Expanding delirium prevention during COVID-19 with the Modified and Expanded Hospital Elder Life Program (HELP-ME)

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Contributed by Tamara G. Fong, MD PhD, Associate Professor of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, and Hebrew SeniorLife, Boston, MA USA; Jason Albaum, Vassar College, USA; and Sharon K. Inouye, MD MPH, Milton and Shirley F. Levy Family Chair and Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, and Hebrew SeniorLife, Boston, MA, USA

This work was supported by grants from the Interventional Studies in Aging Center (ISAC), Marcus Institute for Aging Research, Hebrew SeniorLife and the National Institute on Aging, Grant/Award Number R33AG071744

Delirium prevention methods were challenged by the COVID-19 pandemic

Delirium, a common complication of hospitalization for older adults, is associated with
increased rates of morbidity, institutionalization, and mortality. 1 Multiple studies have shown at least 40% of cases may be preventable using multicomponent strategies such as the Hospital Elder Life Program (HELP), the original delirium prevention model published in 1999.2-5

During the COVID-19 pandemic, delirium became epidemic, with prevalence rates of 25%–65% reported in numerous studies.6-8 Although the need for HELP assumed even greater importance, many HELP programs had their staff redeployed, and volunteers, a key component of HELP, were not allowed in many hospitals. Thus, we designed the Modified and Extended Hospital Elder Life Program (HELP-ME), an innovative adaptation of HELP for remote and/or physically distanced purposes. 9 We aimed to demonstrate the feasibility and acceptability of HELP-ME at four sites across the U.S., with goals to enroll 100 hospitalized patients and achieve at least 75% adherence to protocols.

We designed and implemented HELP-ME to address the need for remote delirium prevention

To adapt key HELP protocols for remote and/or physically distanced application, we assembled an expert working group with representatives from Hebrew SeniorLife (the coordinating center) and four expert HELP sites (Allegheny Health Network, California Pacific Medical Center, Maine Medical Center, and University of Utah Health). Using a modified Delphi approach, the expert working group established standardized protocols, e.g., sleep enhancement, orientation, and therapeutic activities, and created a HELP-ME Operations Manual.

For HELP-ME, we adapted eleven existing HELP protocols to be as remote-based as possible. After an onsite nurse or HELP-ME staff member set up a touchscreen tablet in the enrolled patient’s room, HELP-ME protocols were administered remotely by hospital staff or offsite volunteers based at each center. Additionally, sites developed a “HELP Gift Box”,10 given to each patient, with supplies needed to partake in HELP-ME protocols. For example, to promote the nonpharmacological sleep enhancement protocol, the HELP Gift Box contained an informational notecard on “What Should I Know About Sleep?”, instructions for a progressive relaxation technique, ear plugs, an eye mask, and herbal tea. Other supplies included in-room exercise instructions, crossword puzzles, exercise bands, and adaptive equipment. Boxes were customizable to the unique needs of each patient.

From January 8th, 2021, through September 24th, 2021, we aimed to enroll 25 participants per site (100 total), targeting patients at moderate to high risk for delirium and able to participate in HELP-ME protocols. To monitor implementation across the four sites, we conducted seven virtual learning sessions and four coaching calls. During the enrollment and data collection phase, sites entered deidentified data daily into a secure REDCap database, including the type of visit, specific protocols assigned that day, and whether each protocol was completed fully, partially, or not at all. Upon completion of enrollment, focus group sessions were held to provide feedback and assessment of HELP-ME efficacy.

HELP-ME was feasible and acceptable at 4 sites across the US

The sites enrolled a total of 106 patients and collected data for 214 patient-days. Overall adherence to HELP-ME protocols was 82% (1473 completed protocols/1798 patient-days), exceeding our feasibility target of 75% adherence. Among individual protocols, eight out of eleven achieved adherence rates above 75%. Individual protocols with high adherence rates included the nursing delirium prevention protocol (96%), nursing medication review (96%), vision (89%), hearing (87%), and orientation (88%), whereas lower adherence occurred with fluid repletion (64%) and range-of-motion exercises (55%). Focus groups provided generally positive feedback regarding the acceptability of HELP-ME and recommended that an optimal approach would be hybrid, balancing in-person and remote interventions for potency and long-term sustainability.11

HELP-ME can improve care for older adults when traditional HELP is not possible

HELP-ME has the potential to broaden the reach of established multicomponent delirium prevention models and aid in improving the care of older adults. HELP-ME is feasible to implement and generally acceptable to staff and patients. Importantly, HELP-ME allowed for additional interaction that would not have otherwise been possible during the pandemic.

