The unfavorable nature of preoperative delirium in elderly hip fractured patients

Factors Associated with Improvement in Activities of Daily Living during Hospitalization: A Retrospective Study of Older Patients with Hip Fractures

BACKGROUND

In this study, we aimed to examine the changes in delirium during hospitalization of patients and its association with behavioral and psychological symptoms of dementia (BPSD), as well as improvements in activities of daily living (ADL).

METHODS

A longitudinal, retrospective cohort study was conducted involving 83 older adults (≥65 years) with hip fractures. We collected Mini-Mental State Examination (MMSE) and Functional Independence Measure-motor domain (m-FIM) assessment results from the medical charts at two time points: baseline (first week of hospitalization) and pre-discharge (final week before discharge). Additionally, we collected data on delirium and BPSD at three points: baseline, week 2 post-admission, and pre-discharge. We performed univariate logistic regression analysis using changes in m-FIM scores as the dependent variable and MMSE and m-FIM scores at baseline and pre-discharge, along with delirium and BPSD subtypes at baseline, week 2 post-admission, and pre-discharge, as the explanatory variables. Finally, we performed a multivariate logistic regression analysis incorporating the significant variables from the univariate analysis to identify factors associated with ADL improvement during hospitalization.

RESULTS

We observed significant correlations between ADL improvement during hospitalization and baseline m-FIM and MMSE scores, hypoactive delirium state, and BPSD subtype pre-discharge. Notably, all participants with hypoactive symptoms before discharge exhibited some subtype of delirium and BPSD at baseline.

CONCLUSION

Besides ADL ability and cognitive function at admission, the presence of hypoactive delirium and BPSD subtype before discharge may hinder ADL improvement during hospitalization.

Measurement of Mobility and Physical Function in Patients Hospitalized With Hip Fracture: A Systematic Review of Instruments and Their Measurement Properties

OBJECTIVE

Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting.

METHODS

Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist.

RESULTS

Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed "Up & Go" Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63-2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] >0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%-60% of patients). The TUG, CAS, and BI all had good clinical utility.

CONCLUSION

Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting.

IMPACT

This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

Association between multidimensional prognostic index (MPI) and pre-operative delirium in older patients with hip fracture

Pre-operative delirium may cause delay in surgical intervention in older patients hospitalized for hip fracture. Also it has been associated with higher risk of post-surgical complications and worst functional outcomes. Aim of this retrospective cohort study was to evaluate whether the multidimensional prognostic index (MPI) at hospital admission was associated with pre-operative delirium in older individuals with hip fracture who are deemed to require surgical intervention. Consecutive older patients (≥ 65 years) with hip fracture underwent a comprehensive geriatric assessment to calculate the MPI at hospital admission. According to previously established cut-offs, MPI was expressed in three grades, i.e. MPI-1 (low-risk), MPI-2 (moderate-risk) and MPI-3 (high risk of mortality). Pre-operative delirium was assessed using the four 'A's Test. Out of 244 older patients who underwent surgery for hip fracture, 104 subjects (43%) received a diagnosis of delirium. Overall, the incidence of delirium before surgery was significantly higher in patients with more severe MPI score at admission. Higher MPI grade (MPI-3) was independently associated with higher risk of pre-operative delirium (OR 2.45, CI 1.21-4.96). Therefore, the MPI at hospital admission might help in early identification of older patients with hip fracture at risk for pre-operative delirium.

Derivation and validation of a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty

Introduction

Postoperative delirium is a common complication of patients undergoing hip fracture surgery or arthroplasty and is related to decreased survival time and physical function. In this study, we aim to build and validate a prediction score of postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty.

Methods

A retrospective cohort of geriatric patients undergoing hip fracture surgery or hip arthroplasty was established. Variables of included patients were collected as candidate predictors of postoperative delirium. The least absolute shrinkage and selection operator (LASSO) regression and logistic regression were used to derive a predictive score for postoperative delirium. The accuracy of the score was evaluated by the area under the curve (AUC) of the receiver operating curve (ROC). We used bootstrapping resamples for model calibration. The prediction score was validated in an extra cohort.

Results

There were 1,312 patients in the derivation cohort, and the incidence of postoperative delirium was 14.33%. Of 40 variables, 9 were identified as predictors, including preoperative delirium, cerebrovascular accident (CVA) with the modified Rankin scale, diabetes with a random glucose level, Charlson comorbidity index (CCI), age, application of benzodiazepines in surgery, surgical delay ≥2 days, creatine ≥90 μmol/L, and active smoker. The prediction score achieved a mean AUC of 0.848 in the derivation cohort. In the validation cohort, the mean AUC was 0.833. The prediction model was well-calibrated in the two cohorts.

