Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study

Postoperative delirium in elderly citizens and current practice

Postoperative delirium (POD) represents an acute brain dysfunction in the postsurgical period. Perioperative physicians caring for the older adults are familiar with the care of dysfunction of organs such as lungs, heart, liver, or kidney in the perioperative setting, but they are less familiar with management of brain dysfunction. As early detection and prompt treatment of inciting factors are utmost important to prevent or minimize the deleterious outcomes of delirium. The purpose of this review is to prepare perioperative physicians with a set of current clinical practice recommendations to provide optimal perioperative care of older adults, with a special focus on specific perioperative interventions that have been shown to prevent POD. On literature search in EMBASE, CINAHL, and PUBMED between January 2000 and September 2015 using search words delirium, POD, acute postoperative confusion, and brain dysfunction resulted in 9710 articles. Among them, 73 articles were chosen for review, in addition, National Institute for Health and Clinical Excellence guidelines, American Geriatric Society guidelines, hospital elderly life program-confusion assessment method training manual, New York geriatric nursing protocols, World Health Organization's International Classification of Diseases, 10th Revision classification of mental disorders, Food and Drug Administration requests boxed warnings on older class of antipsychotic drugs 2008 and delirium in Miller's text book of anesthesia were reviewed and relevant information presented in this article.

One-year mortality after hip fracture in older individuals: the effects of delirium and dementia

BACKGROUND

Delirium is common in older hip fracture patients, yet its association with mortality after hip fracture remains uncertain. This study aimed to determine whether delirium was associated with all-cause one-year mortality after hip fracture in older patients and whether the effect of delirium was independent of dementia status.

METHOD

A retrospective analysis of linked hospitalisation and mortality data for patients aged ≥65 years with a hip fracture during 1 January 2010 to 30 June 2014 in New South Wales, Australia. The association between delirium and mortality after a hip fracture was assessed using Cox proportional hazard regression.

RESULTS

There were 4,065 (14.6%) of 27,888 hip fracture hospitalisations identified with delirium during hospitalisation. Individuals with delirium had a higher age-adjusted rate of all-cause one-year mortality after hip fracture compared to individuals without delirium (35.3% versus 23.9%). After adjusting for covariates, the risk of all-cause mortality was increased at one-year post-admission for older individuals compared to those aged 65-69 years, for individuals with multiple comorbidities, dementia (Hazard Ratio (HR): 1.14; 95%CI:1.08-1.20), delirium (HR: 1.19; 95%CI:1.12-1.26), and who had an Intensive Care Unit admission (HR: 1.44; 95%CI:1.31-1.59). Comorbid delirium did not add additional mortality risk for individuals with a hip fracture who have dementia.

CONCLUSIONS

Delirium identified in hospital was associated with all-cause one-year mortality after hip fracture in older Australians without dementia. As delirium is potentially preventable, better systematic assessment and documentation of a hip fracture patient's cognitive state is warranted to select the most effective strategies to prevent and manage delirium.

Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial

OBJECTIVES

To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted postoperative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders.

DESIGN

Pragmatic clinical trial to evaluate a quality improvement intervention.

SETTING

Tertiary care hospital.

PARTICIPANTS

Individuals aged 65 and older admitted for hip fracture repair (N = 283).

INTERVENTION

PPOs with delirium-friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements.

MEASUREMENTS

Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini-Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in-hospital mortality were recorded.

RESULTS

Orthopedic nurses adhered reasonably well with delirium-friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between-group difference in these outcomes.

CONCLUSION

It is possible to introduce delirium-friendly PPOs into routine post-hip fracture care in a representative elderly population including individuals with dementia. Delirium-friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.

Elderly trauma

Across the world, the population is aging. Adults 65 years and older make up one of the fastest growing segments of the US population. Trauma is a disease process that affects all age groups. The mortality and morbidity that result from an injury can be influenced by many factors including age, physical condition, and comorbidities. The management of the elderly trauma patient can present some unique challenges. This paper addresses the differences that occur in the management of elderly patient who has been injured. This paper also includes a discussion of how to prevent injury in the elderly.

Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial

INTRODUCTION

Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.

METHODS

The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).

RESULTS

Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58).

CONCLUSION

PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.

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.

Perioperative Cognitive Protection-Cognitive Exercise and Cognitive Reserve (The Neurobics Trial): A Single-blind Randomized Trial

PURPOSE

The Neurobics Trial is a single-blind, parallel-group, randomized, controlled trial. The main study objective is to compare effectiveness of preoperative cognitive exercise versus no intervention for lowering the incidence of postoperative delirium. Enrollment began March 2015 and is ongoing.

METHODS

Eligible participants include patients older than 60 years of age scheduled for nonemergent, noncardiac, nonneurological surgery at our institution. Patients provide consent and are screened at our Outpatient Preoperative Assessment Clinic to rule out preexisting cognitive dysfunction, significant mental health disorders, and history of surgery requiring general anesthesia in the preceding 6 months. Participants meeting criteria are randomized to complete 1 hour daily of electronic tablet-based cognitive exercise for 10 days before surgery or no preoperative intervention. Compliance with the effective dose of 10 total hours of preoperative exercise is verified on return of the patient for surgery with time logs created by the software application and by patient self-reporting. After surgery, patients are evaluated for delirium in the postanesthesia recovery area, and then twice daily for the remainder of their hospitalization. Additionally, postoperative quality of recovery is assessed daily, along with pain scores and opiate use. More comprehensive cognitive assessments are completed just before discharge for baseline comparison, and quality of recovery is assessed via telephone interview 7, 30, and 90 days post-surgery. The primary outcome is the incidence of delirium during the postoperative hospitalization period. Randomization is computer generated, with allocation concealment in opaque envelopes. All postoperative assessments are completed by blinded study personnel.

FINDINGS

The study is actively recruiting with 19 patients having provided consent to date, and a total of 264 patients is required for study completion; therefore, no data analysis is currently under way (www.clinicaltrials.gov; NCT02230605).

IMPLICATIONS

To our knowledge, the Neurobics Trial is the first randomized, controlled study to investigate the effectiveness of a significant preoperative cognitive exercise regimen for the prevention of delirium after noncardiac, nonneurological surgery in elderly patients.

General versus spinal anaesthesia and postoperative delirium in an orthogeriatric population

AIM

Postoperative delirium is common among elderly hip surgery patients. We aimed to pragmatically evaluate whether type of anaesthesia influenced postoperative delirium in an orthogeriatric population following hip fracture.

METHOD

This observational study comprises prospectively collected data on hip fracture patients admitted between October 2010 and November 2011. Delirium was diagnosed clinically by geriatricians.

RESULTS

Of the 344 patients admitted, seven managed conservatively and 19 with incomplete data were excluded; 318 patients were analysed. Average age was 81.6 (SD 9.8) years; 28% were men and 167 (53%) were administered general anaesthesia. Mean length of stay was 18 (SD 9.4) days. Overall, 172 patients (54%) experienced delirium. There was no apparent difference in postoperative delirium by anaesthetic type (88 vs 84, P = 0.15).

CONCLUSION

Delirium was common in both general and spinal anaesthetic patients. Further randomised controlled trials would be required to determine whether anaesthesia type influenced delirium rates.

Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures?

BACKGROUND

Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures.

METHODS

A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated.

RESULTS

Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01).

CONCLUSION

The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home.

LEVEL OF EVIDENCE

Therapeutic level III.

Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series

Background

Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making.

Methods and Findings

We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I²=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I²=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium.

Conclusions

In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.

[Initial experiences of an orthogeriatric unit]

OBJECTIVE

To report the design and outcomes obtained during the first operational years of the Orthogeriatric Unit (OGU) established in the Zaragoza-1 (Spain) Health-Sector.

MATERIAL AND METHODS

A total of 494 patients >70 years old treated in the OGU from February 2009 to December 2012. An analysis was performed using the following variables: demography, previous functional level, comorbidities, surgical delay, fracture type and surgical technique, complications, hospital stay, functional outcomes, destination after hospital discharge, and short and long term mortality.