Several caveats are important to mention. Concerns were raised by the sites that remote protocols may not be potent enough for effective delirium prevention. Additionally, it was not possible to fully substitute remote protocols for all the face-to-face HELP protocols, such as those involving feeding or ambulating. Some patients also had difficulty using the touchscreen tablets, but this was often addressed through training, support, and encouragement. In this feasibility study, we did not measure delirium rates or other clinical outcomes, and a future randomized trial will be needed to test the effectiveness of HELP-ME.

In circumstances where traditional HELP is not feasible, HELP-ME may maintain access to delirium prevention resources. Considering the limitations of HELP-ME, the expert sites recommended a hybrid approach combining remote and in-person protocols, which could be used for patients in isolation or when staffing is inadequate. Furthermore, remote delirium screening tools, such as the Ultra-Brief CAM,12, 13 could aid future studies evaluating the effectiveness of HELP-ME. The availability of this remote program may extend the reach of HELP, such as in rural or other isolated settings where adequate geriatric-trained staff may not be available for delirium prevention.

References

  1. Wilson JE, Mart MF, Cunningham C, et al. Delirium. Nat Rev Dis Primers. 2020;6(1):90. doi: 10.1038/s41572-020-00223-4
  2. Khan A, Ph DO, Oh-Park M, Ph DN, Ph DM, Oldham M. Preventing Delirium Takes a Village: Systematic Review and Meta-analysis of Delirium Preventive Models of Care. J Hosp Med. 2019;14(9):558-564. doi: 10.12788/jhm.3212
  3. Inouye SK, Bogardus ST, Jr., Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676. doi: 10.1056/NEJM199903043400901
  4. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520. doi:10.1001/jamainternmed.2014.7779
  5. Hshieh TT, Inouye SK, Oh ES. Delirium in the Elderly. Clin Geriatr Med. 2020;36(2):183-199. doi: 10.1016/j.cger.2019.11.001
  6. Ward CF, Figiel GS, McDonald WM. Altered Mental Status as a Novel Initial Clinical Presentation for COVID-19 Infection in the Elderly. Am J Geriatr Psychiatry. 2020;28(8):808-811. doi:10.1016/j.jagp.2020.05.013
  7. O’Hanlon S, Inouye SK. Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing. 2020;49(4):497-498. doi: 10.1093/ageing/afaa094
  8. Gan JM, Kho J, Akhunbay-Fudge M, et al. Atypical presentation of COVID-19 in hospitalised older adults. Ir J Med Sci. 2021;190(2):469-474. doi:10.1007/s11845-020-02372-7
  9. Fong TG, Albaum JA, Anderson ML et al. The Modified and Extended Hospital Elder Life Program: A remote model of care to expand delirium prevention. J Am Geriatr Soc. 2023 Mar;71(3):935-945. doi: 10.1111/jgs.18212
  10. Inouye SK. The Importance of Delirium and Delirium Prevention in Older Adults During Lockdowns. JAMA. 2021;325(17):1779-1780. doi: 10.1001/jama.2021.2211
  11. Schulman-Green DJ, Inouye SK, Tabloski P, et al. Clinicians’ perceptions of a Modified Hospital Elder Life Program for delirium prevention during COVID-19. J Am Med Dir Assoc. 2023 Aug;24(8):1133-1142. doi: 10.1016/j.jamda.2023.05.032
  12. Husser EK, Fick DM, Boltz M, et al. Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators. J Am Geriatr Soc. 2021;69(5):1349-1356. doi:10.1111/jgs.17026
  13. Motyl CM, Ngo L, Zhou W, et al. Comparative Accuracy and Efficiency of Four Delirium Screening Protocols. J Am Geriatr Soc. 2020;68(11):2572-2578.  doi: 10.1111/jgs.16711

Suggested Citation

Fong, Tamara; Inouye, Sharon. Expanding delirium prevention during COVID-19 with the Modified and Expanded Hospital Elder Life Program (HELP-ME), Network for Investigation of Delirium: Unifying Scientists (NIDUS); November, 2023, Available at: https://deliriumnetwork.org/expanding-delirium-prevention-during-covid-19-with-the-modified-and-expanded-hospital-elder-life-program-help-me/ (accessed today’s date)

Posted in AD/ADRD, Delirium Research.

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