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Published On September 28, 2017

CLINICAL CARE

Lost in the Hospital

In a noisy, disorienting institutional environment, older patients often fall victim to delirium, a severe mental malady. Geriatric expert Sharon Inouye describes a program that can head off problems.

Delirium often comes on suddenly in the hospital, with effects ranging from agitation, paranoia and hallucinations to lethargy and withdrawal. The damage to older patients may be irreversible in some cases, leading to permanent cognitive decline and life in a nursing home.

To help prevent such outcomes, Sharon Inouye, director of the Aging Brain Center at the Institute for Aging Research, Hebrew SeniorLife in Boston, and professor of medicine at Harvard Medical School, created the Hospital Elder Life Program, or HELP. An innovative approach now used in some 200 U.S. hospitals as well as in institutions in seven other countries, HELP trains nurses, physicians and volunteers to prevent delirium with daily interventions designed to keep patients mobile and oriented to their surroundings as they continue to eat, drink fluids and get adequate sleep. A recent randomized trial of older patients who had undergone abdominal surgery found that the likelihood of delirium was reduced by 56% and hospital stays were two days shorter when HELP methods were used.

Q: How big a problem is delirium for hospitalized patients?

A: It’s huge. Five older hospitalized adults develop delirium every minute in the United States. And while it is usually temporary, delirium is associated with cognitive decline that lasts for at least three years in about 15% of cases. It’s as devastating as having mild cognitive impairment, or MCI—a slight but noticeable decline in cognitive abilities that puts the patient at an increased risk of developing Alzheimer’s. In people who already have dementia, delirium can double the pace of their decline. Those who don’t recover from delirium have a very high mortality rate and severe loss of function, and often need to be in a nursing home.

Q: Why are older people so susceptible to delirium?

A: Our hypothesis is that aging brains emit weaker signals between brain regions and are less plastic, making older people vulnerable to cognitive dysfunction, especially under the stressful conditions of a hospital stay—sleep deprivation, pain, toxicity from multiple medications, being bedbound.

Q: How is delirium treated?

A: Once delirium occurs, it’s very hard to stop. Preventing it is really the only thing that works well. Fortunately, studies have shown that up to 50% of delirium is preventable.

Q: What’s required for a hospital to offer HELP?

A: Many hospitals with a HELP program enlist a corps of trained volunteers. Others use existing aides or nursing staff to carry out the interventions that need to be done every day for as long as a patient is hospitalized. There also needs to be a dedicated full-time staffer to run the program.

Q: What interventions are used?

A: Volunteers who visit two or three times a day can be especially effective in helping elderly patients avoid becoming disoriented. They can socialize and play games with patients for cognitive stimulation, make sure curtains are open during the day, provide companionship during meals or help them eat, and watch for signs of behavior changes or confusion.

Another core principle is daily exercise and walking assistance. If patients are having trouble hearing or seeing because they left hearing aids or glasses at home, we give them devices so they aren’t impaired. We make sure they stay hydrated and are eating properly. And at night, those who have trouble sleeping may get warm milk or herbal tea, a massage, soothing music—but not sleeping pills.

Q: Which patients can benefit from HELP?

A: Our official recommendation is that any patient 70 or older who has at least one risk factor for cognitive decline should be enrolled in HELP. Ideally, though, HELP should be available to any patient who might need it. Recent research has shown the effectiveness of the program for the prevention of hospital falls and functional decline, as well as for dramatic cost savings and reduction in readmissions. HELP has also been adapted for use by other fields and departments, including surgical units, ICUs, emergency rooms, palliative care and long-term care. 

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