New MyTrees.com Surnames canada gé chateau

   New Names Added in 2011

39051 Names Added Dec 29 2011
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A Surnames Added

A Aamundsdotter Aanonsen Aaron Abbey Abbiati Abbott Abel Abell Abernathe Abernathe Abernathy Abernathy Abigail Abney Abraham Abrams Abshire Absolonson Ackermann Ackley Acklin Ackworth Acland Acthemeier Acton Adamczyk Adams Adamski Adee Adelaide Adkins Adler Aelfthryth Agee Agnaes Agnes Agusta Ahlqvist Aiello Aiken Ainsworth Akers Alabaster Alan Albee Alberts Albi Albinger Albrant Alcock Alcott Alden Alden Mayflower Alderman Alderton Aldis Aldithley Aldobrandeschi Aldrich Aldridge Alee Alena Alencon Alexander Algeyer Algra Alice Allanshaw Allard Allcock Allen Allerton Allerton Mayflower Alley Allie Allison Allott Allright Allyn Alma Almich Almy Alrust Alsbury Alsop Alsteen Alsteens Alt Altman Alvord Amauri Amboise Ambrose Amelia Amerideth Ames Amiens Amiot Amirault Ammerman Ammermann Amory Amsden Amundsdatter Amy Ancetre Andera Anders Andersdatter Andersdotter Andersen Anderson Andersson Andrea Andreini Andrew Andrews Andrews Shank Andriessen Andrina Andrulaitis Anewalt Angelina Angeline Angelos Angelus Angier Angiers Anglin Angouleme Anhalt Anice Anjou Anjou And Orleans Anklam Ann Anna Annable Annala Anne Annett Annette Annie Antell Anthiaume Anthony Antoniusson Antrade Antrobus Ap Alkwn Ap Anarawd Ap Arthen Ap Bleddig Ap Bleddyn Ap Cadell Ap Cadfan Ap Cadwaladr Ap Cadwallon Ap Caradoc Ap Ceneu Ap Clydog Ap Cynfyn Ap Cynwrig Ap Dafydd Ap Dwywg Ap Ednywain Ap Edwin Ap Einion Ap Elidir Ap Enion Ap Evan Ap Griffith Ap Gronwy Ap Gruffudd Ap Gruffydd Ap Gwaethfoed Ap Gwair Ap Gwerystan Ap Gwriad Ap Gwst Ap Gwyn Ap Hyfaidd Ap Hywell Ap Idwal Ap Iorwerth Ap Llewellyn Ap Llewelyn Ap Llewllyn Ap Llywarch Ap Llywelyn Ap Madog Ap Maredudd Ap Meirchion Ap Meredith Ap Meredydd Ap Merfyn Ap Meyrick Ap Owain Ap Owen Ap Seisyll Ap Tewdwr Apgruffydd Apllewelyn Appleby Appleton Aquitaine Aragon Archambault Archdeacon Of Richmond Archibald Arcimas Arcuri Arends Argabright Arizaga Arkley Arles Armistead Armiston Armoine Arms Armsby Armstrong Arnaud Arndt Arnesdatter Arneson Arnett Arnold Arrowood Arscott Arsonnelle Artois Asalos Asay Ash Ashby Asher Ashley Ashton Asp Aspinwall Asserson Athellred Atkins Atkinson Aton Attwood Atwood Aubert Aubigny Aucoin Audrey Augusta Ault Aunois Aupais Austen Austin Autin Autreuil Autun Averill Avery Avicia Avisse Avranches Awood Ayer Ayers Aymard Ayres B Surnames Added

B Babbage Babbitt Babcock Babeau Bachand Bachand Vertefeuille Bachasson Bachmann Backer Backhurst Backman Bacon Baden Badger Badgley Baer Baerenz Bagley Bagshawe Baguley Bailey Baillargeon Baillon Baily Bain Baines Bajgier Bajolet Bakalarcyzk Bakalarzck Bakelmans Baker Bakken Bakkum Balch Baldwin Ball Ballantine Ballard Ballenger Ballou Balthazar Baltus Bancroft Banghart Bangs Banka Bankin Banks Banliac Bannister Banyster Bar Sur Aube Baravetto Barbage Barbara Barber Barboize Barcelona Barden Bardolf Bardoux Bardsley Bareau Barents Barentsdochter Barger Baribeau Barillot Baring Barker Barksdale Barkus Barlow Barlowe Barnake Barnard Barne Barnes Barneski Barnhart Barnhill Barnhouse Barnum Baron Baron Beauchamp Baron Herbert Baron Montague Baron Stafford Baron Stourton Barr Barreau Barres Barret Barrett Barriault Barrington Barron Barrows Barry Barstow Bartholomew Bartlett Bartley Bartlme Barton Bartram Bartz Bascom Basden Basile Basinger Baskerville Bass Basselle Basset Bassett Bastian Bastil Batchelder Batchelor Bate Bateman Bates Batka Battenberg Battisford Baucher Baucher Dit Montmorency Baudet Baudreau Graveline Bauer Baugh Baumann Baumgaet Baumgartner Bavaria Baxley Baxter Baye Bayer Baynham Beach Beaham Beal Beale Beamer Beamon Bean Bear Beard Beardsley Bearse Beastrom Beatice Beatrice Beatty Beauchamp Beauchamp Lepetit Beauchemin Beauchesne Beauclerk Beaudet Beaudoin Beaudry Beauford Beaufort Beaulieu Beaumont Beaumont Earl Of Buchan Beaupre Beauregard Beaver Bechok Beck Becker Beckerine Becket Beckett Becki Beckley Beckman Beckwith Bedell Bedor Beebe Beedham Beeker Beeler Beeman Beers Begnier Behling Beignier Beil Beilke Beilcke Beke Belanger Belcher Belcourt Belden Belding Belgard Belknap Bell Bella Belleau Bellegarde Beller Bellerose Bellile Bellomontensis Bellows Belminski Belongia Belser Belt Belter Bemis Benard Benbow Bence Bendel Bender Benedict Benham Benish Benjamin Benjamin Scott Bennet Bennett Benoit Benson Bent Bentley Benton Benzschawel Beranger Bercier Berenger Berenger Count O Provence Bergen Bergeon Berger Bergeron Bergerson Bergman Berk Berkeley Berlaimont Bernadotte Bernard Bernier Berns Bernsteen Bero Berry Bert Bertha Bertrand Besinger Besnard Besom Besse Bessette Bessey Best Bet Beth Bethke Betschick Betsey Betsy Bett Bettinger Bettis Betty Beula Beutels Beutler Beverly Bevern Beyea Beyer Bicknell Bidet Bidet Dit Desroussels Bidum Bidwell Bieher Bienfang Biernier Biesek Biesik Bigelow Bigod Bigsby Bilaude Billardello Biller Billing Billings Billington Billiou Billy Bilot Bindara Binder Bineau Bingham Bingli Binion Bird Birdseye Birge Birmingham Bisbee Bisbing Bisby Bischoff Bishop Bisson Bissonet Bissonette Bissonnette Bitfield Bitsen Bixby Bjerke Bjornholt Bjornson Bjornsson Black Blackburn Blackmore Blackstrom Blackwell Bladen Blair Blaisdell Blake Blakeley Blakenship Blakeslee Blakney Blanchard Blanche Blanchet Blankenship Blaxton Blazak Bleninger Blessing Bleyer Bleylor Bliss Block Blodgett Bloget Blois Blood Bloom Bloomquist Blott Blou Blount Blow Blucks Bluett Blumreich Blundell Blyssynge Boardman Bobbitt Boccaccio Bocek Bochnak Bock Bockhaus Bocuicio Bodamer Boe Boeckmann Boeger Boehler Boehmer Boelter Bogardus Bogart Bogert Boggs Bohemia Bohnet Bohython Boigeou Boisleau Boissy Boissy Lagrillade Boisvert Boivin Bold Boleyn Bolin Bolio Bolitho Bolster Bolte Bolton Bolz Bonaparte Bonar Bonczynska Bonczynski Bond Bondy Bonell Bonneau Bonner Boomer Boorman Boorn Boosey Boosy Booth Borchardt Borden Borders Borem Boreo Borkowski Born Borodell Borrel Bortkevicius Bos Boscalli Bosch Bosshart Bossom Boster Bosworth Boteler Botetourt Botsford Bottrell Bouart Bouchard Boucher Boucher Desrosiers Boudrot Bouffiou Boughey Boughton Bouillet Boulanger Bould Boulet Boulin Bounds Bour Bourassa Bourbeau Bourbon Bourchier Bourg Bourgeois Bourgogne Bourn Bourne Bourque Bouteiller Boutell Bouthillette Bouton Boutot Bowchiew Bowden Bowdish Bowen Bowers Bowes Lyon Bowker Bowler Bowley Bowman Bown Bowtell Boyce Boyd Boyden Boyer Boyle Boynton Boyse Bozza Braaten Braatz Brabazon Brace Brackett Brackhonge Bradbury Bradford Bradford Mayflower Bradley Bradstreet Bradt Braem Braganza Bragg Brainard Braithwaite Brakebush Brand Brand Trevor Brandenburg Schwedt Brandeston Brando Brandon Brandt Branham Branks Brann Brannon Branstetter Brantley Braose Brashear Brass Brassard Brasseur Brault Braun Braya Brayman Brazer Brazier Bread Brecher Breckenridge Breed Breeden Breeding Breese Brehme Breitenstein Breivogel Brenton Bressler Breteuil Breton Brevard Brewer Brewster Brewster Mayflower Briant Brickley Bricks Bridgeman Bridges Bridget Bridwell Brienne Briere Briggs Brigham Bright Brinckerhoff Brinkerhoff Brintnal Brisset Brisson Brister Britain Britiany Brittany Britten Britton Britz Briwere Broach Broad Broadfield Broadway Brock Brockman Brockway Broder Brody Brogden Bromhall Bromley Bromnell Bronk Bronka Bronn Bronson Brooks Brooksby Broom Brooman Broome Brophey Brot Broughton Brouillet Lavigueur Brown Browne Brownell Browning Brownlee Broyles Bruce Brucker Brudenell Bruen Bruening Bruhn Bruley Brummans Brun Brunelle Bruner Brunet Brunette Brungger Brunk Brunke Brunning Brunsell Brunt Brus Brush Brusoe Brustad Bruyette Bruyn Bryan Bryant Brych Brydges Brzezinski Bss Lisle Bubar Bublitz Buchanan Buchannan Buchet Buchholtz Buchholz Buck Bucke Buckland Buckmaster Buckminster Buckner Buczak Budnik Budzislawska Buechler Buffington Buffum Buisson Bulkeley Bulkley Bull Bullard Bullion Bullmore Bulloch Bullock Bulmer Bumster Bundy Bunker Bunton Burbank Burbatt Burchard Burden Burdick Bureau Bures Burgard Burge Burger Burges Burgess Burghersh Burghull Burgraf Burgundy Burke Burkes Burkhardt Burley Burnett Burnham Burns Burr Burrall Burrill Burrows Bursell Bursley Burt Burton Burzec Busby Busch Busecot Bush Busher Bushnell Bushway Buss Butcher Butkus Butler Butterfield Butters Butterworth Button Buttrick Butts Butz Buxton Buzzell Byam Byers Byington Byram Byrd Byron Byshoppe Bysinger Bystrom Bythers Bã–Hringer C Surnames Added

