary VA hospital, delirium risk was assessed using cognitive impairment, vision impairment, and dehydration. Delirium risk was communicated to providers via electronic medical record. To modify delirium risk, interventions were provided in cognitive stimulation, sensory improvement, and sleep promotion. Primary outcomes included length of stay, restraint use, discharge to rehabilitation, and hospital variable direct costs. Outcomes were compared using a propensity-matched cohort of patients without intervention. Number of intervention categories was compared with primary outcomes.

RESULTS

Patients (n = 1527) were older (78.2 ± 8.3 years) and male (98%). Propensity-matched patients (n = 566) were well matched for age, gender, cognitive deficits, vision impairment, and dehydration. Patients with interventions were discharged to rehabilitation similarly (mean difference [MD] 2.2%, 95% CI -2.5-6.9) and had lower lengths of stay (MD -0.7 day, 95% CI -1.3 to -0.1), lower restraint use (MD -4.0%, 95% CI -6.7 to -1.2) and trended toward lower variable direct costs (MD -$1390, 95% CI -3586-807). Increasing number of interventions was associated with shorter length of stay, lower rate of restraint use, and lower variable direct costs.

CONCLUSIONS

This delirium risk modification project was associated with patient outcomes and reduced costs. Serious consideration should be given to delirium risk identification and modification programs.