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Hospitals may be able to reduce the number and duration of sudden episodes of delirium in at-risk older patients by using a new clinical approach, according to results of a study appearing in the March 4, 1999 issue of the New England Journal of Medicine 1 . The study, conducted at Yale-New Haven Hospital in Connecticut, is the first large-scale clinical trial targeted toward prevention of delirium, a condition which is prevalent among hospitalized older adults and is a frequent contributor to hospital complications and death. The National Institute on Aging (NIA) funded the study.
"Delirium is an extremely frustrating and often harmful problem for patients, hospital staff, and families alike," said Sharon K. Inouye, M.D., M.P.H., Associate Professor of Medicine at Yale University School of Medicine, who directed the study. "We now know that there are a set of clearly identifiable factors that place patients at risk for development of delirium. By addressing each of these within a team setting, we may actually be able to prevent a very troubling condition."
In the study, participants were divided into two groups: those receiving usual, standard hospital care or those receiving care under a multidisciplinary team of specialists, including staff nurses, nurse specialists, recreational therapists, physical therapists, geriatricians, and trained volunteers. While 15 percent of those receiving standard hospital services experienced at least one episode of delirium, only 9.9 percent of those receiving the team approach experienced an episode. Patients receiving the multicomponent approach experienced fewer episodes and a reduction in the number of days of delirium. However, the intervention did not affect either the duration of hospital stay or the rate of readmission.
Study investigators found the significant benefits of the team approach by targeting patients with one or more of six risk factors for delirium, including cognitive impairment, sleep deprivation, immobility, dehydration, or impaired vision or hearing. To address these risk factors, care-team members used targeted intervention protocols, such as word games and orientation and memory aids to sharpen thinking; relaxation tapes, massage, and warm drinks at bedtime to promote sleep; exercise to increase mobility; vision and hearing aids to improve sight and hearing; and provision of oral fluids to prevent dehydration.
"Once delirium occurs, the cat's out of the bag," says Dr. Inouye. "It seems that prevention is much more effective than treatment. We found that we could indeed prevent episodes of delirium using this approach, but not recurrences. The greatest effect was on prevention of an initial episode of delirium. We were also able to substantially reduce the total number of targeted risk factors for delirium in hospitalized patients, and we also saw improved cognition, reduced need for sedative drugs for sleep, and increased mobility, vision, and hearing. The matched design of this clinical trial provides a much-needed alternative when randomization to study groups is not possible."
The total cost of the Yale program, called the Elder Life Program, was $139,506, or $327 per patient. All 852 participants in the 3-year study were over the age of 70 and were patients at Yale's teaching hospital.
"This study of delirium shows the consequence of not following best practices -- like making sure patients wear their glasses and hearing aids, making sure they get enough water to drink, enough sleep, and exercise for mobility," said Neil Buckholtz, Ph.D., Chief of the NIA's Dementia Branch. "In addition, a low-tech intervention of this type might make adult hospitalization a less frightening experience for patients."
Sharon K. Inouye, M.D., M.P.H., Sidney T. Bogardus, Jr., M..D., Peter A. Charpentier, M.P.H., Linda Leo-Summers, M.P.H., Denise Acampora, M.P.H., Theodore R. Holford, Ph.D., and Leo M. Cooney, Jr, M.D. "A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients," New England Journal of Medicine , March 4, 1999, pp. 669-676.
The NIA is one of 25 Institutes and Centers at the National Institutes of Health and supports basic, clinical, epidemiological, and social research on aging and on the special needs of older people.