TRIAL TO REDUCE DELIRIUM IN AGED POST ACUTE PATIENTS

谵妄是一种常见的、病态的、昂贵的疾病，影响着三分之一的住院老年人，并在导致功能下降和丧失独立性的一连串不良事件中起着核心作用。此外，随着急性护理时间的不断缩短，越来越多的证据表明谵妄可能持续数周，对谵妄的关注不能再局限于医院。我们自己的工作和其他人的初步数据表明，在急症后护理机构接受治疗的老年人中，有25%的人神志不清，其中三分之二的人在一个月后仍然神志不清。我们的假设是，持续谵妄对急性护理后的功能恢复有显著的负面影响。为了验证这一点，我们提出了一项随机对照介入性试验，涉及在四家急性后医院收治的500名谵妄患者。谵妄治疗计划（DAP）将采用专门的方案：1)诊断谵妄，2)治疗谵妄的常见原因，3)预防谵妄并发症，4)恢复功能。DAP将在两个干预设施实施，由医生监督。马尔坎托尼奥和墨菲。另外两个根据人口统计、设施和临床特征与干预地点相匹配的设施将作为对照。为了评估DAP的有效性，受试者将在入院时接受谵妄、认知和功能状态的盲法评估，在急性后设施中每周进行评估，在入院后1、3和6个月进行评估。采用双变量、多变量和纵向分析，我们将评估DAP对谵妄患病率和严重程度的影响，以及急性入院后两周和一个月的ADL功能改善率。我们还将评估我们的干预对急性入院后3个月和6个月ADL功能恢复的长期影响。这项研究将是第一个研究急性后持续谵妄的自然历史和影响的研究。如果DAP在减少谵妄和改善功能恢复方面取得成功，我们的研究结果将作为一种有针对性的方法来改善急性后环境中老年人的护理。

Common, morbid, and costly, delirium affects one third of hospitalized elders, and plays a central role in the cascade of adverse events that leads to functional decline and loss of independence. Moreover, as acute care stays continue to shorten and evidence mounts that delirium may persist for many weeks, concern about delirium can no longer be confined to the hospital. Preliminary data from our own work and others suggest that 25 percent of elders admitted to post-acute care facilities are delirious, and that two-thirds of these remain delirious one month later. It is our hypothesis that persistent delirium exerts a significant negative influence on functional recovery in post-acute care. To test this, we propose a randomized controlled interventional trial involving 500 subjects admitted with delirium at four post-acute facilities. A Delirium Abatement Program (DAP) will be developed using specialized protocols for: 1) diagnosing delirium, 2) treating common causes of delirium, 3) preventing complications of delirium, and 4) restoring function. The DAP will be implemented at two intervention facilities under the supervision of Drs. Marcantonio and Murphy. Two additional facilities, matched by demographic, facility, and clinical characteristics to the intervention sites, will serve as controls. To assess the effectiveness of the DAP, subjects will undergo blinded assessments of delirium, cognitive, and functional status at intake, weekly while in the post-acute facilities, and at one, three, and six months after admission. Using bivariable, multivariable, and longitudinal analyses, we will assess the impact of the DAP on the prevalence and severity of delirium, and the rate of ADL functional improvement two weeks and one month after post-acute admission. We will also assess the long term impact of our intervention on ADL functional recovery three and six months after post-acute admission. This study will be the first to examine the natural history and impact of persistent delirium in-the post-acute setting. If the DAP is successful in reducing delirium and improving functional recovery, our findings will serve as a model of a targeted approach to improve the care of elders in the post-acute setting.