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 wardsPATIENTS: 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 declineRESULTS: 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 ProgramCognitive
Impairment
•Vision/Hearing Aids•Adaptive EquipmentVision/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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