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Key References (in reverse chronological order) last updated 10/03/09

Delirium in Hospitalized Older Persons: Recognition, Etiology, and Management

Selected Bibliography

Reviews
  1. Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004;75:362-367.
  2. Cole MG. Delirium in elderly patients. Am J Geriatr Psychiatry: 2004; 12:7-21. A comprehensive review, with recommendations for intervention.
  3. Gleason OC. Delirium. Am Fam Physician: 2003;67:1027-1034. Advice on recognizing and managing delirium for the family physician.
  4. Foreman MD, Wakefield B, Culp K, Milisen K. Delirium in elderly patients: an overview of the state of the science. Journal of Gerontological Nursing: 2001:27:12-20. A review with discussion of the frequency of misdiagnosis.
  5. Meagher DJ. Delirium: optimising management. BMJ. 2001;322:144-149. Up-to-date review of the literature on delirium.
  6. Inouye SK. Delirium in Hospitalized Older Patients. Clinics in Geriatric Medicine. 1998;14:745-764. General review of topic.
  7. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in Elderly Patients: Evaluation and Management. Mayo Clin Proc. 1995;70:989-98. Recent review of aspects of clinical presentation and management approaches .
  8. Inouye SK. The Dilemma of Delirium: Clinical and Research Controversies Regarding Diagnosis and Evaluation of Delirium in Hospitalized Elderly Medical Patients. Amer J Med. 1994;97:278-88 . Highlights areas of controversy and discrepancies in the current knowledge base about delirium. Outlines an empiric approach to evaluation of delirium. Proposes research agenda for delirium.
  9. Francis J. Delirium in Older Patients. J Am Geriatr Soc. 1992;40:829-38. State-of-the-Art review which includes a comprehensive reference list.
  10. Beresin EV. Delirium in the Elderly. J Geriatr Psychiatry Neurol. 1988;1:127-43. Helpful clinically-focused review with clear, succinct tables.

Recognition

  1. Elissa A, Andre MJ, Baker RA. Postoperative confusion assessed with the Short Portable Mental Status Questionnaire. ANZ Journal of Surgery 2003;73:9:697-700.
  2. Ely EW, Inouye SK, Gordon S, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Margolin R, Hart RP, Bernard GR. Delirium in mechanically ventilated patients: Validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286:2703-2710.
  3. Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM. Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001;161:2467-2473. Documents poor recognition of delirium and its symptoms by nurses during routine clinical care.
  4. Albert MS, Levkoff SE, Reilly C, et al. The Delirium Symptom Interview: an interview for the detection of delirium symptoms in hospitalized patients. J Geriatr Psychiatry Neurol. 1992;5:14-21. Presents Delirium Symptom Interview (DSI), designed to be administered by clinical or trained lay interviewer.
  5. Inouye SK, vanDyck CH, Alessi CA, Balkin S. Siegal AP, Horwitz RI. Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium. Ann Intern Med. 1990;113:941-48. Simplified instrument and diagnostic method designed to improve detection of delirium by non-psychiatrist.
  6. Trzepacz PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res. 1988;23:89-97. Presents the Delirium Rating Scale (DRS), a detailed clinical scale designed to be completed after psychiatric assessment.

Etiology / Risk Factors

  1. Wakefield BJ. Risk for acute confusion on hospital admission. Clinical Nursing Research:2002;11:153-172. Recognizing the risk factors for delirium.
  2. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med. 2001; 161:2091-2097. Documents substantial adverse effects of Benadryl in older patients.
  3. Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-212 . Provides review of studies on risk factors for delirium.
  4. Inouye SK, Charpentier PA. Precipitating Factors for Delirium in Hospitalized Elderly Persons: Predictive Model and Inter-Relationship with Baseline Vulnerability. JAMA. 1996;275:852-7. Validated predictive model for delirium based on hospitalization-related factors: physical restraints, malnutrition, psychoactive medications, bladder catheters, and any iatrogenic event.
  5. Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. Ann Intern Med. 1993;119:474-81. Standardized, validated predictive model for delirium, based on 4 risk factors: vision impairment, severe illness, chronic cognitive impairment, and high BUN/Cr ratio.
  6. Schor JD, Levkoff SE, Lipsitz LA, et al. Risk Factors for Delirium in Hospitalized Elderly. JAMA. 1992;267:827-31. Prospective cohort study (N = 291) identifying 7 independent risk factors: chronic cognitive impairment; fracture; age > 80 yrs; male gender; infection; neuroleptic or narcotic use.
  7. Francis J, Martin D, Kapoor WN. A Prospective Study of Delirium in Hospitalized Elderly. JAMA. 1990;263:1097-101. Prospective cohort study (N = 229) identifying 6 independent risk factors: abnormal sodium level; severe illness; chronic cognitive impairment; fever or hypothermia; psychoactive drug use; azotemia.

