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West Penn Hospital adopts program to help curb delirium

Wes Venteicher
| Monday, June 6, 2016, 9:00 p.m.
Allegheny Health Network geriatrician and director of geriatric education Christine Herb, 35, of Allison Park and geriatric acute care nurse practitioner Matthew LaVelle, 37, of Ohio Township, visit with a 85-year-old patient at Allegheny General Hospital Thursday, May 26, 2016.
Jasmine Goldband | Tribune-Review
Allegheny Health Network geriatrician and director of geriatric education Christine Herb, 35, of Allison Park and geriatric acute care nurse practitioner Matthew LaVelle, 37, of Ohio Township, visit with a 85-year-old patient at Allegheny General Hospital Thursday, May 26, 2016.
Allegheny Health Network trauma medical director Al Philp, center, meets with a group of geriatric professionals to talk about their patient's health at Allegheny General Hospital Thursday, May 26, 2016.
Jasmine Goldband | Tribune-Review
Allegheny Health Network trauma medical director Al Philp, center, meets with a group of geriatric professionals to talk about their patient's health at Allegheny General Hospital Thursday, May 26, 2016.

Allegheny Health Network hospitals are sharpening efforts to prevent delirium in elderly patients, targeting a condition whose often-subtle onset can trigger lasting — and sometimes fatal — effects.

Often mistaken for dementia or a natural symptom of aging, delirium expresses itself in many older people as lethargy, slow or confused responses to questions or a lack of movement. In other patients, it can produce hallucinations, restlessness and agitation.

Studies have shown it is associated with long-term cognitive decline, and one study found that patients with persistent delirium were three times more likely to die within a year of developing it than patients without delirium.

West Penn Hospital adopted a program in May, known as the Hospital Elder Life Program, that uses volunteers to help prevent delirium in patients over 70, who are more likely than younger patients to develop delirium in hospitals.

In other hospitals, the program has helped preserve patients' mental and physical abilities, decreased falls, reduced nursing home admissions, shortened hospital stays and saved money, studies show.

Simple changes have driven the improvements, said Dr. Lyn Weinberg, director of the HELP program at West Penn.

“They're really making conversation,” Weinberg said of the volunteers' work. “But they're dropping in cues that help prevent that disorientation from setting in.”

HELP program coordinator Autumn Corcoran screens participants after admission for conditions that might place patients at increased risk of developing delirium. Conditions include dementia, psychoactive medications, hearing or vision impairment and pain.

Then volunteers take over, visiting patients around meal times to check that they are eating and drinking and to engage them in conversation, Weinberg said.

Little is known about the physical causes of delirium, including why it increases mortality risk, but researchers over the past two decades have learned to recognize conditions that increase the risk of developing it. West Penn volunteers address two major risk factors by helping seniors avoid malnutrition and dehydration, Weinberg said.

They are trained to foster intellectual engagement, which has also been shown to help fend off delirium. The volunteers reference in conversations with patients where they are and what day it is, and try to get patients to talk about their past and their families.

“They might have become kind of complacent sitting in there, and now they're reminiscing,” Corcoran said.

Delirium affects as much as 50 percent of the elderly population, according to a 2014 review article published in The Lancet by Dr. Sharon Inouye, founder of the HELP program and a Harvard Medical School professor. Yet 30 percent to 40 percent of cases are preventable, according to the article.

West Penn joins more than 200 other hospitals around the world, including UPMC Shadyside, that have adopted HELP.

Shadyside started the program in 2002, said Dr. Fred Rubin, who started the program there and is chief of the hospital's Department of Medicine. The hospital reduced its rate of delirium from an estimated baseline of 41 percent in 2001 to 18 percent in 2008, Rubin wrote in a 2011 article published in the Journal of the American Geriatrics Society.

Patients who are at intermediate risk of developing delirium are the most likely to be helped by preventive efforts, Rubin said. About 22 percent of patients in that group would be expected to develop delirium, but at Shadyside, only 3 percent become delirious, Rubin said.

“This is an extremely effective program,” he said.

Other hospitals target delirium in other ways.

Allegheny General Hospital, which is also part of Allegheny Health Network, started a program in March that targets the condition in elderly patients in its intensive care unit. Patients in an ICU are much more likely to develop delirium and have a two- to four-times increased risk of death compared with those who do not develop delirium, according to Inouye.

The hospital's ICU-based program revolves around the efforts of Dr. Christine Herb, director of geriatric education for Allegheny Health Network, and Matthew LaVelle, an adult geriatric acute care nurse practitioner.

In recent patient visits, Herb and LaVelle asked patients what day it was and gauged their mental state by having them recite the days of the week backward. They checked for delirium-associated medications such as Benadryl and Ativan. They took time to talk with patients.

LaVelle, who is tall, said he sits down to make patients more comfortable.

“I want them to feel like they're just talking to somebody, not like they're in a hospital,” he said.

Other UPMC hospitals have not adopted HELP, but nurses take steps to try to keep patients on regular sleeping schedules, keep them hydrated and fed and offer them reading materials, said Betty Robison, gerontology educator at the Aging Institute of UPMC and the University of Pittsburgh.

Mount Lebanon-based St. Clair Hospital and Westmoreland County-based hospital system Excela Health screen for delirium and involve patients' doctors and family members in prevention efforts, spokespeople for the systems said.

Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676 or wventeicher@tribweb.com.

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