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Non-pharmaceutical Techniques Can Decrease Delirium, Associated Problems

BOSTON – As complicated as hospital care for an older patient can be, delirium multiples the difficulties many times over.

A sudden onset of confusion, which frequently is seen in older patients, increases the risk of falls, often leads to lengthy hospital stays and can contribute to more than over $164 billion in healthcare costs, according to a study published recently in JAMA Internal Medicine.

A study team from Brigham and Women’s Hospital and Hebrew SeniorLife’s Institute for Aging Research, suggest that delirium is preventable and that non-medication strategies can reduce risk and improve outcomes.

To reach those results, researchers conducted a meta-analysis of 14 studies involving multi-component non-pharmacologic interventions for delirium.

"Delirium is a major problem at many hospitals and preventing its downstream consequences, including falls, is a priority,” said lead author Tammy Hshieh, MD. “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.”

Six interventions that targeted delirium risk factors, guided by principles derived from the original delirium prevention study, the Hospital Elder Life Program, were reviewed.

Interventions included strategies:

  • To improve patients’ nutrition and hydration;
  • To ensure uninterrupted sleep;
  • To make available daily exercise and therapeutic activities to improve cognition; and
  • To introduce “re-orientation” techniques such as 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,” explained senior author Sharon K. Inouye, MD, MPH. “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.”

Older patients who received non-medication based interventions were at decreased risk of both delirium and falls, according to study results. The authors also say they found trends toward decreased length of hospital stay and institutionalization. Based on their results, they estimate that, each year, about 1 million cases of delirium could be prevented using non-medication based interventions, resulting in a Medicare cost savings of $10 billion per year.

The report notes that 29-64% of hospitalized elderly patients suffer from delirium, with the wide range and under-diagnosis explained by its confusing presentation. Patients can exhibit anything from agitation to confusion or just be non-responsive.

“Multicomponent non-pharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization,” the authors conclude. “Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.”