Cabble Cadoret Cady Caen Cager Cagle Cahak Caille Calamito Calbat Calder Calderwood Caldwell Caleb Calef Calfee Calkins Call Callahan Callaway Calloway Calvert Cambray Cambridge Camilo Camp Campanelli Campbell Candavene Canfield Canniff Cannon Canterbury Cantilupe Capen Capet Capet King Of France Capwell Carbonneau Carden Cardin Cardinal Pole Carey Carinthia Carle Carleton Carley Carlile Carlin Carlisle Carlson Carlton Carmack Carmella Carmichael Carminow Carnahan Carney Carol Caroline Carolingian Carolingians Caron Carow Carpenter Carpentier Carpiaux Carr Carraway Carre Carreau Carrie Carrier Carriere Carswell Carter Cartwright Carver Cary Caryl Case Casebeer Casey Cash Casper Caspers Cassatt Castaneda Castell Castile Cate Catharine Catherine Cathey Catlett Catrina Catron Catudel St Jean Cauchon Caulkins Caunton Causey Cauz Cavanaugh Cavendish Cayer Cayvot Cecil Cecile Ceelen Celia Cellin Centro Cerny Chabot Chadbourne Chadwick Chafee Chaffee Chafin Chagnon Chagnon Larose Chagnon Shonion Chagnon Shonyo Chalfant Chalker Chalons Chamber Chamberlain Chamberland Chamberlin Chambers Champagne Champeau Champernon Champion Champlain Champlin Champney Champou Chandler Chaney Chapeau Chaperon Chapin Chaplin Chapman Chappel Chappelear Charbonneau Chardon Charest Charles Charlot Charlotte Charlton Charon Dit Laferriere Charpentier Charron Charter Chartier Chase Chaslut Chastain Chasteau Chastian Chatellerault Chauniere Sabourin Chauvin Chawkley Chaworth Cheadle Cheffey Chenay Cheney Chepman Cherney Cherry Chesebrough Cheshire Chesley Chesnay Chester Chesterman Chesters Chestnut Chetwode Chevalier Chevreau Chichester Child Childebrand Childers Childs Chileab Chillingsworth Chillingworth Chilton Chipman Chittenden Chloe Choke Cholet Chopalski Choquet Choret Christ Christensdatter Christensdotter Christensen Christenson Christian Christiansen Christianson Christina Christopher Christophers Christophersdatter Chubbuck Chudleigh Chugg Church Churchill Churchman Chute Ciminella Ciminello Cindy Cirilli Cizek Claflin Clapham Clapp Clara Clare Clarence Clarissa Clark Clarke Clay Cleaveland Cleland Clemanson Clements Clere Clerice Clermont Cleveland Cliff Clifford Clifton Cline Clinton Cloe Clopton Close Clough Cloutier Clure Coates Coats Cobb Cobleigh Coburn Cocghnower Cochran Cochrane Cocke Cocking Cockrum Coder Coe Coeymans Coffey Coffin Cogan Coggswell Cognac Cogswell Cohen Coiffes Colborn Colburn Colby Colcord Colder Coldicot Cole Coleman Coles Coleson Coley Colie Re Collar Collet Collier Collins Colloraffi Colman Colson Colton Colvin Colwick Coman Combe Combs Comeau Comings Comnena Compeau Comstock Comtee Comyn Countess Of Buchan Cona Conant Conarroe Conat Condella Condella Candela Conflans Conkle Conklin Conkling Conley Connant Connelly Conner Connolly Connor Connors Conover Conrad Conrady Conroe Conrow Constable Constance Conteville Contois Converse Conway Conyers Cook Cooke Cooke Mayflower Cool Coolbath Cooley Coolidge Coolidge Whitney Coombs Coon Coons Coop Cooper Cope Copeland Copener Copley Copp Copus Corbeil Corbet Corbett Corbicon Corbin Lacroix Corder Cordillo Corey Corington Cormier Cornel Cornelius Cornell Cornwall Cornwell Corrigan Corriveau Corsellis Corson Cory Cosgrove Cossart Costello Cote Cotton Couillard Coulter Council Count Devreaux Count Of Rouen Count Of Senlis Count Of ÉVreux Courchesne Courtenay Courtois Courville Cousineau Coutancineau Couteau Couture Couturier Couwenhoven Cove Covell Coverdale Coville Cowdry Cowell Cowenhoven Cox Cox Brown Coyle Crabtree Craddock Craig Crandall Crane Cranston Craswell Craven Craver Craw Crawford Cray Creager Creapeau Creech Creger Crego Crepon Crevet Crevier Cribley Crispel Croade Crobach Crocker Crockett Croffoot Crofut Cromer Cromune Croney Cronkite Crooke Crookenden Crosbie Crosby Cross Crosse Crossman Crothers Crowder Crowe Crowell Crowmer Crozier Cruickshank Crum Crunkerene Cruver Cryan Crysler Cubisha Cuddaback Culbertson Cule Culliford Culpepper Culver Cumber Cummings Cummings Or Comings Cunegonde Cunningham Cure Curl Curran Currier Curry Curtice Curtis Curtiss Curzon Howe Cushing Cushman Cusson Custis Cutiloup Cutler Cutter Cychosz Cyfeiliog Czapiga D Surnames Added

