Study finds persistent delirium in skilled nursing facilities has dropped between 2014 and 2019

A new study that looked at possible improvements in post-acute care quality and outcomes following the 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act found that delirium prevalence at admission to skilled nursing facilities (SNF) decreased over the five years, from 4.3% in 2014 to 2.5% in 2019.

Each year, more than 2 million Medicare beneficiaries are discharged from acute care hospitals to SNFs for post-acute care. Delirium, an acute disorder characterized by fluctuating inattention, confusion, and levels of consciousness, is prevalent among older adults in SNF and is considered an indicator of quality of care.  The persistence of delirium is associated with poor outcomes, including hospital readmission, mortality and long-term institutionalization; identifying and managing delirium holds potential for clinical and policy implications.

The study, “Persistence of Delirium in Postacute Care at Skilled Nursing Facilities,” published in JAMA Network Open, reviewed a nationally representative 5% random sample of Medicare beneficiaries who were admitted to SNF in 2 calendar years: 226,039 SNF admissions in 2014 and 205,998 admissions in 2019. Researchers found delirium resolution rates increased from 29.1% in 2014 to 37.4% in 2019 and persistent delirium decreased from 62.3% in 2014 to 54.7% in 2019. The study also found a significant reduction of persistent delirium in 2019 among female, frail, and dementia subgroups. 

These positive trends align with the enactment of the IMPACT Act and enhancements to the Minimum Data Set (MDS) at SNF admission, which includes antipsychotic medication reviews. This suggests at least an indirect influence of these initiatives. According to the researchers, other factors might include enhanced care coordination and quality reporting as well as increased standardization of patient assessments to more accurately identify patient needs and more consistent management practices—all of which may have contributed to improved patient outcomes.

The decrease in the prevalence of delirium at the time of SNF admission may also reflect the efforts of acute hospitals to prevent and manage delirium through interventions such as the Hospital Elder Life Program, which has resulted in models, protocols, pathways, and guidelines. More recently, it has led to the Age-Friendly Health Systems Initiative, which implements the 4Ms framework (What Matters, Medication, Mentation, and Mobility), which has also increased awareness and implementation of delirium prevention protocols in acute hospitals.

According to Chan Mi Park, MD, MPH, Assistant Scientist I at the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife, “Our findings call for delirium prevention and management strategies in the SNF setting, such as staff training for identifying delirium, the adoption of systematic delirium prevention and management programs such as Hospital Elder Life Program, and multidisciplinary strategies to improve patient care in skilled nursing facilities.”

However, while the study found a reduction in the prevalence of delirium at SNF admission and an improvement in delirium resolution during the stay, five years after the IMPAC Act, the delirium rate within SNFs remains high.

“Despite overall progress, the continued high prevalence of persistent delirium warrants further efforts to improve delirium management in SNFs,” Dr. Park added.

The study was supported by grants R33AG071744 (to Dr. Inouye), PO1AG031720 (to Dr. Inouye), and (R01079864 to Dr. Vasunilashorn) from the NIA. Dr. Kim is supported by grants R01AG071809 and K24AG07327 from the NIA. Dr. Inouye holds the Milton and Shirley F. Levy Family Chair at Hebrew SeniorLife/Harvard Medical School.

The researchers included Sandra Shi, MD, MPH, Assistant Scientist II at the Marcus Institute; Richard N. Jones, ScD, an epidemiologist and methodologist in the Department of Psychiatry and Human Behavior at the Brown University Warren Alpert Medical School; Eran D. Metzger, MD, Medical Director of Psychiatry at Hebrew SeniorLife; Sarinnapha Vasunilashorn, PhD, Instructor in Medicine at Harvard Medical School (HMS) and the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center (BIDMC); Tamara G. Fong, MD, PhD, Associate Scientist at the Marcus Institute; Dae Hyun Kim, MD, MPH, ScD, Associate Scientist, at the Marcus Institute; Sharon K. Inouye, MD, MPH, Senior Scientist, Milton and Shirley F. Levy Family Chair at the Marcus Institute.

About Hebrew SeniorLife

Hebrew SeniorLife, an affiliate of Harvard Medical School, is a national senior services leader uniquely dedicated to rethinking, researching, and redefining the possibilities of aging. Hebrew SeniorLife cares for more than 4,500 seniors a day across seven campuses throughout Greater Boston. Locations include: Hebrew Rehabilitation Center-Boston and Hebrew Rehabilitation Center-NewBridge in Dedham; NewBridge on the Charles, Dedham; Orchard Cove, Canton; Simon C. Fireman Community, Randolph; Center Communities of Brookline, Brookline; Jack Satter House, Revere; and Leyland Community, Dorchester. Founded in 1903, Hebrew SeniorLife also conducts influential research into aging at the Hinda and Arthur Marcus Institute for Aging Research, which has a portfolio of more than $98 million, making it one of the largest gerontological research facilities in the U.S. in a clinical setting. It also trains more than 500 geriatric care providers each year. For more information about Hebrew SeniorLife, visit our website or follow us on our blog, Facebook, Instagram, Threads, and LinkedIn.

About the Hinda and Arthur Marcus Institute for Aging Research

Scientists at the Marcus Institute seek to transform the human experience of aging by conducting research that will ensure a life of health, dignity, and productivity into advanced age. The Marcus Institute carries out rigorous studies that discover the mechanisms of age-related disease and disability; lead to the prevention, treatment, and cure of disease; advance the standard of care for older people; and inform public decision-making.