Multicomponent Interventions Reduce High‐Risk Medications for Delirium in Hospitalized Older Adults

Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology‐assisted medication review, age‐conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.     

The 6‐ and 12‐Month Outcomes of Older Medical Inpatients Who Recover from Subsyndromal Delirium

OBJECTIVES: To compare the 6‐ and 12‐month outcomes of patients who recovered from subsyndromal delirium (SSD) by 8 weeks with the outcomes of patients who did not recover or did not have an index episode. DESIGN: Secondary analysis of data collected for a cohort study of the prognosis of delirium. SETTING: University‐affiliated primary acute care hospital. PARTICIPANTS: Older medical inpatients with prevalent, incident, or no SSD were classified into three mutually exclusive groups at 8 weeks (SSD‐recovered, SSD‐not recovered, no SSD) and followed up at 6 and 12 months. MEASUREMENTS: The primary hierarchical composite outcome was death, institutionalization, or cognitive or functional decline at 6 and 12 months. In secondary analyses, components of the primary outcome were examined separately. RESULTS: Of the 129 patients assessed at 8 weeks, 51, 47, and 31 met criteria for SSD‐recovered, SSD‐not recovered and no SSD, respectively. At 6 and 12 months, the primary and secondary outcomes of the SSD‐recovered group were better than the outcomes of the SSD‐not recovered group and, for the most part, intermediate between the outcomes of the SSD‐not recovered and no SSD groups. CONCLUSION: Recovery from SSD appears to predict better longer‐term outcomes than no recovery. Efforts to identify and treat SSD in older medical inpatients may improve outcomes.     

American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.     

The Overlap Syndrome of Depression and Delirium in Older Hospitalized Patients

OBJECTIVES: To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients.
DESIGN: Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial.
SETTING: General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge.
PARTICIPANTS: Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission.
MEASUREMENTS: Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year.
RESULTS: Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57–18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14–9.56) than patients with neither condition.
CONCLUSION: The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients.     

Hazards of Hospitalization: Hospitalists and Geriatricians Educating Medical Students About Delirium and Falls in Geriatric Inpatients

ABSTRACT

Geriatric patients are at increased risk for complications from delirium or falls during hospitalization. Medical education, however, generally places little emphasis on the hazards of hospitalization for older inpatients. Geriatricians conducted a faculty development workshop for hospitalists about the hazards of hospitalization for geriatric patients, focusing on two common geriatric syndromes: delirium and falls. The hospitalists then ran workshops for third-year medical students during their inpatient medicine clerkship, introducing two simple tools for assessing fall risk and diagnosing delirium. Students used these tools to evaluate their own patients and then reviewed cases with a geriatrician at the end of one month. A total of 101 students participated in the project and completed a post-intervention multiple choice test, and 73 (72.2%) returned the records of 278 patient evaluations. Compared to the control group from the end of the previous year, test scores increased by an average of 0.84 out of 9 points (9.3% increase, p?=?0.005, t _117,.05/2?= 2.87, p?=?0.0048). Students also identified 81 patients with delirium and 65 patients at high risk for falling. Hospitalists and geriatricians can effectively partner to increase students' knowledge of two major hazards of hospitalization for geriatric patients.