Intervention / Prevention

  1. Lundstrom M, Edlund A, Karlsson S. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Naughton BJ, Saltzman S, Ramadan F, et al. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005;51:18-23.
  2. Tabet N, Hudson S, Sweeney V, et al. An educational intervention can prevent delirium on acute medical wards. Age Aging. 2005;34:152-156.
  3. Carnes M, Howell T, Rosenberg M, Francis J, Hildebrand C, Knuppel J. Physicians vary in approaches to clinical management of delirium. J Am Geriatr Soc: 2003;51:234-239. Survey of physician strategies for managing delirium.
  4. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516-522 (with editorial Pgs. 678-679). Randomized controlled trial of proactive geriatric consultation, which successfully reduced occurrence of delirium in hip fracture patients.
  5. Milisen K, Foreman MD, Abraham IL et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc. 2001;49:523-532. Intervention focused at education of nursing staff, systematic cognitive screening, and geriatric assessment reduced the duration and severity of delirium after hip fracture.
  6. Inouye SK, Bogardus ST, Baker DI, Leo-Summers L, Cooney LM. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc. 2000;48:1697-1706.
  7. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156 (5 Suppl): 1-20.
  8. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine. 1999;340:669-676 (with editorial). Controlled clinical trial documenting effectiveness of targeted risk factor intervention strategy for primary prevention of delirium.
  9. McDowell JA, Mion LC, Inouye SK. A non-pharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46:700-705. Prospective study evaluating effectiveness of non-pharmacologic approach to improve sleep in hospital setting.
  10. Cole MG, Primeau F, McCusker J. Effectiveness of interventions to prevent delirium in hospitalized patients: a systematic review. Can Med Assoc J: 1996;155:1263-8. Assessment of the effectivenss of various interventions to prevent delirium.
  11. Palmer RM. Acute hospital care of the elderly: Minimizing the risk of functional decline. Cleve Clin J Med: 1995;62:117-128. An interdisciplinary approach to preventing functional decline.

Prognosis/Impact

  1. Leslie DL, Zhang Y, Bogardus ST, Holford RT, Leo-Summers L, Inouye SK. Premature death associated with delirium at one year follow-up. Arch Intern Med. 2005;165:1657-62.
  2. McCusker J, Cole M, Dendukuri N, Belzile K. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. Can Med Assoc J:2001;165:575-83. Implications of delirium for patient prognosis.
  3. O'Keeffe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc: 1997;45:1174-178. How delirium impacts prognosis.

Policy

  1. In 2008, Centers for Medicare and Medicaid Services (CMS) implemented payment changes designed to encourage the prevention of life-threatening conditions acquired by hospitalized patients, including hospital falls and trauma. Their inclusion in the initiative implies that falls occur as the result of lapses in the health care system delivery and that they can be reasonably prevented through the application of evidenced-based guideline. However, unlike other conditions selected by CMS, falls and injuries can occur even when hospitals provide the best possible care. Furthermore, efforts to prevent falls may result in unintended, negative consequences such as increased restraint use. New England Journal of Medicine 2009;360:2390-93
  2. Leslie DL, Zhang Y, Bogardus ST, Holford RT, Leo-Summers L, Inouye SK. Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc. 2005;53:405-9.
  3. Inouye, SK. Delirium: A barometer for quality of hospital care in older patients (Editorial). Hospital Practice. 2001;36:15-16,18.
  4. Rizzo JA, Bogardus ST, Leo-Summers L, Williams CS, Acampora D, Inouye SK. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Medical Care. 2001;39:740-752.
  5. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106:565-573 . Overview of pathways leading to delirium in older hospitalized patients, with recommended interventions.

