By Anayo Akunne
Delirium is a common but serious condition that affects many older people admitted to hospital. It is characterised by disturbed consciousness and changes in cognitive function or perception that develop over a short period of time. This condition is sometimes called “acute confusional state.”
It is associated with poor outcomes. People with delirium have higher chances of developing new dementia, new admission to institutions, extended stays in the hospital, as well as higher risk of death. Delirium also increases the chances of hospital-acquired complications such as falls and pressure ulcers. Poor outcomes resulting from delirium will reduce the patient’s health-related quality of life but also increase the cost of health care.
Delirium can be prevented if dealt with urgently. Enhanced care systems based on multi-component prevention interventions are associated with the potential to prevent new cases of delirium in hospitals. Prevention in a hospital or long-term care setting will lead to the avoidance of costs resulting from patients’ care. For example, the cost of caring for a patient with severe long-term cognitive impairment is high, and prevention of delirium could reduce the number of patients with such impairment. It will therefore reduce the cost of caring for such patients. Prevention could reduce lost life years and loss in health-related quality of life due to other adverse health outcomes associated with delirium.
The multi-component prevention interventions involve making an assessment of people at risk in order to identify and then modify risk factors associated with delirium. Delirium risk factors targeted in such interventions normally include cognitive impairment, sleep deprivation, immobility, visual and hearing impairments, and dehydration. The people at risk of delirium have their risk of delirium reduced through such interventions. The implementation of these interventions is usually done by a trained multi-disciplinary team of health-care staff. This means additional implementation cost. It would therefore be useful to know if this set of prevention interventions would be cost-effective. It was indeed found to be convincingly cost-effective by the UK National Institute for Health and Clinical Excellence (NICE) and was recommended for use in medically ill people admitted to hospital.
It is cost-effective to target multi-component prevention interventions at elderly people at both intermediate and high risk for delirium. It is an attractive intervention to health-care systems. In the United Kingdom the savings for the intervention would spread unevenly between the National Health Service (NHS) and social care providers. The savings to the NHS may be modest and largely accrue through lower costs resulting from reduced hospital stay, whereas the savings to social care are likely to be more considerable resulting from an enduring and diminished burden of dependency and dementia, particularly reduced need for expensive care in long-term care settings. The NHS acute providers may need to invest to implement the intervention and to accrue savings to the wider public sector. The current NHS hospital funding system does not incentivise this type of investment, and this could be a major structural barrier to a widespread uptake of delirium prevention systems of care in the UK.
In the work undertaken as part of the NICE guideline on delirium, the additional cost of implementing the intervention was based on the description of the intervention that required additional staff for delivery. It is possible that the guideline provides an important under-estimate of cost-effectiveness. This is because it might be possible to implement the intervention within existing resources. The intervention is designed to address risk factors for delirium by delivering the sort of person-centred routine care that people might expect to receive. For example, better attention to hydration, nutrition, medication reviews, mobilisation etc. Such an approach appears feasible in routine care although more scientific evidence is needed to demonstrate a reduction in new cases of delirium.
The case for widely deploying multi-component delirium prevention interventions is strong. Such interventions are very likely to be cost-effective in older people who are at risk of delirium. Such interventions will cost-effectively reduce the additional burden of delirium in older people who are likely to be battling with other co-morbidities.
Anayo Akunne is a Health Economist and Director of KSG-Trans Limited. He trained as a Pharmacist with a master’s degree and a PhD in public health / health economics. He worked as a health economist on the NICE Guideline on the diagnosis, prevention and management of delirium (CG 103). He is a co-author (with John Young and Lakshmi Murthy) of the paper “Cost-effectiveness of multi-component interventions to prevent delirium in older people admitted to medical wards.” This paper has been made publicly available by the journal Age and Ageing. You can read it in full and for free here.