Multicomponent Interventions Reduce High‐Risk Medications for Delirium in Hospitalized Older Adults

Abstract

Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology-assisted medication review, age-conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.

Effectiveness of the spaced education pedagogy for clinicians’ continuing professional development: a systematic review

“…Although there is ample evidence that spaced education, when delivered in an online format, can increase knowledge, this review has confirmed that clinicians’ retention of new knowledge is much greater with spaced education than traditional learning formats, and this knowledge is retained well after the initial online learning encounter . Spaced education's capacity to increase knowledge and change behaviour is reflected in its integration into recent multicomponent clinical practice change interventions . Although the observed changes noted in these two multicomponent interventions are not directly attributed to spaced education, the evidence emerging from our systematic review suggests that spaced learning pedagogy is likely to be a valuable addition to CPD interventions designed to promote the adoption of new evidence and drive practice change, but this needs to be confirmed in adequately powered RCTs.…”

“…51,61 Spaced education's capacity to increase knowledge and change behaviour is reflected in its integration into recent multicomponent clinical practice change interventions. 71,72 Although the observed changes noted in these two multicomponent interventions are not directly attributed to spaced education, the evidence emerging from our systematic review suggests that spaced learning pedagogy is likely to be a valuable addition to CPD interventions designed to promote the adoption of new evidence and drive practice change, but this needs to be confirmed in adequately powered RCTs.…”

Burden and impact of multifactorial geriatric syndromes in allogeneic hematopoietic cell transplantation for older adults

“…Taken together, our results suggest that strategies for preventing potential delirium and falls based on the patient's risk factors during allo-HCT may warrant further investigation. 32,37,43 Delirium and fall have profound negative impacts on the function, survival, and quality of life for general medical, surgical, and cancer patients, [17][18][19][20][21][22] although their impact on older allo-HCT patients is unknown. We have demonstrated that transplant-related delirium or fall was associated with significantly increased NRM.…”

“…Second, the identification of potentially modifiable risk factors suggests that all older patients should benefit from pretransplant geriatric assessment and targeted interventions such as a pharmacist-led medication review, 46,47 pre-habilitation, and peritransplant delirium and fall prevention strategies. 32,37,43,48,49 We summarize potential prevention and intervention strategies in supplemental Table 4. Finally, given the negative consequences of geriatric syndromes, focused geriatric interventions such as intensified neurocognitive, physical, and occupational rehabilitation should be strongly considered for patients who developed these complications peritransplant.…”

Impact of a delirium prevention project among older hospitalized patients who underwent orthopedic surgery: a retrospective cohort study

“…Nurses provided a mini handbook on POD to patients and their caregivers who had been identified via screening to be at risk of POD. A pharmacist and a group of geriatricians defined a list of 15 medications (chlorpheniramine, diphenhydramine, hydroxyzine, amitriptyline, scopolamine, alprazolam, clonazepam, diazepam, etizolam, lorazepam, triazolam, zolpidem, pethidine, famotidine, and ranitidine) that were reported to potentially cause delirium based on a review of previous studies and the frequency of use of these medications [17, 18]. To make a list of inappropriate medications for the elderly, we used the medication list in our hospital (2012 SNUBH Inappropriate Medication for Elderly Criteria), which is based on the 2008 Screening Tool of Older People’s Prescriptions criteria and 2012 Beers criteria [19].…”