Anti-delirium strategy reduces after-surgery confusion in elderly

(Reuters Health) - A daily 30-minute regimen designed to help elderly surgery patients stay oriented can cut the rate of post-operative delirium in half and help them return home sooner, according to a test among 377 volunteers in Taipei.

After they were moved out of the intensive care unit (ICU), 15.1 percent given conventional treatment experienced delirium. But when hospital workers got patients moving faster, helped them brush their teeth, gave them facial exercises and talked to them in ways to help them understand what was happening to them, the delirium rate was just 6.6 percent.

And while the patients who didn’t get the intervention typically stayed in the hospital for 14 days, those who did were discharged an average two days sooner.

The study “draws needed attention to delirium,” which can cause problems for doctors and nurses when confused patients, for example, try to extricate themselves from the tubes and equipment needed to recover, said Dr. Lillian Kao, acute care surgery chief for McGovern Medical School at the University of Texas Health Science Center in Houston.

Kao, who was not involved in the research, told Reuters Health that other hospitals already use a similar but more involved strategy, known as Enhanced Recovery After Surgery (ERAS), particularly after colorectal surgery.

But chief author Cheryl Chia-Hui Chen, professor of nursing at National Taiwan University, said the strategy used in the study, known as mHELP, is easier to implement and focuses more on getting patients oriented.

So even with ERAS, Chen said, hospitals “might want to consider mHELP as an effective protocol to reduce delirium and shorten length of stay.”

Estimates on the problem posed by delirium vary widely, ranging from 13 percent to 50 percent among people who have non-heart surgery, according to an accompanying editorial in JAMA Surgery by Drs Pasithorn Suwanabol and Daniel Hinshaw of the University of Michigan in Ann Arbor.

People aged 65 and older are particularly vulnerable. Delirium is believed to cost the U.S. healthcare system more than $164 billion a year, yet up to 40 percent of cases could be preventable, Chen’s team writes.

In the new study, all 377 patients were hospitalized for abdominal surgeries, about 90 percent of them involving removal of a malignant tumor. They ranged in age from about 69 to 80 years old, and half were randomly assigned to receive the usual care and half to receive the mHELP intervention.

Specially-trained nurses started visiting the mHELP patients as soon as they were moved to the inpatient ward from the ICU. The nurse asked each patient about events of the past days to try to orient them, or simply to get them talking on a subject that interested them. They also had patients practice exercises involved in eating and oral health. As in hospitals that use the ERAS system, the patients were also encouraged to stretch, stand and start walking as quickly as possible.

Another pair of trained nurses, unaware of which experimental group a patient was in, assessed all the study participants daily for delirium. The patients were considered to be delirious if they couldn’t pay attention and if they experienced either an altered state of consciousness or disorganized thinking.

Chen and her colleagues estimated that for every dozen people treated with mHELP, one case of delirium would be prevented.

“I have no reason to believe it won’t work for other types of surgery,” Chen said.

“Thus, with an additional 30 minutes of nursing time per older patient, mHELP reduced delirium by 56 percent and shortened LOS (length of stay) by 2 days, which will greatly reduce medical costs,” the study team writes.

“By extrapolation, older patients in the United States had 7.96 million surgical hospital stays in 2012, with a mean cost of $11,600 per stay,” the authors calculate. “Thus, mHELP could have prevented approximately 674,576 cases of delirium in the surgical service in 2012, resulting in a Medicare cost savings of approximately $10,000 per case or $6.7 billion for the year.”

And with two fewer days in the hospital, that would save an additional $12.9 billion per year, they note.

Kao said that in the United States the emphasis on countering delirium begins even sooner, focusing on a patient’s stay in the ICU right after surgery.

“So there has been a big push by various medical societies in the U.S. like the Society for Critical Care Medicine to implement interventions in the ICU to prevent delirium,” she said. “This article reminds us that delirium can occur in all parts of the hospital and we need to pay attention to it.”

SOURCE: JAMA Surgery, online May 24, 2017.