RESULTS

Mean age 85.22 years. High incidence of comorbidities (Charlson Index): 24.3%. Dementia: 38.5%. Surgical delay: 2.57 days. Mean hospital stay between admission and discharge/transfer to convalescence unit, 20.9 days (Traumatology 6.45+OGU 14.49). More than a third (34.6%) of patients suffered from delirium. Mean functional improvement (Barthel index at hospital discharge-Barthel index at hospital admission): 27.25 points. Montebello index: 0.49. In-hospital mortality: 6.9%.

CONCLUSION

Hip fracture is such a frequent and disabling pathology among the geriatric population that its treatment requires an interdisciplinary approach. This must be managed by the geriatrician, who has to assure the continuity and integration of the diverse treatment and care schedules, with the participation of the entire professional team in the decision-making process. We are very satisfied with the creation of our interdisciplinary Unit that enables us to report competitive outcomes. We believe that the progression of this Unit from providing subacute to acute care will improve the general outcomes in the future.

The Incidence of Delirium at the Postoperative Intensive Care Unit in Adult Patients

OBJECTIVE

In this study, we aimed to determine the risk factors and the incidence of delirium in patients who were followed postoperatively in our surgical intensive care unit for 24 h using the confusion assessment method (CAM).

METHODS

After obtaining approval from the ethics committee, 250 patients were included in the study. Patients who were operated under general anaesthesia or regional anaesthesia and followed in the surgical intensive care unit were evaluated by the Ramsay Sedation Scale on the first postoperative day. CAM was applied to the patients who had a Ramsey Sedation Score of ≤4. Patients' age, gender, American Society of Anesthesiologists (ASA) scores, preoperative risk factors, type of anaesthesia, operation time, intra-operative procedures, pain scores evaluated by the visual analogue scale (VAS) and postoperative analgesia methods were recorded.

RESULTS

The incidence of delirium was found to be 18.4%. The average age of patients who developed delirium was greater than the others (68.8±12.7 and 57.6±12, p=0.001, respectively). It was observed that a one-unit increase in the ASA score resulted in a 3.3-fold increase in the risk of delirium. The incidence of delirium in patients undergoing regional anaesthesia was 34.6%, whereas it was 16.5% in patients receiving general anaesthesia (p=0.024). The existence of preoperative diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) was shown to improve the development of delirium (p<0.05). Delirium incidence was significantly higher in patients who were administered meperidine for postoperative analgesia (p=0.013). The VAS scores of patients who developed delirium were found to be significantly higher (p=0.006).

CONCLUSION

As a result, we found that older age, high ASA score, preoperative DM and COPD are important risk factors for the development of delirium. Regional anaesthesia, high postoperative pain scores and meperidine use were observed to be associated with the development of delirium. In the postoperative period, addition of CAM, a simple measurement technique, to the daily follow-up forms can provide the early recognition of delirium, which is often underdiagnosed. We think that identification and prevention of effective risk factors have the primary importance for postoperative delirium.

Impact of intraoperative hypotension and blood pressure fluctuations on early postoperative delirium after non-cardiac surgery

INTRODUCTION

Postoperative delirium is common in older patients. Despite its prognostic significance, the pathophysiology is incompletely understood. Although many risk factors have been identified, no reversible factors, particularly ones potentially modifiable by anaesthetic management, have been identified. The goal of this prospective cohort study was to investigate whether intraoperative hypotension was associated with postoperative delirium in older patients undergoing major non-cardiac surgery.

METHODS

Study subjects were patients >65 years of age, undergoing major non-cardiac surgery, who were enrolled in an ongoing prospective observational study of the pathophysiology of postoperative delirium. Intraoperative blood pressure was measured and predefined criteria were used to define hypotension. Delirium was measured by the Confusion Assessment Method on the first two postoperative days. Data were analysed using t-tests, two-sample proportion tests and ordered logistic regression multivariable models, including correction for multiple comparisons.