Conclusion

Based on retrospective data, a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty was derived and validated. The performance of the scoring system outperformed the models from previous studies. Although the generalization ability of the score needs to be tested in similar populations, the scoring system will enable delirium risk stratification for hip fracture patients and facilitate the development of strategies for delirium prevention.

Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials

Objective

Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD.

Methods

Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model.

Results

Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63).

Conclusions

There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.

Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis

OBJECTIVES

Delirium is an acute neuropsychiatric syndrome associated with poor outcomes. Older adults undergoing surgery have a higher risk of manifesting perioperative delirium, particularly those having associated comorbidities. It remains unclear whether delirium frequency varies across surgical settings and if it has remained stable across the years. We conducted a systematic review to (1) determine the overall frequency of delirium in older people undergoing noncardiac surgery; (2) explore factors explaining the variability of the estimates; and (3) determine the changing of the estimates over the past 2 decades.

DESIGN

Systematic review and meta-analysis. Literature search was performed in MEDLINE, PubMed, ISI Web of Science, EBSCO, ISRCTN registry, ScienceDirect, and Embase in January 2020 for studies published from 1995 to 2020.

SETTING

Noncardiac surgical settings.

PARTICIPANTS

Forty-nine studies were included with a total of 26,865 patients screened for delirium.

METHODS

We included observational and controlled trials reporting incidence, prevalence, or proportion of delirium in adults aged ≥60 years undergoing any noncardiac surgery requiring hospitalization. Data extracted included sample size, reported delirium frequencies, surgery type, anesthesia type, delirium diagnosis method, length of hospitalization, and year of assessment. (PROSPERO registration no.: CRD42020160045).

RESULTS

We found an overall pooled frequency of preoperative delirium of 17.9% and postoperative delirium (POD) of 23.8%. The POD estimates increased between 1995 and 2020 at an average rate of 3% per year. Pooled estimates of POD were significantly higher in studies not excluding patients with lower cognitive performance before surgery (28% vs 16%) and when general anesthesia was used in comparison to local, spinal, or epidural anesthesia (28% vs 20%).

CONCLUSIONS AND IMPLICATIONS

Type of anesthesia and preoperative cognitive status were significant moderators of delirium frequency. POD in noncardiac surgery has been increasing across the years, suggesting that more resources should be allocated to delirium prevention and management.

Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture

BACKGROUND

Post-hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed.

METHODS

The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model.

RESULTS

Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78-10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05-2.76], 3 points); (3) age (reference, 60-69 years of age) (age 70-79: aOR, 1.60 [95% CI, 1.20-2.12], 2 points; age 80-89: aOR, 2.09 [95% CI, 1.59-2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82-3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13-1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III-V (aOR, 1.40 [95% CI, 1.14-1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17-1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07-1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09-1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14-1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76-0.78) and 0.77 (95% CI, 0.76-0.78), respectively, with similar results in the validation cohort.

CONCLUSIONS

A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy.

Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery

BACKGROUND

Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

(a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome.

MAIN RESULTS

We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162).

AUTHORS' CONCLUSIONS

We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

STUDY OBJECTIVE

To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery.

PATIENTS

8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.

INTERVENTIONS

We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.

MEASUREMENTS

Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.

MAIN RESULTS

After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without.

CONCLUSIONS

After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

The effect of a multidisciplinary co-management program for the older hip fracture patients in Beijing: a "pre- and post-" retrospective study

Hip fracture becomes a major public health issue with the growing aging population. This study evaluated a multidisciplinary co-management program for older hip fracture patients and found it significantly improved the best practice indicators. It provided preliminary evidence to support the use of such intervention in hip fracture management.

PURPOSE/INTRODUCTION

Hip fracture leads to high morbidity and mortality in older people. A previous study found a significant disparity in hip fracture management in Beijing Jishuitan Hospital (JSTH) compared to best practice care in the United Kingdom (UK). Following this audit, JSTH launched a multidisciplinary co-management care plan for older hip fracture patients. This study aims to evaluate the effect of this program on the six standards recommended in the UK hip fracture best practice guidelines.

METHODS

In this retrospective study, electronic medical record data were collected before and after the intervention. Eligible patients were aged ≥ 65 years, had X-ray confirmed hip fracture, and were admitted to JSTH within 30 days of injury. Patient demographic information, time from emergency department presentation to admission, time from admission to surgery, pressure ulcers, osteoporosis assessment, and falls prevention were collected. Multivariable logistic and median regression models were used for binary and continuous outcomes respectively. Segment regression was also performed for time-related outcomes.

