Delirium and the "know-do" gap in acute care for elders.

Approximately 40% of all adult hospital admissions and 50% of all costs for acute care are attributed topatients 65years and older.1 Unfortunately, complications fromhospitalization are fairly common for this population. Delirium is a powerful case in point: as many as 50%ofolder adultswill experience an episode of delirium during acute care, with costs in excess of $164 billion per year.2,3 In this issueof JAMAInternalMedicine,Hshiehet al4 combined the results from 14 high-quality trials studying multicomponentnonpharmacological interventions involving4267 patientsand foundthat thesesimple interventions reduceddelirium by 53%. These results are evenmore striking considering thatdeliriumis thenumberonepredisposing factor for falls. Accordingly, Hshieh et al were able to demonstrate a 62% reduction in falls owing to these interventions as well. Overall, these reduced complications of delirium and falls could save an estimated $15 billion to $17 billion annually. To put this in the context of what is perhaps the most influential health policy initiative to reduce costs and improve the quality for seniors currently—the Medicare Hospital ReadmissionsReductionProgram—onlyabout20%ofolderadults experience a readmission, with costs exceeding $7 billion per year.5 Although a very modest trend toward lower rates has beenobservednationally in recentyears, acorrespondingtrend toward “negative” readmission reduction interventions has shown that it is alsogettingharder to reduce readmissions, despite intensive efforts.6 Moreover, while debate over the preventabilityof readmissionscontinues, the literatureshowsthat delirium is preventable in 30% to 40% of cases.2 Given the higher prevalence, costs, and preventability of delirium comparedwith readmission, onewould think that it would be of higher importance in the current policy landscape. Yet, despite 15 to 20 years of evidence for protocols to reduce inpatientcomplications forolderadults suchas theHospital Elder Life Program (HELP)7 and Acute Care for the Elderly (ACE)8units, policies to speed thedisseminationof such programs are nowhere on the horizon. Increasingly, efforts to prevent adverse events for older adults in the hospital seem stymied inapernicious“know-do”gap: as theevidencegrows, the state of implementation is not keeping up. Of course, a lackofpolicy incentivesneednot impedehospitals and health care professionals from acting on the evidence independently.Why then are these protocols notmore widely implemented?Althoughmany factors are likely inplay, at least 2 seemworth mentioning. First, there may be an assumption held by many physicians and hospital leaders along the lines of “aren’t we doing all this stuff already?” Perhaps becausemost of the interventions to reducedeliriumareprotocolbasedandnursingdriven, it may be easy to assume that such measures are already in place and running in the background at many hospitals. Numerous components of these interventionsmay simply seem too simple to question that they are not being done already. These include frequent orientation of patients to time, place, and situation; earlymobilization; attention to hearing and visual deficits and aids as appropriate; preservation of sleepwake cycles; and adequate hydration. Indeed, it is quite likely that someof these interventionsareoccurringsomeof the time at many, if not most, hospitals, but the key to their effectiveness may well lie in the consistency of their application. A second and related assumption runs along the lines of “even if our hospital isn’t doing all these things consistently, how good is the evidence that they make a difference?” It is here thatHshieh et al4make their greatest contribution to the literature.Whilemost published studies onmulticomponent nonpharmacological interventions to reduce delirium have shownbenefit, relatively small sample sizes (amean of 369 in the 14 studies analyzedbyHshieh et al)mayhave limited generalizability and implementation previously. By combining these studies conductedat 12 sites, includingmedical and surgicalwards in academic and community settings,Hshieh et al have provided a definitive, affirmative answer to questions about the strength of evidence for these interventions. Beyond the significant reduction in primary outcomes (53% for delirium and 62% for falls), the authors also showed a trend toward shorter length of stay (0.16 day less for intervention patients). Given these findings, it is worth pondering what strategies might be effective to seal the implementation gap going forward. First, although the business case for these interventionsmay be as strong as the patient safety case, thismay not be enough to drive change in practice. Rather than approachingthese interventionsasstand-aloneprotocols, theymayneed to be embedded in broader, team-based changes in the way acute care is delivered to older adults—such as throughHELP or ACE—to see benefits in terms of outcomes and costs. Second,whilepolicyat the levelof theCenters forMedicare&Medicaid Servicesmight also onedayprovide sticks and carrots to incentivize implementation, theprocessof standardizingmeasures, then publicly reporting, and finally linking to payments is deliberative and slow. Perhaps pressure to change could come fromwithin the profession. As one example, the American Board of Internal Medicine Foundation’s “ChoosingWisely”9 campaignhas enjoyed success bygenerating specialty-specific lists of “things providers and patients should question.” While this campaign focuses on tests or procedures that should be avoided because they are expensive and ineffective, it could also include “things providers and patients should request” because they are proven to be effective and cost saving. Returning to thecomparisonbetween thecurrent focuson preventingreadmissionsandtheunderdevelopedfocusonpreRelated article page 512 Meta-analysis of Delirium Prevention Original Investigation Research