A program designed to reduce six risk factors for delirium in hospitalized patients 70 years old or older successfully cut the number of patients who developed symptoms by 40 percent compared to a control group, a Yale study has shown. Published in the March 4 issue of the New England Journal of Medicine, the study measured the effectiveness of the first major clinical program designed to prevent rather than treat delirium, which can be a major obstacle to recovery in older hospitalized patients. "It's not unusual for active, independent older people to start a downward spiral, both mentally and physically, during a routine hospital stay. As a result, they may require long-term home care after hospitalization, or even a transfer to a rehabilitation center or nursing home," says Dr. Sharon Inouye, associate professor of medicine and geriatrics at the School of Medicine and the study's leader. "We wanted to see if some common-sense steps to reduce well-known risk factors for delirium would help prevent that downward spiral from starting." The result was the Elder Life Program, which focuses on reducing six risk factors for delirium: vision loss, hearing impairment, dehydration, sleep deprivation, cognitive impairment and immobility from prolonged bed rest. The program was tested in a study of 852 patients between the ages of 70 and 97 treated at Yale-New Haven Hospital from March 1995 through March 1998. So successful were the results that the program was adopted recently by the hospital's board as a permanent program and now serves more than 800 elderly patients a year, Inouye says. In the Yale study, patients showed significantly less disorientation with the help of trained volunteers and various memory aids, such as a bedside bulletin board with a daily schedule of tests and activities, along with doctors' and nurses' names. The volunteers helped patients fight the effects of immobility by taking them for walks three times a day; reduced their need for sleep sedatives by giving them warm milk, back rubs and relaxation audiotapes at night; and played word games and talked about current events with them to keep them mentally active. The 40 volunteers, each of whom spent 16 hours in classroom training and an additional 16 hours observing an experienced volunteer, provided help for each patient 20-30 minutes, three times daily. An interdisciplinary team that included specially trained elder life specialists, a nurse specialist, a geriatric physician, rehabilitation specialists, a geriatric chaplain, a dietician and a pharmacist also worked with patients to reduce dehydration, restore muscle strength, avoid over-medication and reduce anxiety. Nurses joined in the program with unit-wide noise reduction at night to enhance sleep. They used silent pill crushers and vibrating beepers, monitored hallway noise, and adjusted the nightly medication routine and taking of vital signs to reduce sleep interruption. Preventing delirium In the study, each patient in the intervention group was matched with a patient in a control group of similar age, gender and delirium risk, yielding matched-odds ratios. The matched design of this study is an important innovation, providing a much-needed alternative when randomization to study groups is not possible, Inouye explains. The final study included 426 matched pairs (852 subjects). None of the patients showed delirium upon admission, although they were categorized as either intermediate or high risk for developing delirium. The researchers found that delirium developed in only 9.9 percent of the intervention group, compared with 15 percent of the control group receiving routine care -- a 40 percent lower rate in matched analyses. Significantly lower rates for the intervention group also were found in total delirium days (105 days vs. 161 days) and number of delirium episodes (62 vs. 90). "The intervention program was most effective in patients at intermediate risk for delirium," Inouye says. "Once delirium occurs, however, the cat's more-or-less out of the bag. The intervention has no significant effect on severity or recurrence, showing that prevention of delirium is much more effective than treatment." Incidence on the rise Each year, delirium complicates hospital stays for more than 2.3 million older persons, involving more than 17.5 million inpatient days and accounting for more than $4 billion (1994 dollars) of Medicare expenditures, according to a 1996 U.S. Bureau of the Census statistical abstract. The incidence of delirium is expected to increase with the aging of the population in coming years as baby boomers retire. Total cost for the Elder Life Program was $139,506, or $327 per patient in the intervention group. Because there were 22 fewer cases of delirium in the intervention group, the cost per delirium case prevented was $6,341, Inouye says. That compares favorably with costs for other prevention programs, such as falls prevented ($7,727-$11,834 per case), and heart attacks prevented ($19,800-$42,900 per case). "While most studies have focused on treating symptoms of delirium after they appear, the Elder Life Program is the first major clinical program with the goal of preventing delirium. The practical, real-world nature of the interventions is a major strength of this study," Inouye says. "We need further evaluation to determine cost-effectiveness and the impact of the program on mortality, rehospitalization, institutionalization, home health care and long-term cognitive function. But the early results are extremely promising." Inouye, who is codirector of the Claude D. Pepper Older Americans Independence Center at the school of medicine, received the 1998 Otsuka/American Geriatrics Society Outstanding Scientific Achievement for Clinical Investigation Award., which recognized her for clinical research with older adults as a physician/investigator involved in direct patient care. Other members of the research team were Drs. Sidney T. Bogardus Jr. and Leo M. Cooney Jr.; biostatistician Theodore R. Holford; data analysts Peter A. Charpentier and Linda Leo-Summers; and project manager Denise Acampora. This research was funded by the National Institute on Aging, the Commonwealth Fund, The Retirement Research Foundation, the Community Foundation for Greater New Haven, and The Patrick and Catherine Weldon Donaghue Medical Research Foundation. T H I SW E E K ' SS T O R I E S Yale study finds Elder Life Program helps curb 'downward spiral' . . . 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PHOTO BY MICHAEL MARSLAND  In the Elder Life Program, volunteers take elderly hospitalized patients on walks three times daily to fight the effect of immobility.