D D Abancourt D Acton D Amiens D Anthenaise D Aumale D Auvergne D Avranches D Estouteville D Evereux D'Albini D'Alsace D'Angers D'Anjou D'Anneville D'Aubigny D'Aubingy D'Eevreux D'Esperon D'Este D'Eu D'Hainaut D'Issoudun D'Orleans Dabney Dacheff Daggett Dagobert Dahl Dahlberg Dahlin Daigle Daily Dale Dalen Dallmann Dalrymple Dalson Dalton Damazyn Dambrill Dameron Dammartin Damois Damon Damoys Damron Damsgaard Dana Dandonneau Danes Danforth Daniecki Daniel Danielle Daniels Dank Danvers Daquitaine Darby Darcy Darke Darling Darmine Darnell Dart Darte Daubner Daude Daudelin Daugherty Dault Daux Davenport David Davids Davies Davis Davison Dawley Dawn Dawson Day Dayton De De Acton De Acton Hellesby De Albini De Alditheley De Aldwaldley De Alencon De Alselyn De Amory De Aragon De Arles De Arques De Artois De Atholl De Audley De Aumale De Autun De Auvergne De Avranches De Badlesmere De Balsareny De Bar De Bar Sur Aube De Bardolf De Bassett De Baudement De Beauchamp De Beauchamps De Beauford De Beaufort De Beauharnais De Beaujeu De Beaumetz De Beaumont De Beauvau De Beke De Belleme De Berekley De Berenger De Berkeley De Bermingham De Bigorre De Blaison De Blois De Blondville De Bobbio De Bohun De Bombelles De Bonville De Botetourt De Bothwell De Bourbon De Bourbon Parma De Bourbon Penthievre De Bourbon Sicily De Bourgogne De Boys De Brabant De Braganza De Brancestre De Braose De Bretagne De Bretton De Brie De Brien De Brienne De Briole De Brito De Brittany De Briwere De Broyes De Bruce De Bruley De Brus De Buci De Bueil De Bure De Burgh De Burghersh De Burgundy De Burley De Camoys De Campofranco De Camville De Carcassonne De Carteret De Castile De Caux De Cauz De Chacomb De Champagne De Chateau Porcien De Chatillon De Chaworth De Chelius De Cherleton De Cherlton De Chesney De Chevrainville De Clare De Clermont De Cleves De Clifford De Cobham De Cogan De Colewick De Collaton De Comminges De Condet De Conteville De Cotentin De Coucy De Coughton De Courtenay De Craon De Creil De Crepon De CrãŠPon De Cuurey De Dagworth De Dammartin De Dampierre De Denton De Derwentwater De Devereux De Dinan De Dol De Dreux De Dunstanville De Echingham De Ellis De Estouteville De Evereaux De Evereux De Ewrus De Ewyas De Falaise De Ferrars De Ferreres De Ferrers De Ferrieres De Fiennes De Fixby De Flanders De Flandre De Flandres De Foix De Folville De Fougeres De Freville De Furnival De Galloway De Gand De Garlende De Gay De Geneville De Gerlaise De Gernon De Gevaudan De Glouchester De Goello De Gometz De Goviz De Gray De Grey De Gueldres De Guise De Guitre De Hainault De Harcourt De Harington De Hastings De Haversham De Heaton De Hemingford De Hesding De Heyton De Holand De Holland De Holt De Hooges De Hummet De Huntingdon De Huntington De Jonge De Kerouaille De Kevelioc De Keveliock De La Gueripiere De La Haye De La Lee De La Marche De La Mare De La Planche De La Pole De La Roche De La Spine De La Warr De Lacy De Lalande De Lancaster De Laon De Lapraye De Laval De Leigh De Leinster De Leon De Lexington De Limoges De Linoges De Lisle De Lluca De Lobstock De Loches De Londoniis De Longespee De Longwy De Lorraine De Lostock De Lucy De Lusignan De Luvetot De Luxemburg De Maatenloch De Mainwaring De Malesours De Malherbe De Malpas De Maltravers De Marche De Marchena De Martel De Mayenne De Mello De Merton De Meschines De Metz De Meulan De Milano De Mohun De Moleyns De Molle De Montagu De Montague De Montaguerre De Montagules De Montalivet De Montford De Montfort De Monthermer De Montlhery De Montmierl En Brie De Montmorency De Mortimer De Morvois De Mountford De Mowbray De Mulford De Musters De Namur De Navarra De Navarre De Neville De Newhall De Newmarch De Nivelles De Normandie De Normandy De Normanville De Notton De Orleans De Ormsby De Oxton De Pantulph De Percy De Perigord De Peshall De Plesley De Poitiers De Ponthieu De Porhoet De Portugal De Powis De Poynings De Praers De Preaux De Prindergast De Provence De Quincy De Rainville De Renthel De Reresby De Rethel De Reviers De Riddlesford De Ridel De Ridelisford De Rieux De Rising De Romaignan De Ros De Roucy De Rouen De Rouergue De Rutland De Sable De Sacre De Salisbury De Santis De Savoi De Savoie De Savoy De Say De Saye De Seagrave De Seine De Sens De Seymour De Shoresworth De Sille De Skelton De Somery De Sommery De Spencer De Spenser De Spine De Spineto De St Clair De St Liz De St Paul De St Pere De Stafford De Staunton De Stier De Stuteville De Suffolk De Sutton De Taillefer De Talbot De Tateshall De Tattershall De Toeni De Toni De Torby De Toulouse De Touluse De Trafford De Traves De Trussell De Ufford De Umfreville De Valence De Valoines De Valois De Vaux De Venables De Vendome De Verdon De Verdun De Vere De Vermandois De Vermondais De Vernon De Vesci De Viennois De Vipont De Vos De Vouzy De Warenne De Warren De Warrenne De Welles De Wells De West De Weyland De Whatton De Winter De Witt De Worcester De Workesley De Worseley De Worsley De York De Yvery De Zouche Deacon Deaguilar Dean Deane Deanna Dearborn Deatley Deaton Debohun Deborah Debot Debure Decelle Dechard Decker Decosse Defoe Degerlaise Degroot Dehaie Dehan Dehart Deheubarth Dehooges Dehuse Howes Deichsel Deincourt Dejardin Dejarlais Delacroix Delamarche Deland Delaney Delaper Delaunay Delaurentis Delbec Delcorps Delcour Delfosse Delia Deloney Delong Delonguemerliere Delores Delvaux Delveaux Demers Demidoff Deming Demohun Dempsey Denamur Denevers Denis Denison Denmark Denning Dennis Dennison Denoyer Densell Denslow Dent Denton Depas Deppe Depuis Depuy Derbyshire Derfuss Derifield Dering Derocher Deroos Derrick Dervetski Derwentwater Des Roches Des Sicambrian Desautel Desavoy Desbrough Deschenes Descoteaux Desfosses Desha Deshaies Desilets Desjarlais Desmarais Despault Despencer Desportes Desroche Desrosiers Dessellier Detri Detry Devall Devault Devereau Devereaux Devine Devisser Devon Devos Devouzy Devries Dewey Dewez Dewitt Dewolfe Deyoung Di Sicilia Dibble Dickelman Dickerman Dickerson Dickey Dickinson Dickison Dickman Dickson Dicus Didron Dienst Dierikx Dietler Dietz Diggins Dighton Dillen Dillinger Dimmock Dimon Dina Dinah Dines Dinet Dingledine Dinnis Dinsmore Dinwiddie Dirby Dircks Dirigle Disborough Disbrowe Disney Dit Vien Ditier Dittmar Divita Dix Dixon Dodd Doddington Dodge Doe Doffelmeyer Doggett Dolbere Dolgorukaja Doll Dolling Dolloff Dolly Domaika Domanski Dombeck Domenig Domina Domingo Domnaill Donahoe Donna Donnelly Donnely Donovan Doolittle Doors Dora Dorcet Dorens Dorian Doris Dorn Dorothy Dorsey Dorshak Doterinde Dotson Doublet Doucet Doud Doud Eisenhower Doughty Douglas Douglas Scott Doundy Dout Doutt Douville Dow Dowell Dowler Dowman Downard Downe Downer Downham Downs Dowrish Doyle Drach Draeger Drafz Drake Drakeford Drane Draper Dreger Dreher Dreikosen Dresser Drew Drexler Driby Drier Dries Drinkwater Drinwater Drisco Drisko Drollinger Druckrey Drury Dryden Drã†Gne Drã†Gni Du Berry Du Cailar Du Corneau Du Hommet Du Maine Du Thy Du Tremblay Dubay Dubbels Dubbin Dube Dubois Dubuque Ducharme Duck Dudgin Dudley Dudly Dudzik Duersteler Duff Duffey Duffy Dufresne Dugas Duhamel Duhamelle Duke Of Aquitaine Dulick Dulka Dumas Dummer Dummiego Dumont Dumpprope Dunavant Dunbar Duncan Duncombe Dunfee Dunham Dunkeld Dunklee Dunlap Dunn Dunnaway Dunshee Dunstanville Dunster Dupee Dupont Dupuy Durand Durant Durham Durkee Durkin Durrieux Durvassal Dusson Dustin Dutton Duty Duval Dwight Dye Dyer Dykes Dã–Ring E Surnames Added

