Hshieh Tammy T, Yue Jirong, Oh Esther, Puelle Margaret, Dowal Sarah, Travison Thomas, Inouye Sharon K
Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts2Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
Department of Geriatrics, West China Hospital, Sichuan University, Chengdu.
JAMA Intern Med. 2015 Apr;175(4):512-20. doi: 10.1001/jamainternmed.2014.7779.
Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these strategies for preventing subsequent adverse outcomes has been limited to small studies to date.
To evaluate available evidence on multicomponent nonpharmacological delirium interventions in reducing incident delirium and preventing poor outcomes associated with delirium.
PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews from January 1, 1999, to December 31, 2013.
Studies examining the following outcomes were included: delirium incidence, falls, length of stay, rate of discharge to a long-term care institution (institutionalization), and change in functional or cognitive status.
Two experienced physician reviewers independently and blindly abstracted data on outcome measures using a standardized approach. The reviewers conducted quality ratings based on the Cochrane risk-of-bias criteria for each study.
We identified 14 interventional studies. The results for outcomes of delirium incidence, falls, length of stay, and institutionalization were pooled for the meta-analysis, but heterogeneity limited our meta-analysis of the results for change in functional or cognitive status. Overall, 11 studies demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58). Four randomized or matched trials reduced delirium incidence by 44% (OR, 0.56; 95% CI, 0.42-0.76). The rate of falls decreased significantly among intervention patients in 4 studies (OR, 0.38; 95% CI, 0.25-0.60); in 2 randomized or matched trials, the rate of falls was reduced by 64% (OR, 0.36; 95% CI, 0.22-0.61). Length of stay and institutionalization also trended toward decreases in the intervention groups, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) day shorter and the odds of institutionalization 5% lower (OR, 0.95; 95% CI, 0.71-1.26). Among higher-quality randomized or matched trials, length of stay trended -0.33 (95% CI, -1.38 to 0.72) day shorter, and the odds of institutionalization trended 6% lower (OR, 0.94; 95% CI, 0.69-1.30).
Multicomponent nonpharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization. Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.
谵妄是一种发病率和死亡率都很高的急性疾病，通常可通过多组分非药物策略预防。迄今为止，这些策略预防后续不良结局的疗效仅限于小型研究。
评估关于多组分非药物性谵妄干预措施在降低谵妄发生率及预防与谵妄相关的不良结局方面的现有证据。
1999年1月1日至2013年12月31日期间的PubMed、谷歌学术、ScienceDirect以及Cochrane系统评价数据库。
纳入考察以下结局的研究：谵妄发生率、跌倒、住院时间、转至长期护理机构（机构化）的比率以及功能或认知状态的变化。
两位经验丰富的医生审阅者采用标准化方法独立且盲法提取关于结局指标的数据。审阅者根据Cochrane偏倚风险标准对每项研究进行质量评级。
我们确定了14项干预性研究。将谵妄发生率、跌倒、住院时间和机构化结局的结果合并进行荟萃分析，但异质性限制了我们对功能或认知状态变化结果的荟萃分析。总体而言，11项研究表明谵妄发生率显著降低（比值比[OR]，0.47；95%置信区间[CI]，0.38 - 0.58）。4项随机或匹配试验使谵妄发生率降低了44%（OR，0.56；95% CI，0.42 - 0.76）。4项研究中干预组患者跌倒率显著降低（OR，0.38；95% CI，0.25 - 0.60）；在2项随机或匹配试验中，跌倒率降低了64%（OR，0.36；95% CI，0.22 - 0.61）。干预组的住院时间和机构化比率也有下降趋势，住院时间平均缩短0.16天（95% CI， - 0.97至0.64天），机构化几率降低5%（OR，0.95；95% CI，0.71 - 1.26）。在质量较高的随机或匹配试验中，住院时间有缩短0.33天的趋势（95% CI， - 1.38至0.72天），机构化几率有降低6%的趋势（OR，0.94；95% CI，0.69 - 1.30）。
多组分非药物性谵妄预防干预措施在降低谵妄发生率和预防跌倒方面有效，且有缩短住院时间和避免机构化的趋势。鉴于当前对预防医院并发症及提高医疗成本效益的关注，这项荟萃分析支持使用这些干预措施来推进对老年人的急性护理。