RESULTS

A total of 3540 eligible patients were identified. After the intervention, half of the patients who received co-management received surgery within 48 h of ward admission compared to 6.4% previously, 0.3% (vs 1.4%) developed pressure ulcers, and 76% (vs 19%) received osteoporosis assessment. No significant differences were observed in fall assessment rates. However, there was a higher rate of ward admission within 4 h of arrival in emergency for patients admitted pre-intervention (61% vs 34%).

CONCLUSIONS

The introduction of the co-management model significantly reduced the time from admission to surgery and improved other practice outcomes. A multicenter randomized controlled trial is needed to evaluate the impact of this model on patient health outcomes.

[Multidisciplinary geriatric rehabilitation in the patient with hip fracture and dementia]

Hip fracture and dementia rates increase with age, and both groups of patients suffer increased morbidity and mortality and functional impairment. The management of these patients is a challenge for the orthogeriatric and rehabilitation team process, as despite the evidence on the benefit, the results analysed are still worse than in patients without cognitive impairment. For this reason, and due to the limitation in health resources, many of them have problems in accessibility to them, or are limited to a less intense rehabilitation. There are insufficient studies on the best rehabilitation interventions in this group of patients, but it is suggested: 1) to use a multidisciplinary rehabilitation model adapted to the patient with dementia, and 2) to redefine results of the rehabilitation of these patients not only in terms of functional improvement, without highlighting other concepts, such as quality of life, decrease in complications or improved social support.

Older people with hip fracture transferred to intermediate care: outcomes in an integrated health and social care model

Following surgery for hip fracture almost a quarter of patients do not return directly to their usual residence, using the resources within intermediate care and enablement. This was a retrospective cohort study involving 156 Salford residents admitted with hip fracture in 2015. Linked health data were collected on those discharged to intermediate care vs home in terms of readmissions, mortality, lengths of stay, delayed transfers of care, diagnoses of delirium and pre-existing forms of dementia. The median duration of the continuous care episode in the intermediate care cohort, inclusive of readmissions to hospital, was 52 days. There was a 26% (n=20) readmission rate from intermediate care. Readmission rates at 120 days were higher among those discharged to intermediate care vs home (OR 3.21, 95% CI 1.37-7.54, p=0.007) and among those with a form of dementia (OR 4.76, 95% CI 1.79-12.63, p=0.0017). Patients with delirium during their acute admission were more likely to be discharged to intermediate care (OR 5.43, 95% CI 2.36-12.47, p=0.0001) and were less likely to ultimately be discharged home (OR 6.40, 95% CI 2.25-18.21, p=0.0005), as were those with some form of dementia (OR 6.60, 95% CI 1.97-22.08, p=0.002). Measurement of the entire care episode demonstrates significant lengths of stay. Medium term readmission rates are higher in those discharged to intermediate care. Delirium and dementia are associated with higher readmission rates and lower rates of discharge to own home. It is imperative that a whole pathway approach to commissioning hip fracture services is established.

Optimal Modified Frailty Index Cutoff in Older Gastrointestinal Cancer Patients

The newly characterized modified frailty index (mFI) is a robust predictor of postoperative outcomes for surgical patients. The present study investigates the optimal cutoff for mFI specifically in older gastrointestinal (GI) cancer patients undergoing surgery. All patients more than 60 years old who underwent surgery for a GI malignancy (esophagus, stomach, colon, rectum, pancreas, liver, and bile duct) were identified in the 2005 to 2012 National Surgical Quality Improvement Program, Participant Use Data File (NSQIP PUF). Patients undergoing emergency procedures, of American Society of Anesthesiologists (ASA) five status, or diagnosed with preoperative sepsis were excluded. Logistic regression modeling and 10-fold cross validation were used to identify an optimal mFI cutoff. A total of 41,455 patients (mean age 72, 47.4% female) met the eligibility criteria. Among them, 19.0 per cent (n = 7891) developed a major postoperative complication and 2.8 per cent (n = 1150) died within 30 days. A random sampling by a cancer site was performed to create 90 per cent training and 10 per cent test sample datasets. Using 10-fold cross validation, logistical regression models evaluated the association between mFI and endpoints of 30-day mortality and major morbidity at various cutoffs. Optimal cutoffs for 30-day mortality and major morbidity were mFI ≥ 0.1 and ≥0.2, respectively. After adjusting for age, sex, ASA, albumin ≥3g/dl, and body mass index ≥ 30 kg/m2, mFI ≥ 0.1 was associated with increased mortality (odds ratio (OR) 1.49, 1.30-1.71 95% confidence interval (CI), P < 0.001) and mFI ≥ 0.2 was associated with increased morbidity (OR 1.52, 1.39-1.65 95% CI, P < 0.001). For older GI cancer patients, a very low mFI was a predictor of poor postoperative outcomes with an optimal cutoff of two or more mFI characteristics.

Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis

OBJECTIVE

Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery.

METHODS

Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach.

RESULTS

A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium.

CONCLUSION

Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.

Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study

AIMS AND OBJECTIVES

To determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission.

BACKGROUND

Incident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients who are most susceptible to incident delirium.

DESIGN

Retrospective case-control study with two controls per case.

METHODS

An audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data were collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1 January 2012 and 31 December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation.

RESULTS

Identified using logistic regression modelling, predisposing risk factors for incident delirium were dementia, cognitive impairment, functional impairment, previous delirium and fracture on admission. Precipitating risk factors for incident delirium were use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission.

CONCLUSIONS

Multiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other healthcare professionals should be aware of patients who have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

Prevalence and Characteristics of Pre-Operative Delirium in Hip Fracture Patients

Background: Delirium is a common complication of hip fracture and is associated with negative outcomes. Previous studies document risk factors for post-operative delirium but have frequently excluded patients with pre-operative delirium. Objective: This study endeavours to document prevalence and risk factors for pre-operative delirium in hip fracture patients and compares risk factor profiles and outcomes between pre- and post-operative delirium. Methods: 283 hip fracture patients were assessed pre-operatively with the Delirium Elderly At Risk (DEAR) instrument, Mini-Mental State Examination (MMSE), and Confusion Assessment Method (CAM). They were followed on post-operative days 1, 3, and 5 for the presence of delirium. Doses of opioids were recorded. Wait time to surgery, length of stay, and discharge site were noted. Results: Delirium was present in 57.6% patients pre-operatively and 41.7% post-surgery. Not all patients (62%) with pre-operative delirium also had post-operative delirium. There was a considerable overlap in risk factors, with some differences. Wait time to surgery, number of comorbidities, and total pre-operative opioid and lorazepam doses were associated with pre- but not post-operative delirium. Negative outcomes were more closely associated with post-operative delirium. Conclusion: Delirium is common in pre-hip fracture surgery patients, and not all patients with pre-operative delirium go on to have post-operative delirium. Risk factor profiles are not identical, raising the possibility of identifying and intervening in patients at high risk of delirium pre-operatively.

Factors determining eligibility and access to subacute rehabilitation for elderly people with dementia and hip fracture

With hip fracture and dementia increasing in incidence in the global ageing population, there is a need for the development of specific procedures targeting optimal treatment outcomes for these patients. This paper looks primarily at the factors that limit access to subacute rehabilitation services as a growing body of evidence suggests that access to timely inpatient rehabilitation increases functional outcomes for patients both with dementia and without. Information was gathered by searching electronic data bases (SCOPUS, Medline, CINAHL, Health Source Nursing/Academic Addition, Psychinfo and the Cochrane Library) for relevant articles using the search terms dementia OR Alzheimer* AND hip fracture AND subacute rehabilitation OR convalescence for the period 2005–2015. Abstracts were scanned to identify articles discussing eligibility and access. A total of nine papers were identified that directly addressed this topic. Other papers discussing success or failure of rehabilitation and improved models of care were also reviewed. Barriers to access discussed in the literature include information management, management of comorbidities, attitudes, resource availability, and the quality of evidence and education. By identifying these factors we can identify strategic points of intervention across the trajectory of prevention, treatment and rehabilitation that may improve outcomes for this growing group of vulnerable patients. Emerging best practice for these patients is also discussed.

Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery

BACKGROUND

Hip fracture is a major fall-related injury which causes significant problems for individuals, their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment, and their outcomes after surgery are poorer than those without dementia. It is not clear which care and rehabilitation interventions achieve the best outcomes for these people.

OBJECTIVES

(a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care.(b) To assess the effectiveness for people with dementia of models of care including enhanced rehabilitation strategies which are designed for all older people, regardless of cognitive status, following hip fracture surgery compared to usual care.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, up to and including week 1 June 2014 using the terms hip OR fracture OR surgery OR operation OR femur OR femoral.

