Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults
Authors: Yan-Yan Wang, Ji-Rong Yue, Dong-Mei Xie, Patricia Carter, Quan-Lei Li, Sarah L. Gartaganis, Jie Chen, Sharon K. Inouye
Journal: JAMA Internal Medicine (2019)

<h3>Importance</h3> Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline. <h3>Objective</h3> To investigate the effectiveness of the Tailored, Family-Involved Hospital Elder Life Program (t-HELP) for preventing POD and functional decline in older patients after a noncardiac surgical procedure. <h3>Design, Setting, and Participants</h3> A 2-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted from August 24, 2015, to February 28, 2016, on 6 surgical floors (gastric, colorectal, pancreatic, biliary, thoracic, and thyroid) of West China Hospital in Chengdu, China. Eligible participants (n = 281) admitted to each of the 6 surgical floors were randomized into a nursing unit providing t-HELP (intervention group) or a nursing unit providing usual care (control group). All randomized patients were included in the intention-to-treat analyses for the primary outcome of POD incidence. Statistical analysis was performed from April 3, 2016, to December 30, 2017. <h3>Interventions</h3> In addition to receiving usual care, all participants in the intervention group received the t-HELP protocols, which addressed each patient’s risk factor profile. Besides nursing professionals, family members and paid caregivers were involved in the delivery of many of the program interventions. <h3>Main Outcomes and Measures</h3> The primary outcome was the incidence of POD, evaluated with the Confusion Assessment Method. Secondary outcomes included the pattern of functional and cognitive changes (activities of daily living [ADLs], instrumental activities of daily living [IADLs], Short Portable Mental Status Questionnaire [SPMSQ]) from hospital admission to 30 days after discharge, and the length of hospital stay (LOS). <h3>Results</h3> Of the 475 patients screened for eligibility, 281 (171 [60.9%] male, mean [SD] age 74.7 [5.2] years) were enrolled and randomized to receive t-HELP (n = 152) or usual care (n = 129). Postoperative delirium occurred in 4 participants (2.6%) in the intervention group and in 25 (19.4%) in the control group, with a relative risk of 0.14 (95% CI, 0.05-0.38). The number needed to treat to prevent 1 case of POD was 5.9 (95% CI, 4.2-11.1). Participants in the intervention group compared with the control group showed less decline in physical function (median [interquartile range] for ADLs: −5 [−10 to 0] vs −20 [−30 to −10];<i>P</i> &lt; .001; for IADLs: −2 [−2 to 0] vs −4 [−4 to −2];<i>P</i> &lt; .001) and cognitive function (for the SPMSQ level: 1 [0.8%] vs 8 [7.0%];<i>P</i> = .009) at discharge, as well as shorter mean (SD) LOS (12.15 [3.78] days vs 16.41 [4.69] days;<i>P</i> &lt; .001). <h3>Conclusions and Relevance</h3> The findings suggest that t-HELP, with family involvement at its core, is effective in reducing POD for older patients, maintaining or improving their physical and cognitive functions, and shortening the LOS. The results of this t-HELP trial may improve generalizability and increase the implementation of this program. <h3>Trial Registration</h3> Chinese Clinical Trial Registry Identifier:ChiCTR-POR-15006944