E Eames Earhart Earl Of Derby Earl Of Devon Earl Of Pembroke Earl Of Rutland Earl Of Shrewsbury Earl Of Suffolk Earl Of Westmorland Earle Easterbrooks Eastham Eastman Easton Eaton Ebba Ebeling Ebenwaldner Eberenz Ebner Eccles Echingham Echols Eckert Eckes Eckhols Ecklund Eddy Eddye Eden Edes Edith Edlbeck Edmonds Edmonstone Edmunds Edson Edward Edwards Edwardson Eels Eggleston Egmond Ehlke Ehmann Eichhorst Eichorst Eiermann Eisenhower Elaine Eldred Eldredge Eldridge Eleanor Eleanora Elen Elenz Elerath Elgersma Eliot Elisabeth Elisabetha Elise Elizabeth Elkins Ellen Ellenor Ellenwood Ellice Ellick Ellinger Elliott Ellis Ellison Ellner Ellsworth Elmore Elsie Elting Emard Emberger Emerson Emery Emery Coderre Emilia Emma Emmeline Emmons Emmote Empir Emporer Empson Enard Endersen Endicott Endres Endresdotter Engel Engen England Englefield Engley Eno Enos Eppes Eric Erick Erickson Ericson Eriksdatter Eriksdotter Eriksdtr Erikson Erismann Ermeling Ernestina Err Errington Erskine Erwin Esham Esser Estabrook Estabrooks Estes Estey Esther Estridsen Eternicka Ethel Etheridge Etienne Ettinger Eubach Eunice Eva Evans Evelyn Evendon Evenson Everard Evered Evered Webb Evereux Everingham Eversole Everson Every Evoslage Evreux Ewa Ewen Ewert Ewrus Extrom Eyck Eye Eyerrmann Eyers Eyon Eyre Ezekiel F Surnames Added

F Faerden Fafard Fafard Dit Delorme Fagan Fain Fairbanks Fairbrother Fairchild Fairfield Falconer Faleske Fallon Fallowell Fallows Faria Farley Farmen Farmer Farnham Farnsworth Farr Farrar Farrell Farrington Farwell Fassett Faubian Faucher Faught Fauley Faun Faunce Faure Fauvreau Favor Favreau Fawley Fay Faye Feavord Fechner Federer Feld Felkner Fell Fellows Felt Feltcehr Felton Fenno Fenske Fercher Ferguson Ferkovich Ferland Fernandez Ferre Ferrell Ferrers Ferrieres Ferris Ferry Fessenden Fetis Feuillon Fex Fiebelkorn Field Fielder Fielding Fields Fields Field Fiennes Figaroa Filer Filiatrault Filiatrault Dit St Louis Filion Finch Finger Finkenbine Finneman Finney Fiol Fischer Fish Fisher Fisk Fiske Fit Roy Fitch Fitz Alan Fitz John Fitz Maurice Fitz Robert Fitz Roger Fitz Thomas Fitz Walter Fitz Warren Fitzalan Fitzalaric Fitzbaldric Fitzbaldrick Fitzbardolf Fitzcharles Fitzclarence Fitzflaald Fitzgearld Fitzgeorge Fitzgerald Fitzgilbert Fitzgilbert De Clare Fitzhamon Fitzhenry Fitzherbert Fitzhubert Fitzhugh Fitzjames Fitzmaurice Fitzodo Fitzpatrick Fitzrichard Fitzrobert Fitzroger Fitzroy Fitzswaine Fitzthorfin Fitzwalter Fitzwauter Fitzwilliam Fladaaker Fladager Flagg Flaitel Flanders Flanders And Hai Flatt Fleance De Dol Flegg Fleishman Fleitel Fleming Flemming Fletcher Fleury Flinch Flint Flores Fluty Flynn Fobes Fodnes Fogelberg Fogg Fogle Foisy Foisy Freniere Fojut Folb Foley Foliot Folsom Foltz Folure Fonda Fonder Fontaine Foorde Foote Forbush Forcalquier Force Forcier Ford Foreman Forgeron Forrester Forsdick Forseth Fortescue Fortier Fortineux Fortney Fortune Fosdick Foss Fosten Foster Foubert Foument Fountain Fountaine Fouquet Fournier Fowke Fowler Fox Foxcroft Foxley Frailing Fralick France Frances Francis Franciska Frank Franke Frankland Franks Fratwell Frautten Frazier Frech Frechette Frederick Fredericka Fredricke Fredrickson Fredry Freeborn Freedel Freeman Freimark French Frenet Frenette Freres Frerichs Freshwater Fressel Fresset Fretwell Frey Frick Frickenstein Friday Frimutel Frink Frisbie Fritz Frizzell Frodesen Froehlich Froelich Frost Frothingham Fruskey Fry Fryer Frã‰Nette Ftzgearld Fuchs Fuerst Full Fuller Fullmer Fulsom Funk Fuqua Furford Furnival Furson Fus Fychan Fylbrigg Fynymore Fytche G Surnames Added

