In our August 9, 2011 Patient Safety Tip of the Week Frailty and the Surgical Patient we discussed the significant risks of surgery in the elderly and fact that outcomes in this population, particularly the frail elderly, are often not good. We also discussed the value of tools such as the frailty index in predicting outcomes in that group. But we also lamented the fact that predictive tools are just that they often are good at predicting outcomes but dont allow you to intervene in a fashion that improves outcomes.
However, in many of our prior columns on delirium we have mentioned multimodality intervention programs that were promising in reducing the incidence or severity of delirium in hospitalized patients (see our Patient Safety Tips of the Week for October 21, 2008 Preventing Delirium, October 14, 2009 Managing Delirium, February 10, 2009 Sedation in the ICU: The Dexmedetomidine Study, March 31, 2009 Screening Patients for Risk of Delirium and January 26, 2010 Preventing Postoperative Delirium).
One of those interventions was HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week ). Inouye et al () had shown in a landmark study of 852 medical patients aged 70 and older that management of 6 risk factors was able to reduce the incidence of delirium from 15% to 9.9%. The number of days with delirium and the number of episodes of delirium was also reduced by the intervention. The intervention targeted cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. This was strong evidence that a multicomponent intervention could be of benefit in reducing delirium.
Recently, investigators (Chen 2011) studied the effect of a modified HELP protocol on outcomes of elderly patients undergoing abdominal surgery. They focoused on three key elements of HELP (early ambulation, nutritional management, and cognitive activities). A trained HELP nurse oversaw early ambulation (or active ROM exercises) 3 times daily, oral care, nutritional screening and dietary counseling, feeding assistance, orienting communication and cognitively stimulating activities. Compared to a historical control group, those receiving the HELP intervention had significantly less functional decline and less delirium, less decline in cognitive function, and less depression. Though there was no difference in average length of hospital stay, the above outcomes were clinically meaningful. And the cost of implementing this program was modest. One HELP nurse could manage 4-5 patients, doing 3 visits daily.
The authors note that some of the HELP interventions are also part of the approach taken in fast-track (also know as Enhanced Recovery After Surgery or ERAS) surgery that has become popular for colon surgery and other procedures (Kehlet 2008). That approach, which utilizes early mobilization, early feeding, and analgesic techniques that avoid use of opiates has been shown to significantly reduce morbidity and LOS in patients undergoing colon surgery.
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676
Chen C C-H, Lin M-T, Tien Y-W, Yen C-J, Huang G-H, Inouye SK. Modified Hospital Elder Life Program: Effects on Abdominal Surgery Patients. J Amer Coll Surg 2011; 213(2): 245-252
Kehlet H, Wilmore DW. Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery. Annals of Surgery 2008; 248(2): 189-198