The Evidence Behind the Hospital Elder Life

Program

Shared Risk Factors for Distinct Geriatric SyndromeInouye S. et al. J Am Geriatr Soc. 2007 May; 55(5): 780–791.

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Shared risk factors – older age, cognitive impairment , functional impairment and impaired mobility - may lead to geriatric syndromes, which may in turn lead to frailty, with feedback mechanisms enhancing the presence of shared risk factors and geriatric syndromes

A different approach needed when frailty intersects with a challenging environment

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A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program. Inouye, Sk et al . J Am Geriatr Soc. 1993;41(12):1353-

OBJECTIVE:

To test the effectiveness of a nursing-centered intervention to prevent functional decline among hospitalized elderly medical patients.

DESIGN:

Prospective matched cohort study on medicine wards

PATIENTS:

Two hundred sixteen patients aged > or = 70 years (85 intervention and 131 control patients).

INTERVENTION:

Identification and surveillance of frail older patients, twice-weekly rounds of the Geriatric Care Team, and a nursing educational program.

MAIN OUTCOME MEASURE:

Functional decline

RESULTS: reduction in functional decline from 64% in controls to 41% in the intervention group

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. The Yale Geriatric Care Program: Challenges

initial difficulties with recruitment and retainment of geriatric resource nurses (due to high nursing turnover and the increased time commitment required),

breakdown in communication and carryover of recommendations between nursing shifts,

and obstacles to communication between the nursing and medical staff.

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Preventing Functional Decline and Delirium

Yale Delirium Prevention Trial

N= 852 admissions to acute medical wards

Standardized protocols targeting delirium risk factors:

Cognitive Impairment

Sleep Deprivation

Immobility and new onset functional deficit

Vision Impairment and Hearing Impairment

Dehydration

Inouye SK, et al. N Engl J Med 1999;340:669-76 Photo credit: Niklas Pivic

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Yale Delirium Prevention Trial Outcomes

Significant reduction in the development of delirium (9.9% of intervention patients vs. 15% of usual care patients, odds radio = 0.60, P=0.02).

Significant reduction in total number of days with delirium (105 vs. 161 in usual care, P=0.02).

Significant reduction in functional decline and nursing home placement

Inouye SK, et al. N Engl J Med 1999;340:669-76

Elder Life Program Interventions

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•Reality orientation

•Therapeutic Activities Program

Cognitive Impairment

•Vision/Hearing Aids

•Adaptive Equipment

Vision/Hearing Impairment

•Early Mobilization

•Minimizing immobilizing equipment

Immobilization

•Nonpharmacologic approaches to sleep/anxiety

•Restricted use of sleeping

Psychoactive Medication Use

•Early recognition

•Volume repletion

Dehydration

•Noise reduction strategies

•Sleep enhancement program

Sleep Deprivation

Risk Factors Intervention

Other Hospital Elder Life Program Interventions

Geriatric nursing assessment and intervention

Interdisciplinary roundsGeriatrician consultationInterdisciplinary consultationProvider education programCommunity linkages and

telephone follow-up

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Photo credit: Sebastian Kobs

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Delirium Prevention Trial: Significance

First demonstration of delirium as a preventable medical condition

Targeted multicomponent strategy worksSignificant reduction in risk of delirium

and total delirium days, without significant effect on delirium severity or recurrence

Primary prevention of delirium likely to be most effective treatment strategy

Effectiveness and cost-effectiveness of the program has been demonstrated in multiple studies.

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HELP Websitehttp://hospitalelderlifeprogram.org

How to materials: HELP manuals, videos

Educational materials: on acute hospital care and delirium in older persons for consumers, families, caregivers

Reference list: brief list by topic; comprehensive searchable bibliography

HELP: general background information and study results

Sustainability of HELP:Will HELP Work in Other Settings?

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HELP At Shadyside,UPMC

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HELP started in 2002, 500 bed community hospital, USA

Delirium rate: pre HELP 2001: 46% 2008: 18%Hospital acquired delirium rate : less than 4%.LOS shortened for both delirious/non delirious

patientsTotal patients served: 2008: 7,000 patients annually Paid staff 7.6, 107 volunteers, 7 medical surgical

unitsCost savings $7.3 US million annually

 Rubin FH (2011) J Am Geriatr Soc.59(2)

Sustainability and Scalability of the Hospital Elder Life Program at Shadyside

Journal of the American Geriatrics SocietyVolume 59, Issue 2, pages 359-365, 11 FEB 2011 DOI: 10.1111/j.1532-5415.2010.03243.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03243.x/full#f1

HELP in Taiwan Modified hospital elder life program: effects on

abdominal surgery patients over age 70 Design:2000 bed urban hospital , Pre-post comparative study 3 HELP interventions (mobility, nutrition and cognitive

activities) delivered by a study nurseParticipants: 77 usual care, 102 HELP intervention abdominal surgical

patients, matchedMeasures: change in ADL, nutrition and cognitive status from

admission to discharge Outcomes: ADL and nutritional decline: HELP group < control (p < 0.001) Delirium rate HELP group (0%) < control group (16.7%) (p <

0.001).

Chen CC. Lin MT. Tien YW. Yen CJ. Huang GH. Inouye SK. Journal of the American College of Surgeons. 213(2):245-52, 2011 Aug.

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HELP in AustraliaStage 1 Design:

Stage 1 pre/post study on one ward: 21 patients usual care, 16 pts HELP interventions delivered by volunteers

Stage 1 Outcome: Delirium rate: control 38%; HELP 6.3% (P =

0.032)Stage 2 Design:

Expanded to 5 wards- measured sitter use as proxy; decreased by 314 hours/month

Stage 2 Outcome:Cost savings: $129,186 annually

Caplan GA. Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Intern Med J. 2007 Feb;37(2):95-100.

HELP in SpainControlled intervention study542 medical pts, age 70 +, at risk Usual care and HELP interventions Interventions = educational and HELP clinical protocols delivered by nurses, residents and physicians with a

CNS monitoring and prompting compliance Outcomes: delirium 18.5 % usual care, 11.7 HELP

P=0.005,Functional decline: 45.5% intervention, vs 56.3% in UC,

P=.0375% adherence

An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Delirium During Hospitalization in Elderly Patients Marıa T. Vidan JAGS 57:2029–2036, 2009

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Could HELP work with fewer staff resources? Who in your setting could recruit, train

and schedule volunteers? Is there someone else who can deliver on

the interventions? Who could screen and enroll patients?

Could they be identified automatically on admission?

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Ontario HELP Uptake Ontario HELP Network-11 sites (1 Alberta) -

quarterly teleconference to share ideas, data and challenges

Waterloo-Wellington LHIN is supporting five sites to start HELP

Small hospitals report challenges in resources needed for HELP start up.

Open Access makes a difference!

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