G Gaarden Gordon Gaddy Gael Gage Gager Gagne Gagnon Gagn㉠Gagon Gahan Gaigneur Gajeski Gajewski Galardet Gale Gallagher Gallin Galloway Gallup Galusha Gamar Gambrell Gambrill Gamelin Gamer Gammel Gammon Gamoke Gandin Gane Ganterer Ganzler Gapko Garber Gardanier Gardenier Gardien Gardiner Gardiner Tyler Gardinier Gardner Gareau Gareman Garey Garfield Gargan Gariepy Garland Garlinghouse Garneys Garnier Garrett Garrow Garvey Gary Gascoigne Gass Gassaway Gassen Gastes Gaston Gatchell Gateau Gater Gates Gatinais Gatto Gaudet Gaudin Gaudry Gauerke Gault Gauslin Gauthier Gavalin Gawkroger Gawton Gay Gayney Gear Gechas Gedraht Gelderman Gelifeler Gelina Gelinas Gelinne Gence Gendre Genest Gengel Gensler Geoffroy George Georges Picot Geraldine Gerard Gerbault Gerbeau Gerda Gerdes Gerhard Gerlet Germany Gerone Gerritszen Gerts Gerue Gervaise Geske Getchel Getchell Getty Ghenne Gholson Gholston Ghuenne Gibbons Gibbs Giboulon Lafleur Gibson Giffard Gifford Gignac Gigot Giguere Gilbert Gilbreath Gilchrist Gildner Gill Gilla Patraic Gillam Gillet Gillett Gilliam Gilman Gilmore Gipe Gipoulon Gipoulon Lafleur Gipoulou Gipson Girard Girioux Girodeau Girouard Giroux Gise Giton Glanville Glass Glazier White Gleason Gledhill Glezen Glidden Gloucester Glover Glucksburg Gobble Gobert Gobinet Goble Gochenour Godard Godawa Godbout Godfrey Godin Godwin Goeppner Goers Goetz Goff Goffe Golden Goldhatch Goldstone Goldthwait Goldthwaite Golin Golly Gometz Gomez Gonsalus Gonzales Gooch Goodale Goode Goodell Goodenough Goodenow Goodhue Goodlet Goodnough Goodrich Goodrow Goodspeed Goodvine Goodwin Goody Gordon Gordy Gorges Gorham Gorski Gorsuch Gorton Gosselin Gosweyler Gotchy Gott Gouchenour Gould Goulee Goulet Goushill Gousset Gove Gowland Graeff Graf Graff Grafton Graham Gralow Gramer Granby Grand Grandin Grant Granzeier Grasee Grate Grathwohl Graton Gratto Gratton Gratzek Grave Gravel Graves Gray Graybeal Great Greeley Green Greene Greenfield Greenleaf Greenman Greenslade Greenstreet Gregg Gregor Gregory Gregson Greibel Greis Gremban Grenell Grenier Grenville Greta Grether Gretzinger Greves Grey Griepentrog Griffen Griffin Griffith Griffitts Grigg Griggs Grignon Grillo Grimes Grimm Grimwood Grindall Grindell Grindon Griniff Grinnell Griswold Gritzmacher Grob Groff Groh Groner Groskopf Gross Grossejambe Grossnickle Grosvenor Groth Grout Grover Grubbe Gruber Grubinski Grudzinska Gruffydd Grugel Gubler Gucker Guelph Guerra Guerrero Guertin Guilford Guillaume Guillebourdeau Guillebourg Guillet Guillion Guillot Gulbins Gulick Gundersdatter Gundersdatter Vestre Flaa Gunn Guptill Gurley Gurney Gustafson Gutfleisch Guth Guthrie Guyon Gwyn Gwynedd Gwynne Gye Gylbert Gylbye Gã„Dda Gã„Dda Jungar Gã„Dda Knuts Gã„Dda Sund Gã„Ddnã„S H Surnames Added

H Haagensdotter Haas Hablett Habrunner Habsburg Habsburg Lorraine Habsburg Lotharingen Haburne Hack Hadley Hadlock Haener Haeri Haffner Hafner Hageman Hagen Hager Hagson Hahn Hahnen Haiden Hails Hailstoane Hainault Hainaut Haines Hair Halcott Hale Hales Haley Hall Halliday Halminiak Halsey Halsnoth Halstead Halverson Halvorson Halys Hamann Hamel Hamilton Hamlin Hammerstein Hammerstrom Hammon Hammond Hamner Hampton Hanah Hand Hanersuck Hanford Hangensen Hanke Hankey Hankford Hanly Hanna Hannah Hanneman Hanning Hannum Hanover Hansdatter Hanselyn Hansen Hanslap Hansler Hanson Hansson Hapgood Harbou Harcourt Hardenbroeck Harding Hardington Hardmann Hardwoode Hardy Hare Harel Hargrave Haring Harless Harlow Harman Harmon Harp Harper Harpster Harpur Harres Harrgat Harriagan Harriet Harriman Harrington Harris Harrison Harsant Hart Hartford Hartleigh Hartley Hartman Hartmann Hartmeier Hartwell Harvey Harwood Haseltine Haselton Hasenã–Hrl Hasford Haskell Haskins Hass Hasselquist Hasselqvist Hasseltine Hasselton Hasting Hastings Hatch Hatcher Hatfield Hathaway Hatherly Hathorne Hatikka Hattie Hauenstein Haugeto Haugland Hauk Hausworth Hautala Haute Marche Haven Havens Hawes Hawett Hawke Hawkes Hawkins Hawks Hawley Hawthorne Hayden Haydock Hayes Hayford Hayme Haynes Hayot Hayward Haywood Hazard Hazeltine Hazelwood Hazen Heal Heald Healy Heath Heaton Hebard Hebel Hebert Hecker Hedewige Hedge Hedges Hedman Hedrick Hegeman Hegewald Hegner Heidtke Heighes Heikkenen Hein Heinonen Heinz Heisner Helena Helie Hellmann Helm Helton Hemberstone Hemenway Hemerick Hemingway Hemming Henchman Henderman Hendricks Hendrickson Hendriks Hendriksen Hendrix Heneage Henk Henkelman Henman Henneg Henninger Henno Hennston Henrickson Henry Henshaw Henson Hepburn Hepner Herbert Hergren Herman Hermundson Herndon Heroux Herren Herres Herrick Herring Herron Hersey Herstal Hertault Hesdin Hess Hesser Heusser Hewes Hewett Hexstall Hext Hextall Hey Heydon Heyes Heyward Heywood Hibbard Hickey Hicks Hidde Hidden Hiekkinen Hielsburg Hier Higgins High Hikenai Hilbert Hildreth Hilgart Hilger Hill Hillary Hilliard Hills Hiltoft Hilton Hiltunen Hilty Hinchman Hinckes Hinckley Hincks Hindes Hines Hinkle Hinkley Hinks Hinksman Hinsilwood Hintze Hitchcock Hitt Hitter Hittle Hix Hoadley Hoagland Hoagland Witter Hoaglund Hoare Hobart Hobbs Hobson Hocking Hodde pcqwyfnu. canadá ganso usar Hodge Hodgeman Hodges
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A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients

Sharon K. Inouye, M.D., M.P.H., Sidney T. Bogardus, Jr., M.D., Peter A. Charpentier, M.P.H., Linda Leo-Summers, M.P.H., Denise Acampora, M.P.H., Theodore R. Holford, Ph.D., and Leo M. Cooney, Jr., M.D.

N Engl J Med 1999; 340:669-676 March 4, 1999 DOI: 10.1056/NEJM199903043400901

Share: Abstract

Background

Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.

Methods

We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge.

Results

Delirium developed in 9.9 percent of the intervention group, as compared with 15.0 percent of the usual-care group (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and with a significant reduction in the rate of use of sleep medications among all patients. Among the other risk factors, there were trends toward improvement in immobility, visual impairment, and hearing impairment.

Conclusions

The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Media in This Article

Figure 1 Cumulative Incidence of Delirium According to Study Group. The cumulative incidence of delirium was defined as the probability of the development of delirium by a specified time. Data on patients were censored at the time of discharge or death. The difference between the groups was significant (chi-square= 4.77; P=0.03 by the log-rank test). Kaplan–Meier estimates of the incidence of delirium at the median length of the hospital stay (seven days, indicated by the dotted line) were 0.100 for the intervention group and 0.145 for the usual-care group. Table 1 Risk Factors for Delirium and Intervention Protocols.

Article Activity

1155 articles have cited this article

Article

Delirium, also known as acute confusional state, is a common, serious, and potentially preventable source of morbidity and mortality among hospitalized older patients. 1-3 Delirium has particular importance because patients over 65 years of age account for more than 48 percent of all days of hospital care. 4 Each year, delirium complicates hospital stays for more than 2.3 million older people, involves more than 17.5 million inpatient days, and accounts for more than $4 billion (in 1994 dollars) of Medicare expenditures. 5 Substantial additional costs accrue after discharge from the hospital, because of the increased need for institutionalization, rehabilitation, and home care. 6,7 Moreover, the incidence of delirium will probably increase with the aging of the population. 8

Previous interventional studies of delirium have focused on four types of intervention: general geriatric approaches, 9-14 nursing care, 15-19 family interventions, 20 and anesthesia. 21-23 Although in most of the studies there were trends toward a reduction in delirium in the intervention group, in most cases the reduction was not statistically significant. Many studies had methodologic limitations, such as small samples, use of nontargeted interventions, and use of relatively insensitive outcome measures (e.g., screening mental-status tests or confusion checklists). Finally, most previous studies focused on the treatment of delirium rather than on primary prevention, which was the goal of the present study.

