Therapeutics
Review: Multicomponent nonpharmacologic interventions reduce incident delirium in inpatients Clinical impact ratings:
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Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175:512-20.
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Question
Commentary
In older hospitalized patients, do nonpharmacologic multicomponent interventions (NPMIs) reduce incident delirium?
Of the 14 studies included in the meta-analysis by Hshieh and colleagues, 9 based their NPMIs on adaptations of the Hospital Elder Life Program (HELP) (1), which targets 6 straightforward interventions: frequent reorientation, mental engagement through activities, early mobilization, providing hearing aids and eyeglasses, adequate oral hydration, and sleep hygiene. As shown by Hshieh and colleagues, NPMIs reduce delirium incidence in medical and surgical patients. Given the strong association of delirium with longer length of stay, the failure of NPMIs to shorten length of stay is paradoxical. Even among higherquality studies, study heterogeneity resulting from differences in how well the NPMIs were applied, diagnoses, severity of illness, and other patient characteristics may have contributed to the observed failure of NPMIs to shorten length of stay.
Review scope Included studies compared NPMIs to prevent delirium with controls in hospital inpatients and measured delirium incidence during hospitalization with a validated instrument. Studies were included if the mean or median age of included patients was ≥ 65 years. Studies of patients with terminal illness were excluded. Outcomes included delirium incidence, falls, length of hospital stay, discharge to institution, change in functional status, and change in cognitive status.
Review methods MEDLINE, Cochrane Database of Systematic Reviews, ScienceDirect, Google Scholar, and reference lists (1999 to Dec 2013) were searched for studies published in English. Qualitative studies, case series, reviews, and cost-effectiveness analyses were excluded. 14 studies (n = 4267, mean age 80 y), with durations of 3 to 36 months, met the selection criteria. 4 randomized controlled trials (RCTs), 2 matched studies, and 8 studies with unmatched or historical controls were included. Settings were acute medical and surgical wards. 9 studies used ≥ 4 of 6 evidence-based interventions (cognition or orientation, early mobility, hearing, sleep–wake cycle preservation, vision, and hydration).
Despite the conceptual simplicity of NPMIs, resource-intensive protocols like HELP require substantial institutional commitment. The 57% relative risk reduction for inpatient falls associated with NPMIs suggests that they may generate savings for US hospitals, which cannot charge the federal government for costs related to inpatient falls. Prophylactic antipsychotics have been associated with a 50% risk reduction (95% CI 0.34 to 0.73) in the incidence of delirium in postoperative, predominantly orthopedic, patients (2), but their use remains controversial because of the risk for oversedation and resulting complications, including aspiration and falls. The optimal dosing and duration of treatment with antipsychotics remain uncertain.
Main results
Diphenhydramine and benzodiazepines have been associated with delirium (3). Physicians can play a critical role in delirium prevention by minimizing anticholinergic and sedating medications, optimizing nonopiate pain management, and reducing risk factors for nosocomial infection.
Meta-analysis of RCTs and matched studies showed that multicomponent nonpharmacologic interventions reduced risk for incident delirium and falls (Table). Intervention and control groups did not differ for hospital length of stay, discharge to institution (Table), change in functional status, or change in cognitive status.
Calvin Hirsch, MD University of California, Davis Sacramento, California, USA
Conclusion In older hospitalized patients, multicomponent nonpharmacologic delirium prevention interventions reduce incident delirium.
References 1. Yue J, Tabloski P, Dowal SL, et al. NICE to HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice. J Am Geriatr Soc. 2014;62:754-61.
Source of funding: National Institute on Aging. For correspondence: Dr. T.T. Hshieh, Brigham and Women's Hospital, Boston, MA, USA. E-mail [email protected].
2. Zhang H, Lu Y, Liu M, et al. Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials. Crit Care. 2013;17:R47. 3. Rothberg MB, Herzig SJ, Pekow PS, et al. Association between sedating medications and delirium in older inpatients. J Am Geriatr Soc. 2013;61:923-30.
Nonpharmacologic multicomponent delirium interventions vs control in older hospital inpatients* Outcomes
Number of studies (n)
Falls/1000 patient-d
At 3 to 36 mo
Intervention
Control
RRR (95% CI)
Falls
2 (485)
4.3
12.9
57% (32 to 72)
15 (12 to 20)†
Delirium incidence
4 (1986)
8.1%
40% (21 to 54)
20 (13 to 34)
Discharge to institution
2 (777)
NNT (CI)
Weighted event rates 14%
26%
27%
4% (⫺20 to 25)
Not significant
*Abbreviations defined in Glossary. Meta-analyses included randomized and matched controlled trials only. Weighted intervention event rates, RRR, and CI calculated from control event rates and odds ratios in article using a fixed-effect model. †NNT and CI provided by author.
姝 2015 American College of Physicians
JC4
ACP Journal Club
Annals of Internal Medicine
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/934240/ by a NYU Medical Center Library User on 04/23/2017
21 Jul 2015
Review: Multicomponent nonpharmacologic interventions reduce incident delirium in inpatients Clinical impact ratings:
多多多多多多夞
Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175:512-20.
