The Yale–New Haven Hospital's Elder Life Program was recently found to have achieved remarkable results in preventing delirium in older hospitalized patients. The study, directed by Sharon Inouye, M.D., associate professor of medicine and geriatrics at the Yale University School of Medicine, and published in the March 4 issue of the New England Journal of Medicine, discovered that of 852 patients ages 70 to 92 at risk for delirium, a full 40 percent who participated in the program showed significantly less delirium than a control group. The program has now been adopted permanently by the hospital's board and serves more than 800 elderly patients per year.
Inouye's study, conducted from March 1995 through March 1998 and supported in part by The Commonwealth Fund, measured the effectiveness of the first major clinical program to prevent, rather than treat, delirium—a major obstacle to recovery in older hospitalized patients. The Yale program focuses on reducing six well-known risk factors for delirium: vision loss, hearing impairment, dehydration, sleep deprivation, cognitive impairment, and immobility from prolonged bed rest.
The study involved a group of trained volunteers and the use of various memory aids, such as bedside bulletin boards and a daily schedule of tests and activities. The volunteers helped patients counter the effects of immobility by taking them for walks three times a day; reduced their need for sleep sedatives by giving them warm milk and back rubs and playing relaxation audiotapes at night; and helped keep them mentally active by playing word games and discussing current events. An interdisciplinary team that included Elder Life specialists, a nurse specialist, a geriatric physician, a geriatric chaplain, a dietician, and a pharmacist also worked with patients to reduce dehydration, restore muscle strength, avoid overmedication, and lessen anxiety. Nurses joined in the program by working to reduce noise at night, using silent pill-crushers and vibrating beepers, and adjusting patients' nightly medication routine and the taking of vital signs to minimize sleep interruptions.
The Yale study's findings lend strong support for the use of a multifaceted, targeted approach to prevent delirium in older hospitalized patients. Although a formal analysis of the Elder Life Program's cost-effectiveness is needed, the estimated cost per case of delirium prevented compares favorably with the estimated costs of preventing falls and heart disease among elderly patients in other studies. A complete assessment of delirium-related health care costs may indeed show that the intervention produces net savings.
Facts and Figures
- Delirium, also known as acute confusional state, is a common and serious source of morbidity and mortality among older hospitalized patients.
- Each year, delirium complicates the hospital stays of more than 2.3 million elderly patients and accounts for more than $4 billion of Medicare expenditures.
- The Yale program is most effective with patients who are at intermediate risk for delirium. Once delirium has occurred, the intervention is less effective.