Rarely is delirium caused by a single factor; rather, it is a multifactorial syndrome, resulting from the interaction of vulnerability on the part of the patient (i.e., the presence of predisposing conditions, such as cognitive impairment, severe illness, or visual impairment) and hospital-related insults (i.e., medications and procedures). 1,24 The risk of delirium increases with the number of risk factors present. 24,25 Therefore, a multicomponent approach targeted to the patient's risk factors is the most clinically relevant and potentially effective intervention for delirium.

We conducted a controlled clinical trial of a multicomponent strategy to reduce the number of risk factors for delirium with the goal of preventing delirium in hospitalized older patients. Our aims were to compare the effectiveness of a multicomponent strategy for reducing the risk of delirium with that of a usual plan of care for hospitalized older patients, to determine the level of adherence to the intervention protocol, and to measure the effect of the intervention on the targeted risk factors.

Methods

Study Design

This controlled clinical trial used prospective, individual matching to compare patients admitted to one intervention and two usual-care (control) units at a teaching hospital. Random assignment of subjects to the intervention or usual-care units was not possible because of the large number of patients in all medical units during the time of the study. A pilot study confirmed that randomization was not feasible, because beds in the units intended for study were often unavailable.

The prospective, individual matching strategy was chosen as an alternative to randomization that would ensure that patients in our study groups were comparable at base line. This strategy has been described in detail previously. 26 In brief, all the subjects in the intervention unit who met the eligibility criteria were enrolled. Concurrently, eligible patients from two usual-care units were identified, so that the subject pool was sufficiently large to permit the use of a computerized algorithm 27 designed to match patients according to age within five years, sex, and base-line risk of delirium (intermediate or high) as defined by our previously developed predictive model. 25 The predictive model included four of the risk factors for delirium: visual impairment, severe illness, cognitive impairment, and a high ratio of blood urea nitrogen to creatinine. Intermediate risk was defined as the presence of one or two risk factors at base line, and high risk as the presence of three or four risk factors at base line. The matching factors were selected because previous work had established them as important predictors of the development of delirium. 25,28 To control for changing patterns of care over time, patients in the intervention group and matched usual-care patients were required to have been admitted within 180 days of each other. The computerized algorithm matched patients prospectively, strictly on the basis of their characteristics at admission.

Setting and Patients

Potential participants in the study were consecutive patients admitted to the general-medicine service (non-intensive care) at Yale–New Haven Hospital from March 25, 1995, through March 18, 1998. Yale–New Haven Hospital, an 800-bed urban teaching hospital with 200 medical beds, serves a large number of patients from the community as well as a population of referred patients. A total of 2434 patients were potentially eligible to participate: they were admitted to one of three general-medicine units, were at least 70 years old, had no delirium at the time of admission, and were at intermediate or high risk for delirium at base line. Of these, 1265 patients were excluded because of inability to participate in interviews (because of profound dementia that precluded verbal communication [154 patients], a language barrier [92], profound aphasia [38], or intubation or respiratory isolation [14]), coma or terminal illness (69 patients), a hospital stay of 48 hours or less (219), prior enrollment in this study (324), or other reasons (e.g., unavailability of an interviewer or unavailability of the patient because of examinations or procedures elsewhere in the hospital) (355). Of the remaining 1169 eligible patients, the patient, family, or physician refused enrollment in 250 cases and a matching patient could not be found in 67 cases. Thus, the final study sample included 852 patients, who were matched as 426 pairs of patients receiving the study intervention and usual care.

The 1265 patients who were excluded did not differ significantly from the 852 patients who were enrolled in terms of age, sex, or base-line risk of delirium; however, a larger proportion of patients receiving usual care were excluded (63 percent, vs. 50 percent in the intervention group; P=0.001), mainly because more patients were available for screening in the two usual-care units. The 250 patients who declined to participate did not differ significantly from the 852 who enrolled in terms of age, sex, base-line risk of delirium, or group assignment. Of the 919 qualified patients who agreed to enroll, 67 (7 percent) could not be matched (24 in the intervention group and 43 in the usual-care group). These 67 unmatched patients, as compared with the 852 enrolled patients, were significantly older (mean age, 84 and 80 years, respectively), had a higher risk of delirium at base line (high risk, 42 percent vs. 28 percent), and were more likely to be admitted to a usual-care unit (64 percent vs. 50 percent). These differences were due to the inherent difficulty of finding matches for patients who were at extreme ends of the matching criteria (e.g., extremely old); patients receiving usual care predominated because of the matching algorithm, which kept a pool of unmatched patients receiving usual care available to facilitate subsequent matching.

Informed consent for participation was obtained orally from the patients or, for those with substantial cognitive impairment, from a proxy (usually the closest relative), according to procedures approved by the institutional review board of the Yale University School of Medicine.

Assessments

All the assessments were carried out by members of a research staff who had no role in the intervention and who were unaware of the nature of the study and of the patients' group assignments. The staff was composed of research nurses and experienced clinical researchers, all of whom underwent intensive training and followed standard procedures outlined in a detailed training and coding manual. At base line, standardization of assessments and measurements of interrater reliability verified the consistency of ratings among all the staff members. Subsequently, researchers met monthly to review procedural and coding issues. Quality checks of interviews and assessments of the interrater reliability with respect to the primary outcomes and targeted risk factors were performed every six months. All the data were collected on standardized, precoded forms, and the data were entered twice into a computerized data base and underwent extensive checks of error and validity.

The screening interview included the Mini–Mental State Examination, 29 the Digit Span Test, 30 evaluation by the Confusion Assessment Method, 31 assessment of Katz's Activities of Daily Living, 32 the standard Jaeger test for vision, and chart review to determine the Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score. 33 The Mini–Mental State Examination measures cognitive functioning on a scale of 0 (poor) to 30 (excellent), with a score of less than 24 indicating cognitive impairment. The orientation score consists of the 10 orientation items on the Mini–Mental State Examination, each scored on a scale of 0 to 10, with a score of less than 8 indicating disorientation. The Digit Span Test measures attention span on a scale of 0 to 7, with lower scores indicating inattention. Evaluation of Katz's Activities of Daily Living assesses the ability to perform seven basic-care skills (feeding, bathing, grooming, dressing, using the toilet, transferring between bed and chair, and walking) on a scale of 0 to 14, with lower scores indicating functional impairment.

Eligible patients then underwent the base-line assessment, which included the collection of demographic data, assessment of instrumental activities of daily living, 34 the Whisper Test 35 for hearing, and assessment of sleep. Visual impairment was defined as binocular near vision, after correction, worse than 20/70 as measured by the standard Jaeger test. The APACHE II score measures severity of illness on a scale of 0 to 71, with higher scores indicating increased severity. The instrumental Activities of Daily Living scale assesses the ability to perform seven complex activities (using the telephone, grocery shopping, using transportation, cooking, housekeeping, taking medications, and handling finances) on a scale of 0 to 14, with lower scores indicating functional impairment. The Whisper Test measures hearing according to the number of 12 whispers heard, with 6 or fewer indicating hearing impairment. A family member was interviewed at the time of admission and asked to describe the patient's cognitive functioning before admission and any recent cognitive changes and to complete the modified Blessed Dementia Rating Scale, 36,37 an observer-rated score that correlates directly with the number of neuritic plaques found on postmortem examination of the brain. The modified (shortened) version has been tested 37 ; scores greater than 2 on the modified Blessed Dementia Rating Scale indicate possible dementia. A ratio of blood urea nitrogen to creatinine (both measured in milligrams per deciliter) of 18 or greater was used as an index of dehydration. Screening and base-line assessments were completed within 48 hours after admission.

Subsequently, patients were evaluated daily until discharge with a structured interview consisting of the Digit Span Test, Mini–Mental State Examination, and Confusion Assessment Method rating. On hospital day 5 or at discharge (if discharge was before day 5), patients were reassessed for risk factors for delirium ( Table 1 Table 1 Risk Factors for Delirium and Intervention Protocols. ). After discharge, medical records were reviewed for evidence of delirium, final diagnoses, medications, laboratory results, and destination after discharge.

