title: The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial.
abstract: BACKGROUND
  The impact of adherence on outcome for a nonpharmacologic intervention strategy has not been previously examined.
  
  
  OBJECTIVE
  To examine the impact of level of adherence on effectiveness of the intervention strategy in a large clinical trial of nonpharmacologic interventions to prevent delirium.
  
  
  METHODS
  The subjects included 422 consecutive patients 70 years or older admitted to the medicine service at a university hospital. The intervention protocols were targeted toward 6 delirium risk factors. The primary outcome was new-onset delirium during hospitalization.
  
  
  RESULTS
  During 9882 patient-days, complete adherence rates for individual intervention protocols ranged from 10% for the sleep protocol to 86% for the orientation protocol. The rate of complete adherence with all protocols was 57%, and combined partial and complete adherence was 87%. Higher levels of adherence resulted in lower delirium rates, with a significant graded effect, for orientation, mobility, and therapeutic activities protocols, and for the composite adherence measure. After controlling for potential confounding variables, such as illness severity, comorbidity, baseline delirium risk, and functional status, adherence continued to demonstrate a consistently strong and significant protective effect against delirium (adjusted odds ratio, 0.69; 95% confidence interval, 0.56-0.87). Patients in the highest adherence group demonstrated an 89% reduction in delirium risk compared with patients in the lowest group.
  
  
  CONCLUSIONS
  Adherence played an important independent role in the effectiveness of a nonpharmacologic multicomponent intervention strategy. Higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group. Thus, adherence must be ensured in nonpharmacologic interventions to optimize effectiveness.
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06504, USA.
authors.forename: Sharon K
authors.initials: SK
authors.lastname: Inouye
authors.forename: Sidney T
authors.initials: ST
authors.lastname: Bogardus
authors.forename: Christianna S
authors.initials: CS
authors.lastname: Williams
authors.forename: Linda
authors.initials: L
authors.lastname: Leo-Summers
authors.forename: Joseph V
authors.initials: JV
authors.lastname: Agostini
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002986:Clinical Trials as Topic; D015331:Cohort Studies; D016001:Confidence Intervals; D003693:Delirium / Q000453:epidemiology / Q000517:prevention & control*; D037001:Directive Counseling / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment / Q000379:methods; D006801:Humans; D008297:Male; D016017:Odds Ratio; D010349:Patient Compliance; D012307:Risk Factors; D016896:Treatment Outcome