SELECTION CRITERIA

We include randomised and quasi-randomised controlled clinical trials (RCTs) evaluating the effectiveness for people with dementia of any model of enhanced care and rehabilitation following hip fracture surgery compared to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors working independently selected studies for inclusion and extracted data. We assessed the risk of bias of included studies. We synthesised data only if we considered studies sufficiently homogeneous in terms of participants, interventions and outcomes. We used the GRADE approach to rate the overall quality of evidence for each outcome.

MAIN RESULTS

We included five trials with a total of 316 participants. Four trials evaluated models of enhanced interdisciplinary rehabilitation and care, two of these for inpatients only and two for inpatients and at home after discharge. All were compared with usual rehabilitation and care in the trial settings. The fifth trial compared outcomes of geriatrician-led care in hospital to conventional care led by the orthopaedic team. All papers analysed subgroups of people with dementia/cognitive impairment from larger RCTs of older people following hip fracture. Trial follow-up periods ranged from acute hospital discharge to 24 months post-discharge.We considered all of the studies to be at high risk of bias in more than one domain. As subgroups of larger studies, the analyses lacked power to detect differences between the intervention groups. Further, there were some important differences in the baseline characteristics of the participants in experimental and control groups. Using the GRADE approach, we downgraded the quality of the evidence for all outcomes to 'low' or 'very low'.No study assessed our primary outcome (cognitive function) nor other important dementia-related outcomes including behaviour and quality of life. The effect estimates for most comparisons were very imprecise, so it was not possible to draw firm conclusions from the data. There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications and that enhanced care provided across hospital and home settings reduced the chance of being in institutional care at three months post-discharge (Odds Ratio (OR) 0.46, 95% confidence interval (CI) 0.22 to 0.95, 2 trials, n = 184), but this effect was more uncertain at 12 months (OR 0.90, 95% CI 0.40 to 2.03, 2 trials, n = 177). The effect of enhanced care and rehabilitation in hospital and at home on functional outcomes was very uncertain because the quality of evidence was very low from one small trial. Results on functional outcomes from other trials were inconclusive. The effect of geriatrician-led compared to orthopaedic-led management on the cumulative incidence of delirium was very uncertain (OR 0.73, 95% CI 0.22 to 2.38, 1 trial, n = 126, very low-quality evidence).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to draw conclusions about how effective the models of enhanced rehabilitation and care after hip fracture used in these trials are for people with dementia above active usual care. The current evidence base derives from a small number of studies with quality limitations. This should be addressed as a research priority to determine the optimal strategies to improve outcomes for this growing population of patients.

Effects of Progressive Muscle Relaxation Intervention in Extremity Fracture Surgery Patients

The purpose of this study was to evaluate the impact of progressive muscle relaxation on state anxiety and self-efficacy in hospitalized patients admitted for an extremity fracture receiving elective surgery. Eighty four patients met the inclusion criteria and all were randomly assigned to either the progressive muscle relaxation group or the control group. The control group received standard orthopedic nursing care, and the experimental group received standard care along with daily progressive muscle relaxation throughout their hospitalization. The State Anxiety Inventory and Self-Efficacy Scales were administered before and after the intervention. Both paired-sample t tests and independent t tests showed that progressive muscle relaxation is effective in reducing state anxiety and enhancing the self-efficacy of patients with extremity fracture undergoing an elective surgery.

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)--quality of life during the first 4 months after fracture

The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS.

METHODS

ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire.

RESULTS

The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not.

CONCLUSIONS

The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.

An inpatient rehabilitation model of care targeting patients with cognitive impairment

BACKGROUND

The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation.

METHODS/DESIGN

A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date.

DISCUSSION

Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures.

TRIAL REGISTRATION

The study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Ortho-geriatric service--a literature review comparing different models

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

[Acute orthogeriatric care (II). Clinical aspects]

The present article reviews the clinical principles of acute orthogeriatric care. The application of geriatric medicine to patients with hip fracture is explained. The principal stages of geriatric intervention in this process are mentioned, as are the interventions to be carried out by the geriatric team. Subsequently, we discuss the management of several frequent problems in these patients, such as high surgical risk, pain management, anaemia, delirium, malnutrition, and discharge planning. Lastly, the characteristics of several kinds of patients with special characteristics are mentioned, such as those diagnosed with dementia, nursing home residents or the oldest-old. Areas of improvement in the acute phase are also reviewed, such as mortality reduction, functional outcome improvement and the need for more efficient resource use in patients in the acute phase of hip fracture.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.