Intervention

The intervention strategy, called the Elder Life Program, was implemented by a trained interdisciplinary team, which consisted of a geriatric nurse-specialist, two specially trained Elder Life specialists, a certified therapeutic-recreation specialist, a physical-therapy consultant, a geriatrician, and trained volunteers. The performance of each staff member, including volunteers, was evaluated quarterly, with completion of checklists to ensure competency and consistent and complete adherence to all intervention protocols.

Six risk factors for delirium were targeted for intervention: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. 24,25,28,38 These factors were selected on the basis of evidence of their association with the risk of delirium and because they were amenable to intervention strategies considered feasible in the context of current hospital practice. Table 1 describes the risk group that received each intervention, the standardized intervention protocols for each risk factor, and the targeted outcome for each intervention protocol.

Usual Care

Usual care consisted of standard hospital services provided by physicians, nurses, and support staff (e.g., physical therapists, pharmacists, and nutritionists) in the other general-medicine units. Members of the intervention team did not provide services to patients assigned to usual care. However, the same attending and resident physicians provided care to patients in both study groups.

Outcomes

The primary outcome was delirium, defined according to the Confusion Assessment Method criteria, 31 which consisted of acute onset and a fluctuating course of symptoms of delirium, inattention, and either disorganized thinking or an altered level of consciousness. Each of these features was rated by the researchers on the basis of observations made during the daily interviews. The Confusion Assessment Method criteria provided a standardized rating of delirium, which has been validated against geropsychiatric diagnoses, with a sensitivity of 94 to 100 percent, a specificity of 90 to 95 percent, and high interobserver reliability. 31

For the primary analysis of the effectiveness of the intervention, delirium was considered a binary outcome (present or absent) according to its earliest occurrence, and only one episode of delirium per patient was counted. We also counted the total number of days of delirium (the total person-days of all episodes of delirium) and the number of episodes of delirium in each study group, and we evaluated recurrence (two or more episodes) and severity. The severity of delirium was measured by an additive score for the four designated symptoms (symptom fluctuation, inattention, disorganized thinking, and an altered level of consciousness). Each symptom of delirium except fluctuation was rated by the interviewers as absent (0 points), mild (1 point), or marked (2 points); symptom fluctuation was rated as absent (0 points) or present (1 point). The sum of these ratings yielded a delirium-severity score, ranging from 0 to 7, with higher scores indicating increased severity.

Confusion Assessment Method ratings were completed in 4848 of 4857 daily interviews (99.8 percent). Interrater reliability for these ratings was confirmed in 16 paired observations that involved all the members of the research staff (kappa, 1.0). A total of 108 uncertain ratings, ratings with missing Confusion Assessment Method items, or possible episodes of delirium occurring between interviews were assessed for the presence or absence of delirium by two independent reviewers (a geriatrician and a neuropsychologist who were unaware of the patients' study-group assignments) on review of all interview data and medical records.

Adherence

The level of adherence to the intervention, with reasons for nonadherence, was recorded daily by the intervention staff. Daily adherence was complete if the patient received all parts of the assigned protocol for the total number of times it was to be given. Partial adherence indicated that the patient either received some but not all parts of the protocol or did not receive the protocol for the required number of times that day. Nonadherence indicated that none of the parts of the assigned protocol were received that day.

Statistical Analysis

Characteristics at admission were compared between patients within matched pairs by matched statistical analyses, either paired t-tests for continuous variables or McNemar's test for binary measures. These results were confirmed with unmatched analyses.

All analyses of the effectiveness of the intervention with regard to the primary outcome used the intention-to-treat approach. The effectiveness of the intervention strategy in reducing the incidence of delirium was evaluated by a method of conditional logistic regression developed by Holford et al. 39 for prospectively sampled, individually matched data. To identify potential confounders, all the base-line characteristics were examined in bivariate analyses, and factors associated at a level of P=0.20 with the type of treatment (intervention or usual care) were further examined. Each potential covariate was added individually to the model and was retained if its presence resulted in a modification of the log-linear parameter for an intervention effect of 10 percent or more. 40,41 Subsequently, unmatched analyses by means of traditional logistic regression for new cases of delirium during the hospital stay and Cox proportional-hazards analysis for the risk of delirium per hospital day, with adjustment for the matching factors, were carried out to provide comparisons and alternatives to the matched analyses, as advocated by previous investigators. 42 Kaplan–Meier analysis and the log-rank test were used to compare the cumulative incidence of delirium, defined as the probability that delirium would develop by a specified time, between the study groups.

Total days of delirium, defined as the total number of days with delirium among all the patients in each study group, and the number of episodes of delirium in each group were calculated. Statistical comparisons were carried out in the matched analyses with use of the sign test to assess pairwise differences. The severity and rate of recurrence of delirium among patients with delirium were compared between study groups by means of appropriate statistical analyses for unmatched comparisons.

Adherence rates were calculated according to patient-day in the intervention group. Eligible patient-days were defined as those on which patients were assigned to receive the specified part of the intervention protocol. Changes in risk factors or targeted outcomes at the time of reassessment (on day 5 or at discharge, if earlier) were compared between the subgroups of patients in the intervention and usual-care groups who had the risk factor in question at base line by means of unmatched statistical analyses, including chi-square analysis for categorical variables. Adjusted mean scores at reassessment were calculated as least-squares means with use of analysis of covariance with adjustment for the base-line score.

All statistical tests were two-tailed, and a P value of less than 0.05 was considered to indicate statistical significance.

Results

The characteristics of the patients in each study group at the time of admission are shown in Table 2 Table 2 Characteristics of the Patients on Admission, According to Study Group. . The intervention and usual-care groups did not differ significantly in terms of any of the characteristics. Many patients with dementia were included in the study; scores on the Mini–Mental State Examination ranged from 7 to 30, with 25 percent of the patients having a score of 20 or less. The mean numbers of risk factors per patient at admission were similar in the two groups. The median lengths of stay were 7.0 and 6.5 days in the intervention and usual-care groups, respectively (P=0.95). Six patients in the intervention group (1.4 percent) and seven in the usual-care group (1.6 percent) died during hospitalization (P=0.78); complete information on delirium was available for these subjects.

Overall Effectiveness

The rate of incidence of delirium was significantly lower in the intervention group than in the usual-care group (9.9 percent vs. 15.0 percent, P=0.02). The matched odds ratio of 0.60 (95 percent confidence interval, 0.39 to 0.92) in matched multivariable analyses indicates that a substantial reduction in risk was associated with the intervention ( Table 3 Table 3 Delirium-Related Outcomes during Hospitalization, According to Study Group. ). After examination of all the potential base-line covariates ( Table 2 ), only a Mini–Mental State Examination score of less than 24 was significantly associated with outcome (P<0.01). Adjustment for the score, however, did not substantially affect the overall results, and thus we did not control for this variable in subsequent models. Unmatched multivariable analyses, including both logistic-regression and Cox proportional-hazards analyses, with adjustment for matching factors, confirmed the matched results. The cumulative incidence of delirium was significantly lower in the intervention group than in the usual-care group ( Figure 1 Figure 1 Cumulative Incidence of Delirium According to Study Group. The cumulative incidence of delirium was defined as the probability of the development of delirium by a specified time. Data on patients were censored at the time of discharge or death. The difference between the groups was significant (chi-square= 4.77; P=0.03 by the log-rank test). Kaplan–Meier estimates of the incidence of delirium at the median length of the hospital stay (seven days, indicated by the dotted line) were 0.100 for the intervention group and 0.145 for the usual-care group. ).

The total number of days of delirium was significantly lower in the intervention group than in the group that received usual care (105 vs. 161 days, P=0.02) ( Table 3 ). The total number of episodes of delirium was also significantly lower in the intervention group (62 episodes, vs. 90 in the usual-care group; P=0.03); however, this effect appeared to result primarily from the effects of the intervention on the first episode of delirium rather than on recurrent episodes. Among cases of delirium, severity scores and rates of recurrence did not differ significantly between the two study groups.

In matched-subgroup analyses, the intervention significantly reduced the rate of incidence of delirium in the group at intermediate risk for delirium at base line (odds ratio, 0.52; 95 percent confidence interval, 0.29 to 0.92). In the group at high risk for delirium at base line, the intervention was associated with a reduction in incidence (odds ratio, 0.73; 95 percent confidence interval, 0.38 to 1.38), but the reduction was not statistically significant.

Level of Adherence

The overall rate of adherence (complete and partial adherence) to all the intervention protocols was 87 percent (8716 of 10,056 patient-days). The overall adherence rates for the individual protocols were 96 percent for the orientation protocol (2443 of 2534 patient-days), 92 percent for the vision protocol (487 of 531 patient-days), 92 percent for the hearing protocol (514 of 561 patient-days), 86 percent for therapeutic activities (2188 of 2542 patient-days), 84 percent for early mobilization (2054 of 2452 patient-days), 81 percent for volume repletion (68 of 84 patient-days), and 71 percent for the nonpharmacologic sleep protocol (962 of 1352 patient-days). The most common reasons for nonadherence included refusal by the patient, lack of availability of the patient because of procedures elsewhere in the hospital, medical contraindications, and lack of availability of intervention staff members. No adverse effects were associated with the intervention protocols.

Effect on Targeted Risk Factors

The change in risk factors or targeted outcomes at the reassessment on day 5 or at discharge is shown in Table 4 Table 4 Change in Risk Factors or Targeted Outcomes at Reassessment, According to Study Group. . At reassessment, there was significant improvement in the orientation score and a significant reduction in the rate of use of sedative drugs for sleep in the intervention group as compared with the usual-care group. The Activities of Daily Living score and the score on the Whisper Test demonstrated trends toward improvement in the intervention group. Receipt of early vision correction was also associated with a trend toward improvement in this group. Overall, there were significantly fewer risk factors present in the intervention group than in the usual-care group at reassessment.

Cost of Intervention

The total cost of the intervention, including staff time spent in intervention activities, equipment, supplies, and consultant costs, was $139,506, or an average of $327 per patient in the intervention group. The cost of intervention per case of delirium prevented was $6,341 ($139,506 for 22 cases prevented [64 cases of delirium occurred in patients receiving usual care, as compared with 42 cases in those receiving the intervention]).

Discussion

This controlled clinical trial provides evidence that a multicomponent, targeted intervention strategy, the Elder Life Program, is effective for the prevention of delirium in hospitalized older medical patients. The intervention prevented the initial development of delirium and reduced the total number of days of delirium. It was most effective in patients who were at intermediate risk for delirium at base line. Once an initial episode of delirium had occurred, however, the intervention had no significant effect on the severity of delirium or on the likelihood of recurrence. This finding has an important implication for the treatment of delirium: primary prevention is probably the most effective strategy. Once delirium has occurred, our intervention strategy will be less effective and less efficient.

The strengths of this study include the daily assessment of patients for delirium with a standardized, validated instrument; the completeness of the outcome data, with no losses to follow-up; the targeting of at-risk patients for intervention, an approach that maximizes the efficiency and clinical relevance of the intervention; and the detailed tracking of adherence to the intervention protocols. Moreover, the practical, realistic nature of the intervention protocols, designed to target well-documented risk factors for delirium, enhances their feasibility and the extent to which they can be applied in other settings.

These findings lend strong support to the use of a multicomponent intervention to prevent delirium. The positive trends in the reduction of risk factors at the time of reassessment validate the effectiveness of each intervention protocol. The significant reduction in the total number of risk factors with intervention as compared with usual care suggests that risk-factor reduction contributed at least in part to the effectiveness of the intervention strategy.

Several important limitations of this study deserve comment. Logistic constraints precluded random assignment of the patients to the two treatment groups. However, the prospective, individual-matching strategy allowed balanced assignment of the patients to the two groups. Furthermore, a contamination effect in the usual-care group probably decreased the overall rates of delirium. Contamination was evident in the rates of delirium, which were substantially lower than anticipated on the basis of earlier studies in the same study population, 24,25 and it was also evident in the substantial reduction in risk factors that occurred in the usual-care group. Although efforts were made to avoid contamination, some intervention protocols were disseminated by word of mouth to staff members in usual-care units. Moreover, although the intervention strategies most often involved the nursing staff, the physicians rotated on all hospital floors and carried over some intervention protocols to the usual-care group. Despite these contamination effects, which would have tended to bias the results toward the null hypothesis, the significant overall results substantiate the robustness of the effects of the intervention.

The estimated cost of $6,341 per case of delirium prevented compares favorably with the estimated costs in other studies of $7,727 to $11,834 (in 1996 dollars) per fall prevented 43 and $19,800 to $42,900 (in 1993 dollars) per myocardial infarction prevented. 44 Although a formal cost-effectiveness analysis was beyond the scope of this study, a complete analysis of health care costs related to delirium may demonstrate that the intervention yields a net savings.

This trial holds substantial promise for the prevention of delirium in hospitalized older patients. Further evaluation is needed to determine the cost effectiveness of the intervention; its effects on related outcomes, such as mortality, rehospitalization, institutionalization, use of home health care, and long-term cognitive functioning; and its effectiveness in other settings.

Supported in part by grants from the National Institute on Aging (R01 AG12551), the Commonwealth Fund (95-47 and 94-90), the Retirement Research Foundation (94-71), the Community Foundation for Greater New Haven (940862/SF, 950775/SF, 961081/SF, and 970342/SF), and the Patrick and Catherine Weldon Donaghue Medical Research Foundation (DF98-105).

We are indebted to the patients, families, nurses, and volunteers at Yale–New Haven Hospital who participated in the study; to the Project Recovery research staff (Annette Hopkins, Andrea Benjamin, Jean Bonyai, Wanda Carr, Sandra Ginter, Geraldine Hawthorne, Bernie Hebert, Lynne Iannone, Linda Johnson, Alice Kossack, Nancy Votto, Alice Van Wie, and Karen Wu); to the Elder Life Program intervention and development staff (Leslie Hurst, Jane McDowell, Dana Kalina, Diane Carroll, Kurt Acker, Sandra Alfano, Steve Allegretto, Richard Beattie, Lynn Chapman-Adler, Bea Clary, Eileen Coppola, Pam Corbett, Howard Goldberg, Jean Granata, Derek Heard, Jeannette Hodge, Stephanie Johnson, Joanne Lamb, Steven Leder, Dixie Losey, Courtney Lyder, Thomas Lydon, Lisa Mastroianni, Denna Niedzwiecki, Sally Palumbo, Michael Parisi, Valentine Pascale, Meg Pechar, Janet Shen, and Stephen Zink); to the Elder Life Program Community Advisory Board (Patricia Anderson, Dorothy Baker, Edith Berrios, Edward Dobihal, Margaret Edgerly, Dorothy Giannini-Meyers, Thomas Hardin, Carla Hayes, William Heinrichs, Cynthia Matthews, Paula Milone-Nuzzo, Robert Morgan, Cheryl Pierson, Judy Rolnick, Sam Slie, Agnes Timpson, Hattie Turner, and Edith Wilson); to the Elder Life Program Executive Committee (Dr. Edwin Cadman, Brian Condon, Donna Ukanowicz, and Laura Walsh); to the executive committee for the research project (Drs. Ralph Horwitz, Lorraine Mion, Robert Makuch, and Mary Tinetti); to Dr. Emily Richardson for adjudication of delirium outcomes; to Dr. Richard Marottoli, Dr. Mary Tinetti, and Christianna Williams for helpful review of the manuscript; and especially to Robbin Bonanno and Stephen Helfand.

Source Information

From the Departments of Internal Medicine (S.K.I., S.T.B., D.A., L.M.C.) and Epidemiology and Public Health (P.A.C., L.L.-S., T.R.H.), Yale University School of Medicine, New Haven, Conn.

Address reprint requests to Dr. Inouye at the Yale University School of Medicine, 20 York St., Tompkins 15, New Haven, CT 06504.

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