Throughout the 1990s, Dr. Fred Rubin tried a variety of strategies to prevent elderly patients from experiencing the sudden onset of stress and confusion known as delirium, which often occurs during a hospital stay.
Rubin, a geriatrician and chief of the medicine service at UPMC Shadyside Hospital in Pittsburgh, made sure clocks and calendars were visible from patients' beds. He instructed staff to keep the window shades up during the day. And he avoided medications known to cause confusion. “I tried everything I could think of to prevent it,” he said.
Delirium is caused by many risk factors, including old age, certain medications, dehydration and vision impairment. It's associated with increased complication rates, higher mortality and longer lengths of stay. Awareness of the issue has grown in recent years as new research showed the spiraling financial costs of delirium, estimated to be as much as $100 billion annually when additional post-discharge costs are taken into account.
Delirium affects 30% to 50% of older general medical-surgical patients and 80% to 90% of ICU patients over age 70, Rubin said. A delirium episode in an elderly patient can double or triple mortality risk over the following year. Patients who experience delirium are more likely to need nursing-home care after a hospital stay. And the effects of delirium can linger for weeks and months. One-quarter of patients over 70 with delirium do not return to their baseline cognition within three months, he added.
In 1999, Rubin read a New England Journal of Medicine article touting the benefits of the Hospital Elder Life Program, or HELP, a comprehensive delirium-prevention program, now available free of charge, created by noted geriatrics researcher Dr. Sharon Inouye. HELP uses staff and specially trained volunteers to keep older hospitalized patients mobile, hydrated, rested and oriented to their surroundings. He decided to try to implement it at UPMC Shadyside.