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evident
Original paper
1999NEJMHospital Medicine/General Medicine

Hospital Elder Life Program

A multicomponent intervention to prevent delirium in hospitalized older patients

CohortDelirium

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Overview

In matched older medical inpatients, a multicomponent risk-factor program was associated with less delirium than usual care; this was not a randomized trial.

Clinical takeaway

This controlled, non-randomized, matched-unit study associated a six-risk-factor program with less incident delirium. It does not show that treatment changes severity or recurrence once delirium has started.

Key result

Among 852 matched patients, delirium developed in 9.9% of the intervention group vs 15.0% of usual care (matched OR 0.60, 95% CI 0.39-0.92). Days with delirium (105 vs 161) and episodes (62 vs 90) were lower; severity and recurrence rates were not significantly different.

Practice impact

A structured, multicomponent prevention bundle was associated with less delirium; this is matched, non-randomized evidence, not a randomized trial.

Evidence

Study design

Controlled, non-randomized trial of 852 patients from one intervention unit and two usual-care units, enrolled with a prospective matching strategy.

Enrollment

852

Follow-up

Daily until hospital discharge.

Geography

Not listed

Clinical question

Is a multicomponent strategy targeting delirium risk factors associated with less delirium than usual care in hospitalized older adults?

Population

  • Eight hundred fifty-two patients 70 years of age or older admitted to the general-medicine service at a teaching hospital, matched from one intervention unit and two usual-care units.

Intervention

Standardized protocols for six delirium risk factors: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration.

Comparator

Usual care on two general-medicine units, with prospective matching.

Primary outcome

Delirium, assessed daily until discharge.

In this matched, non-randomized comparison, the intervention was associated with less incident delirium. Severity and recurrence were not significantly different.

Matched odds ratio / 0.6 / 95% CI 0.39-0.92

Key results

  • Delirium developed in 9.9% of the intervention group vs 15.0% of the usual-care group (matched odds ratio 0.60, 95% CI 0.39-0.92).
  • Total days with delirium (105 vs 161; P=0.02) and total episodes (62 vs 90; P=0.03) were lower in the intervention group.
  • Severity of delirium and recurrence rates were not significantly different.
  • Overall adherence was 87%. Targeted risk factors per patient were significantly reduced. The intervention was associated with significant improvement in cognitive impairment among those who had it at admission and with less sleep-medication use among all patients; immobility, visual impairment, and hearing impairment showed only trends.

Harms

Not listed.

Clinical Use

Practice impact

  • A unit-based bundle targeting cognition, sleep, mobility, vision, hearing, and hydration was associated with less incident delirium in matched older medical inpatients.
  • Once delirium occurred, this program was not associated with lower severity or recurrence; prevention is the signal.

Applicability

  • Most applicable to patients 70 years or older on a general-medicine service in a teaching hospital, compared across matched units rather than randomized assignment.

Limitations

  • This was a controlled, non-randomized trial with prospectively matched patients, not a randomized trial.
  • Assignment was by hospital unit (one intervention unit and two usual-care units), so unmeasured unit differences can still confound.
  • The study was done at a single teaching hospital.
  • The intervention did not significantly change delirium severity or recurrence.

Common misinterpretations

  • Do not cite this as a randomized trial. Patients were matched across units.
  • An association with fewer incident cases is not evidence that the same program treats established delirium.

Citation

Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676. doi:10.1056/NEJM199903043400901

The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients.