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Volume 340:669-676 March 4, 1999 Number 9 Next

	Full Text PDF Editorial by Rowe, J. W. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.

Methods We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge.

Results Delirium developed in 9.9 percent of the intervention group, as compared with 15.0 percent of the usual-care group (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and with a significant reduction in the rate of use of sleep medications among all patients. Among the other risk factors, there were trends toward improvement in immobility, visual impairment, and hearing impairment.

Conclusions 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. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Source Information

From the Departments of Internal Medicine (S.K.I., S.T.B., D.A., L.M.C.) and Epidemiology and Public Health (P.A.C., L.L.-S., T.R.H.), Yale University School of Medicine, New Haven, Conn.

Address reprint requests to Dr. Inouye at the Yale University School of Medicine, 20 York St., Tompkins 15, New Haven, CT 06504.

Full Text of this Article

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Delirium in Hospitalized Older Patients
Leff B., Portnoi V.A., Redling T., Amesty S.C., Schwartz C. E., Snyder B. D., Inouye S. K.
Extract | Full Text  
N Engl J Med 1999; 341:369-370, Jul 29, 1999. Correspondence

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• Cole, M. G. (2005). Delirium in Elderly Patients. Focus 3: 320-332 [Abstract] [Full Text]  
• Adamis, D, Martin, F C, Treloar, A, Macdonald, A J D (2005). Capacity, consent, and selection bias in a study of delirium. J. Med. Ethics 31: 137-143 [Abstract] [Full Text]  
• Allore, H. G, Tinettia, M. E, Gill, T. M, Peduzzi, P. N (2005). Experimental designs for multicomponent interventions among persons with multifactorial geriatric syndromes. Clin Trials 2: 13-21 [Abstract]  
• Ellis, G., Langhorne, P. (2005). Comprehensive geriatric assessment for older hospital patients. Br Med Bull 71: 45-59 [Abstract] [Full Text]  
• Kishi, Y., Meller, W. H., Kathol, R. G., Swigart, S. E. (2004). Factors Affecting the Relationship Between the Timing of Psychiatric Consultation and General Hospital Length of Stay. Psychosomatics 45: 470-476 [Abstract] [Full Text]  
• Wood, K. A., Marik, P. E. (2004). ICU Care at the End of Life. Chest 126: 1403-1406 [Full Text]  
• Hjermstad, M. J, Loge, J. H, Kaasa, S. (2004). Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research. Palliat Med 18: 494-506 [Abstract]  
• Han, C.-S., Kim, Y.-K. (2004). A Double-Blind Trial of Risperidone and Haloperidol for the Treatment of Delirium. Psychosomatics 45: 297-301 [Abstract] [Full Text]  
• Ely, E. W., Dittus, R. S. (2004). Pharmacological Treatment of Delirium in the Intensive Care Unit--Reply. JAMA 292: 168-169 [Full Text]  
• Penson, R. T., Daniels, K. J., Lynch, T. J. Jr. (2004). Too Old to Care?. The Oncologist 9: 343-352 [Abstract] [Full Text]  
• Lipsitz, L. A. (2004). Physiological Complexity, Aging, and the Path to Frailty. Sci Aging Knowl Environ 2004: pe16-pe16 [Abstract] [Full Text]  
• Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E. Jr, Inouye, S. K., Bernard, G. R., Dittus, R. S. (2004). Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care Unit. JAMA 291: 1753-1762 [Abstract] [Full Text]  
• Ajilore, O. A., Kumar, A. (2004). Delirium and Dementia. Focus 2: 210-220 [Abstract] [Full Text]  
• Katz, I. R., Curyto, K. J., TenHave, T., Mossey, J., Sands, L., Kallan, M. J. (2004). Validating the Diagnosis of Delirium and Evaluating Its Association With Deterioration Over a One-Year Period. Focus 2: 314-323 [Abstract] [Full Text]  
• Flaherty, J. H., Morley, J. E. (2004). Delirium: A Call to Improve Current Standards of Care. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59: M341-M343 [Full Text]  
• Bourdel-Marchasson, I., Vincent, S., Germain, C., Salles, N., Jenn, J., Rasoamanarivo, E., Emeriau, J.-P., Rainfray, M., Richard-Harston, S. (2004). Delirium Symptoms and Low Dietary Intake in Older Inpatients Are Independent Predictors of Institutionalization: A 1-Year Prospective Population-Based Study. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59: M350-M354 [Abstract] [Full Text]  
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• Burns, A, Gallagley, A, Byrne, J (2004). Delirium. J. Neurol. Neurosurg. Psychiatry 75: 362-367 [Abstract] [Full Text]  
• Serio, R. N (2004). Acute Delirium Associated with Combined Diphenhydramine and Linezolid Use. The Annals of Pharmacotherapy 38: 62-65 [Abstract] [Full Text]  
• Cacchione, P. Z., Culp, K., Dyck, M. J., Laing, J. (2003). Risk for Acute Confusion in Sensory-Impaired, Rural, Long-Term-Care Elders. Clin Nurs Res 12: 340-355 [Abstract]  
• Landefeld, C S. (2003). Improving Health Care for Older Persons. ANN INTERN MED 139: 421-424 [Abstract] [Full Text]  
• Kane, R. L. (2003). The Contribution of Geriatric Health Services Research to Successful Aging. ANN INTERN MED 139: 460-462 [Abstract] [Full Text]  
• Morley, J. E., Flaherty, J. H., Thomas, D. R. (2003). Editorial: Geriatricians, Continuous Quality Improvement, and Improved Care for Older Persons. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58: M809-812 [Full Text]  
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• Gitlin, L. N., Winter, L., Corcoran, M., Dennis, M. P., Schinfeld, S., Hauck, W. W. (2003). Effects of the Home Environmental Skill-Building Program on the Caregiver-Care Recipient Dyad: 6-Month Outcomes From the Philadelphia REACH Initiative. Gerontologist 43: 532-546 [Abstract] [Full Text]  
• Fleminger, S. (2003). Managing agitation and aggression after head injury. BMJ 327: 4-5 [Full Text]  
• Cole, M. G., Dendukuri, N. (2003). Risk Factors for Depression Among Elderly Community Subjects: A Systematic Review and Meta-Analysis. Am. J. Psychiatry 160: 1147-1156 [Abstract] [Full Text]  
• Cook, D. J., Rooke, G. A. (2003). Priorities in Perioperative Geriatrics. Anesth. Analg. 96: 1823-1836 [Full Text]  
• Inouye, S. K., Bogardus, S. T. Jr, Williams, C. S., Leo-Summers, L., Agostini, J. V. (2003). The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions: Evidence From the Delirium Prevention Trial. Arch Intern Med 163: 958-964 [Abstract] [Full Text]