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Original Investigation
October 21, 2019

Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
  • 2School of Nursing, The University of Texas at Austin, Austin
  • 3School of Nursing, The Johns Hopkins University, Baltimore, Maryland
  • 4Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, ‎Massachusetts
  • 5Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
  • 6Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, ‎Massachusetts
JAMA Intern Med. 2020;180(1):17-25. doi:10.1001/jamainternmed.2019.4446
Key Points

Question  Does the Tailored, Family-Involved Hospital Elder Life Program reduce the incidence of postoperative delirium and functional decline in older patients after a noncardiac surgical procedure?

Findings  In this single-blind randomized clinical trial of 281 older adults in China, postoperative delirium occurred in fewer participants randomized to receive the Tailored, Family-Involved Hospital Elder Life Program intervention compared with those randomized to the usual care control group. Decline in physical and cognitive functions during hospitalization was significantly less in patients in the intervention group, and the effect was sustained 30 days after discharge.

Meaning  The Tailored, Family-Involved Hospital Elder Life Program may be beneficial for older patients who undergo noncardiac surgical treatment as it appears to help in reducing postoperative delirium, maintaining physical and cognitive functions, and shortening the length of hospital stay.

Abstract

Importance  Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline.

Objective  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.

Design, Setting, and Participants  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.

Interventions  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.

Main Outcomes and Measures  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).

Results  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]; P < .001; for IADLs: −2 [−2 to 0] vs −4 [−4 to −2]; P < .001) and cognitive function (for the SPMSQ level: 1 [0.8%] vs 8 [7.0%]; P = .009) at discharge, as well as shorter mean (SD) LOS (12.15 [3.78] days vs 16.41 [4.69] days; P < .001).

Conclusions and Relevance  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.

Trial Registration  Chinese Clinical Trial Registry Identifier: ChiCTR-POR-15006944

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