Hospital Elder Life Program in the real world: the many uses of the Hospital Elder Life Program website

Delirium in older adults

This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.

A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons

BACKGROUND/OBJECTIVES

The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium.

DESIGN

Hypothesis testing was carried out using a pretest-posttest design on program administrative data.

SETTING

Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium.

INTERVENTION

A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system.

MEASUREMENTS

Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units.

RESULTS

There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units.

CONCLUSION

Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.

Association Between Characteristics of Injurious Falls and Fall Preventive Interventions in Acute Medical and Surgical Units

BACKGROUND

Hospital falls remain common and approximately 30% of falls in hospital result in injury. The aims of the study were the following: (i) to identify the association between fall interventions present at the time of the injurious fall and injurious faller characteristics and (ii) to identify the association between fall preventive interventions present at the time of the injurious fall and the injurious fall circumstances.

METHODS

Secondary data analysis of deidentified case series of injurious falls across 24 acute medical/surgical units in the United States. Variables of interest were falls prevention interventions (physical therapy, bed alarm, physical restraint, room change, or a sitter) in place at the time of fall. Data were analyzed using logistic regression and hazard ratios.

RESULTS

There were 1,033 patients with an injurious fall, occurrence peaked between Day 1 and Day 4, with 46.8% of injurious falls having occurred by Day 3 of admission. Injurious fallers with a recorded mental state change 24 hours prior to the fall were more likely to have a bed alarm provided (adjusted odds ratio [OR] 2.56, 95% confidence interval [CI] 1.61, 4.08) and receive a physical restraint as fall prevention interventions (adjusted OR 6.36, 95% CI 4.35, 9.30). Injurious fallers restrained fell later (stay Day 6) than those without a restraint (stay Day 4) (p = .007) and had significantly longer lengths of stay (13 days vs 9 days).

CONCLUSIONS

On medical/surgical units, injurious falls occur early following admission suggesting interventions should be commenced immediately. Injurious fallers who had a physical restraint as an intervention had longer lengths of stay.

Activity-based occupational therapy intervention for delirium superimposed on dementia in nursing home setting: a feasibility study

OBJECTIVE

Multi-component interventions can reduce delirium incidence. Occupational therapy (OT) has been effective in the management of dementia. We designed a real-world feasibility study of an OT intervention in the management of delirium superimposed on dementia (DSD).

METHODS

We included a convenient sample of 22 patients older than 65 years of age with delirium and moderate dementia admitted to a nursing home (NH). The OT procedures were standardized according to the level of agitation or sedation of the patient and based on a structured OT evaluation. The Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution.

RESULTS

The mean age was 86.45 ± 6.46 years. The first daily treatment was delivered in the entire sample, while the second was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6. The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min. The mean time of the first treatment varied day 1 through day 6 from 14.8 ± 8.5 to 20 ± 0 min, while the second treatment from 3.9 ± 6.7 to 20.1 ± 0 min. The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution.

CONCLUSIONS

This is the first study to report the feasibility of an OT intervention for the management of DSD in a NH setting. The results are important to support future trials on delirium management in a setting often understudied and underrepresented.

Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness

BACKGROUND

Delirium, defined as an acute disorder of attention and cognition with high morbidity and mortality, can be prevented by multicomponent nonpharmacological interventions. The Hospital Elder Life Program (HELP) is the original evidence-based approach targeted to delirium risk factors, which has been widely disseminated.

OBJECTIVE

To summarize the current state of the evidence regarding HELP and to highlight its effectiveness and cost savings.

METHODS

Systematic review of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1999 to 2017, using a combination of controlled vocabulary and keyword terms.

RESULTS

Of the 44 final articles included, 14 were included in the meta-analysis for effectiveness and 30 were included for examining cost savings, adherence and adaptations, role of volunteers, successes and barriers, and issues in sustainability. The results for delirium incidence, falls, length of stay, and institutionalization were pooled for meta-analyses. Overall, 14 studies demonstrated significant reductions in delirium incidence (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.37-0.59). The rate of falls was reduced by 42% among intervention patients in three comparative studies (OR 0.58, 95% CI 0.35-0.95). In nine studies on cost savings, the program saved $1600-$3800 (2018 U.S. dollars) per patient in hospital costs and over $16,000 (2018 U.S. dollars) per person-year in long-term care costs in the year following delirium. The systematic review revealed that programs were generally successful in adhering to or appropriately adapting HELP (n = 13 studies) and in finding the volunteer role to be valuable (n = 6 studies). Successes and barriers to implementation were examined in 6 studies, including ensuring effective clinician leadership, finding senior administrative champions, and shifting organizational culture. Sustainability factors were examined in 10 studies, including adapting to local circumstances, documenting positive impact and outcomes, and securing long-term funding.