HELP Articles

  1. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora Denise, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. New England Journal of Medicine 1999;340:669-76. Controlled clinical trial documenting effectiveness of targeted risk factor intervention strategy for primary prevention of delirium.
  2. Inouye SK, Bogardus ST Jr, Baker DI, Leo-Summers L, Cooney LM Jr . The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program.
    Journal of the American Geriatrics Society 2000;48:1697-1706. A comprehensive overview of the Hospital Elder Life Program, a model of hospital care designed to prevent functional decline of older persons during hospitalization.
  3. Rizzo JA, Bogardus ST Jr, Leo-Summers L, Williams CS, Acampora D, Inouye SK . Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Medical Care 2001;39:740-752. Analysis of cost implications concluding that the Hospital Elder Life Program is a cost effective treatment option for patients at intermediate risk for developing delirium.
  4. Inouye SK, Bogardus ST Jr, Williams CS, Leo-Summers L, Agostini JV.
    The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions
    Evidence From the Delirium Prevention Trial. Archives of Internal Medicine 2003;163:958-964. Examined the impact of level of adherence on effectiveness of delirium prevention and found that higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion.
  5. Bradley EH, Schlesinger M, Webster TR, Baker D, Inouye SK. Translating research into clinical practice: making change happen. Journal of the American Geriatrics Society 52:1875-1882, 2004. Qualitative study examining common challenges for implementing the Hospital Elder Life Program, and strategies to address them.
  6. Leslie DL, Zhang Y, Bogardus ST, Holford TR, Leo-Summers LS, Inouye SK. Consequences of Preventing Delirium in Hospitalized Older Adults on Nursing Home Costs. Journal of the American Geriatrics Society 2005;52:405-409. Longitudinal follow-up study (N=801) documenting effectiveness of active methods to prevent delirium in decreasing long-term nursing home costs.
  7. Bradley EH, Webster TR, Baker D, Schlesinger M, Inouye, SK. After Adoption: Sustaining the innovation. A case study of disseminating the Hospital Elder Life Program. Journal of the American Geriatrics Society 53:1455-1461, 2005. Longitudinal, qualitative study examining key factors that influence sustainability in the diffusion of the Hospital Elder Life Program.
  8. Rubin FH, Williams JT, Lescisin DA, Mook WJ, Hassan S, Inouye SK. Replicating the Hospital Elder Life Program (HELP) in a Community Hospital and Demonstrating Effectiveness Using Quality Improvement Methodology. J Am Geriatr Soc. 2006;54:969-974. A pretest/posttest quality improvement study evaluating the replication of the Hospital Elder Life Program in a community hospital. The HELP intervention resulting in both clinical and financial benefits.
  9. Bradley EH, Webster TR, Schlesinger M, Baker DI, Inouye SK. The roles of senior management in improving hospital experiences for frail older adults. Journal of Healthcare Management 2006; 51:321-334.
  10. Bradley EH, Webster TR, Schlesinger M, Baker DI, Inouye SK. Patterns of diffusion of evidence-based clinical programs: A case study of the Hospital Elder Life Program. Qual Saf Health Care 2006;15;334-338.
  11. Inouye SK, Baker DI, Fugal P, Bradley EH. Dissemination of the Hospital Elder Life Program: Implementation, adaptation, and successes. J Am Geriatr Soc. 2006;54:10:1492-1499.
  12. Caplan GA, Harper EL. Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Int Med J. 2007;37:95-100. Demonstrates effectiveness and cost-effectivenss of Australian replication of HELP program.
  13. Steel Fisher GK, Martin LA, Dowal SL, Inouye Sk. Sustaining Clinical Programs during Difficult Economic Times; A Case Series from the Hospital Elder Life Program. J Am Geriatr Soc. 2011;59:1873-1882.