While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.
In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:
- Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
- Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
- Early mobilization. Get all patients up and walking three times a day;
- Vision and hearing adaptations;
- Feeding assistance and hydration assistance with encouragement/companionship during meals; and
- Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.
A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.
Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH
Sheri Polley is a frequent contributor to The Hospitalist.
References
- Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
- Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
- Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
- McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
- Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.