多多多多多多夞
Question
Commentary
In older hospitalized patients, do nonpharmacologic multicomponent interventions (NPMIs) reduce incident delirium?
Of the 14 studies included in the meta-analysis by Hshieh and colleagues, 9 based their NPMIs on adaptations of the Hospital Elder Life Program (HELP) (1), which targets 6 straightforward interventions: frequent reorientation, mental engagement through activities, early mobilization, providing hearing aids and eyeglasses, adequate oral hydration, and sleep hygiene. As shown by Hshieh and colleagues, NPMIs reduce delirium incidence in medical and surgical patients. Given the strong association of delirium with longer length of stay, the failure of NPMIs to shorten length of stay is paradoxical. Even among higherquality studies, study heterogeneity resulting from differences in how well the NPMIs were applied, diagnoses, severity of illness, and other patient characteristics may have contributed to the observed failure of NPMIs to shorten length of stay.
Review scope Included studies compared NPMIs to prevent delirium with controls in hospital inpatients and measured delirium incidence during hospitalization with a validated instrument. Studies were included if the mean or median age of included patients was ≥ 65 years. Studies of patients with terminal illness were excluded. Outcomes included delirium incidence, falls, length of hospital stay, discharge to institution, change in functional status, and change in cognitive status.
Review methods MEDLINE, Cochrane Database of Systematic Reviews, ScienceDirect, Google Scholar, and reference lists (1999 to Dec 2013) were searched for studies published in English. Qualitative studies, case series, reviews, and cost-effectiveness analyses were excluded. 14 studies (n = 4267, mean age 80 y), with durations of 3 to 36 months, met the selection criteria. 4 randomized controlled trials (RCTs), 2 matched studies, and 8 studies with unmatched or historical controls were included. Settings were acute medical and surgical wards. 9 studies used ≥ 4 of 6 evidence-based interventions (cognition or orientation, early mobility, hearing, sleep–wake cycle preservation, vision, and hydration).
Despite the conceptual simplicity of NPMIs, resource-intensive protocols like HELP require substantial institutional commitment. The 57% relative risk reduction for inpatient falls associated with NPMIs suggests that they may generate savings for US hospitals, which cannot charge the federal government for costs related to inpatient falls. Prophylactic antipsychotics have been associated with a 50% risk reduction (95% CI 0.34 to 0.73) in the incidence of delirium in postoperative, predominantly orthopedic, patients (2), but their use remains controversial because of the risk for oversedation and resulting complications, including aspiration and falls. The optimal dosing and duration of treatment with antipsychotics remain uncertain.
Main results
Diphenhydramine and benzodiazepines have been associated with delirium (3). Physicians can play a critical role in delirium prevention by minimizing anticholinergic and sedating medications, optimizing nonopiate pain management, and reducing risk factors for nosocomial infection.
Meta-analysis of RCTs and matched studies showed that multicomponent nonpharmacologic interventions reduced risk for incident delirium and falls (Table). Intervention and control groups did not differ for hospital length of stay, discharge to institution (Table), change in functional status, or change in cognitive status.
Calvin Hirsch, MD University of California, Davis Sacramento, California, USA
Conclusion In older hospitalized patients, multicomponent nonpharmacologic delirium prevention interventions reduce incident delirium.
References 1. Yue J, Tabloski P, Dowal SL, et al. NICE to HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice. J Am Geriatr Soc. 2014;62:754-61.
Source of funding: National Institute on Aging. For correspondence: Dr. T.T. Hshieh, Brigham and Women's Hospital, Boston, MA, USA. E-mail [email protected].
2. Zhang H, Lu Y, Liu M, et al. Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials. Crit Care. 2013;17:R47. 3. Rothberg MB, Herzig SJ, Pekow PS, et al. Association between sedating medications and delirium in older inpatients. J Am Geriatr Soc. 2013;61:923-30.
Nonpharmacologic multicomponent delirium interventions vs control in older hospital inpatients* Outcomes
Number of studies (n)
Falls/1000 patient-d
At 3 to 36 mo
Intervention
Control
RRR (95% CI)
Falls
2 (485)
4.3
12.9
57% (32 to 72)
15 (12 to 20)†
Delirium incidence
4 (1986)
8.1%
40% (21 to 54)
20 (13 to 34)
Discharge to institution
2 (777)
NNT (CI)
Weighted event rates 14%
26%
27%
4% (⫺20 to 25)
Not significant
*Abbreviations defined in Glossary. Meta-analyses included randomized and matched controlled trials only. Weighted intervention event rates, RRR, and CI calculated from control event rates and odds ratios in article using a fixed-effect model. †NNT and CI provided by author.
姝 2015 American College of Physicians
JC4
ACP Journal Club
Annals of Internal Medicine
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/934240/ by a NYU Medical Center Library User on 04/23/2017
21 Jul 2015
