Review of nonmedicinal interventions for delirium in older patients

Interventions to prevent delirium that do not involve prescription drugs and have multiple components appeared to be effective at reducing delirium and preventing falls in hospitalized older patients, according to an article published online by JAMA Internal Medicine.

Delirium is a confused state that is marked by inattention and global cognitive dysfunction (impaired memory and thought). Delirium is common among hospitalized older patients and the condition increases the risk of falls, functional decline, dementia, prolonged hospital stays and institutionalization. The Hospital Elder Life Program (HELP) is the original evidence-based approach to target delirium risk factors and it includes practical interventions such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, strategies to improve sleep, and vision and hearing aids, according to background in the study.

Tammy T. Hshieh, M.D., of Brigham and Women's Hospital, Boston, and coauthors reviewed available medical literature and evaluated the evidence on multicomponent nonpharmacological delirium interventions. Their meta-analysis included 14 articles that involved 4,267 patients (average age nearly 80 years) at 12 sites (acute medical and surgical wards).

The authors found that, overall, 11 studies showed significant reductions in the incidence of delirium and four randomized or matched clinical trials reduced delirium by 44 percent. The rate of falls decreased among intervention patients in four studies, and in two randomized or matched trials the rate of falls was reduced by 64 percent. Length of hospital stay and institutionalization also trended toward decreases in intervention groups but the difference was not statistically significant, which the authors explained was not surprising given the multiple complex influences on these outcomes.

"In conclusion, this meta-analysis suggests that multicomponent nonpharmacological interventions are effective in decreasing delirium incidence and preventing falls, potentially saving more than $16 billion annually in the United States alone. Therefore, these strategies hold great promise to influence two of the most important and prevalent conditions affecting seniors during hospitalization. Our systematic review and meta-analysis demonstrate that these interventions decrease the substantial health care and societal burden of delirium incidence and falls, improving quality of life for these patients and their families," the study concludes.

In a related commentary, S. Ryan Greysen, M.D., M.H.S., M.A., of the University of California, San Francisco, writes: "Numerous components of these interventions may simply seem too simple to question that they are not being done already. These include frequent orientation of patients to time, place and situation; early mobilization; attention to hearing and visual deficits and aids as appropriate; preservation of sleep-wake cycles; and adequate hydration. Indeed, it is quite likely that some of these interventions are occurring some of the time at many, if not most, hospitals, but the key to their effectiveness may well lie in the consistency of their application."

"Changing practice in the acute care setting is never easy and is often fraught with great uncertainty about risks and benefits to patients and the system. However, with respect to delirium prevention, the results by Hshieh et al suggest that it may no longer be a matter of evidence or knowing what to do. It may now be a matter of convincing hospitals and health care professionals to just do it," Greysen concludes.