CONCLUSION

The Hospital Elder Life Program is effective in reducing incidence of delirium and rate of falls, with a trend toward decreasing length of stay and preventing institutionalization. With ongoing efforts in continuous program improvement, implementation, adaptations, and sustainability, HELP has emerged as a reference standard model for improving the quality and effectiveness of hospital care for older persons worldwide.

Delirium and correlates of delirium among newly admitted elderly patients: a cross-sectional study in a Saudi general hospital

BACKGROUND

Delirium is a common, often undiagnosed disorder in elderly patients, but no studies have been conducted in Saudi Arabia.

OBJECTIVES

To determine the prevalence of delirium among elderly patients on admission and to identify associated factors.

DESIGN

A cross-sectional study.

SETTING

Tertiary care hospital, Saudi Arabia.

PATIENTS AND METHODS

Elderly patients were evaluated for delirium within 24 hours of admission using the Confusion Assessment Method (CAM). The medical records were also reviewed to identify associated factors and whether the diagnosis of delirium was documented by the admitting physician.

MAIN OUTCOME MEASURES

Prevalence of delirium.

RESULTS

Of 147 patients aged 60 or over screened for delirium within 24 hours of admission, 32 (21.8%) patients were identified with delirium. Seven (21.9%) of the 32 patients with delirium had documentation of their diagnosis in the patient chart by the attending physician. Univariate logistic regression identified greater age (OR=2.70, 95%-CI: 1.21-6.02), higher unemployment rate (OR=3.30, 95%-CI: 1.43-7.61), more often had 3-5 co-morbidities (OR=2.69, 95%-CI: 1.14-6.33), and more cognitive impairment (OR=38.90, 95%-CI: 8.78-172.34) as risk factors for delirium on admission. Multivariate logistic regression analysis identified greater age (OR=2.53, 95%-CI: 1.08-5.88), higher unemployment rate (OR=3.73, 95%-CI: 1.52-9.13) and 3-5 co-morbidities (OR=3.31, 95%-CI: 1.30-8.46) as risk factors for delirium.

CONCLUSIONS

Delirium was common and frequently not recognized in elderly patients admitted to the hospital. Administration of the CAM was very helpful in identifying delirium at admission.

LIMITATIONS

The main limitation of our study was the relatively small number of patients which might have limited the power to detect some associations.

Nursing assessment as an effective tool for the identification of delirium risk in older in-patients: A case-control study

AIMS AND OBJECTIVES

To evaluate the usefulness of comprehensive nursing assessment as a strategy for determining the risk of delirium in older in-patients from a model of care needs based on variables easily measured by nurses.

BACKGROUND

There are many scales of assessment and prediction of risk of delirium, but they are little known and infrequently used by professionals. Recognition of delirium by doctors and nurses continues to be limited.

DESIGN AND METHODS

A case-control study. A specific form of data collection was designed to include the risk factors for delirium commonly identified in the literature and the care needs evaluated from the comprehensive nursing assessment based on the Virginia Henderson model of care needs. We studied 454 in-patient units in a basic general hospital. Data were collected from a review of the records of patients' electronic clinical history.

RESULTS

The areas of care that were significant in patients with delirium were dyspnoea, problems with nutrition, elimination, mobility, rest and sleep, self-care, physical safety, communication and relationships. The specific risk factors identified as independent predictors were as follows: age, urinary incontinence, urinary catheter, alcohol abuse, previous history of dementia, being able to get out of bed/not being at rest, habitual insomnia and history of social risk.

CONCLUSIONS

Comprehensive nursing assessment is a valid and consistent strategy with a multifactorial model of delirium, which enables the personalised risk assessment necessary to define a plan of care with specific interventions for each patient to be made.

RELEVANCE TO CLINICAL PRACTICE

The identification of the risk of delirium is particularly important in the context of prevention. In a model of care based on needs, nursing assessment is a useful component in the risk assessment of delirium and one that is necessary for developing an individualised care regime.