Persistence of Delirium in Postacute Care at Skilled Nursing Facilities

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act aimed to improve postacute care quality and outcomes. This study examines changes in delirium, a key quality indicator, over 5 years following its implementation.

To compare the persistence and resolution of delirium within skilled nursing facilities (SNFs) between 2014 and 2019.

This cross-sectional study included SNF admissions from a 5% Medicare random sample, with delirium assessments conducted between January 1 and December 31 in 2014 and 2019. The analysis of persistent delirium consisted of patients with delirium at SNF admission and a subsequent delirium assessment during their SNF stay. Analyses were conducted from December 2023 to October 2024.

Year 2019 compared with year 2014.

Delirium was measured using the Minimum Data Set (MDS) Confusion Assessment Method at SNF admission and at a subsequent assessment within 30 days of admission. Multinomial logistic regression was used to compare the rates of resolved delirium, persistent delirium, and death between 2014 and 2019 after adjusting for patient characteristics and SNF care factors.

The sample included a total of 432 037 SNF admissions before exclusions and 306 998 after exclusions. For SNF admissions in 2014, 6933 of 162 161 patients (4.3%) had delirium at admission, compared with 3595 of 144 837 patients (2.5%) in 2019. In 2014, there were 6096 patients (mean [SD] age, 80.6 [11.0] years; 3565 women [58.5%]), and in 2019, there were 2778 patients (mean [SD] age, 80.2 [10.7] years; 1546 women [55.7%]) with delirium and follow-up assessments. The adjusted prevalence of persistent delirium decreased from 3347 of 6096 patients (62.3%; 95% CI, 60.2%-64.4%) in 2014 to 1316 of 2778 patients (54.7%; 95% CI, 52.0%-57.4%) in 2019, whereas delirium resolution increased from 1734 of 6096 patients (29.1%; 95% CI, 27.1%-31.1%) in 2014 to 1010 of 2778 patients (37.4%; 95% CI, 34.7%-40.0%) in 2019.

This cross-sectional study found a reduction in the prevalence of delirium at SNF admission and an improvement in delirium resolution during the stay in the 5 years following the IMPACT Act. However, the high prevalence of persistent delirium warrants further efforts to improve delirium management in SNF.