RESULTS

Data from 594 patients with a mean age of 73.6 years (sd 6.2) were studied. Of these 178 (30%) developed delirium on day 1 and 176 (30%) on day 2. Patients developing delirium were older, more often female, had lower preoperative cognitive scores, and underwent longer operations. Relative hypotension (decreases by 20, 30, or 40%) or absolute hypotension [mean arterial pressure (MAP)<50 mm Hg] were not significantly associated with postoperative delirium, nor was the duration of hypotension (MAP<50 mm Hg). Conversely, intraoperative blood pressure variance was significantly associated with postoperative delirium.

DISCUSSION

These results showed that increased blood pressure fluctuation, not absolute or relative hypotension, was predictive of postoperative delirium.

Total hospital stay for hip fracture: measuring the variations due to pre-fracture residence, rehabilitation, complications and comorbidities

BACKGROUND

Hospital treatment for hip fracture is complex, often involving sequential episodes for acute orthopaedics, rehabilitation and care of contingent conditions. Most reports of hospital length of stay (LOS) address only the acute phase of care. This study identifies the frequency and mean duration of the component episodes within total hospital stay, and measures the impacts of patient-level and clinical service variables upon both acute phase and total LOS.

METHODS

Administrative datasets for 2552 subjects hospitalised between 1 July 2008 and 30 June 2009 were linked. Associations between LOS, pre-fracture accommodation status, age, sex, fracture type, hospital separation codes, selected comorbidities and complications were examined in regression models for acute phase and total LOS for patients from residential aged care (RAC) and from the community.

RESULTS

Mean total LOS was 30.8 days, with 43 per cent attributable to acute fracture management, 37 per cent to rehabilitation and 20 per cent to management of contingent conditions. Community patients had unadjusted total LOS of 35.4 days compared with 18.8 days for RAC patients (p <0.001). The proportion of transfers into rehabilitation (57 per cent vs 17 per cent, p <0.001) was the major determinant for this difference. In multivariate analyses, new RAC placement, discharge to other facilities, and complications of pressure ulcer, urinary or surgical site infections increased LOS by at least four days in one or more phases of hospital stay.

CONCLUSION

Pre-fracture residence, selection for rehabilitation, discharge destination and specific complications are key determinants for acute phase and total LOS. Calculating the dimensions of specific determinants for LOS may identify potential efficiencies from targeted interventions such as orthogeriatric care models.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Effect of the overlap syndrome of depressive symptoms and delirium on outcomes in elderly adults with hip fracture: a prospective cohort study

OBJECTIVES

To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study.

MEASUREMENTS

Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded.

RESULTS

Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002).

CONCLUSION

Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.

Perioperative Management of Elderly Patients with Hip Fracture

Hip fracture has devastating consequences in elderly patients with comorbidities. The two main objectives to improve outcome are the needs for early surgery and for a multidisciplinary approach, known as the orthogeriatric concept..

Prevention of post-operative delirium in older patients with cancer undergoing surgery

Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.

Estimating the effect of incident delirium on short-term outcomes in aged hip fracture patients through propensity score analysis

AIM

We aimed to evaluate the factors contributing to delirium after hip fracture and assess the effect of incident delirium on short-term clinical outcomes.

METHODS

A total of 270 non-delirious, consecutive hip fracture patients 60 years and older were included in a prospective cohort study. The patients were assessed with respect to physical status according to the American Society of Anesthesiologists classification, medical comorbidities with the Charlson Comorbidity Index, cognitive function with the Portable Mental Status Questionnaire and depression with the Geriatric Depressive Scale. Incident delirium was evaluated daily. Clinical outcomes and 1-month mortality were recorded.

RESULTS

Incident delirium was present in 53.0% of patients. Patients with delirium were older (P = 0.046), had higher American Society of Anesthesiologists and Charlson Comorbidity Index scores (P < 0.001), lower Portable Mental Status Questionnaire scores and higher Geriatric Depressive Scale scores (P < 0.001, P = 0.003, respectively). After adjusting for age, multivariate regression analysis in the first model showed that patients with delirium were at higher risk of reintervention plus death (P < 0.05), complications P < 0.001), a higher severity complication score (P < 0.05) and longer length of hospital stay (P < 0.001). In the second model, after adjusting for propensity score, patients with delirium were at higher risk of reintervention plus death (P < 0.05) and longer length of hospital stay (P < 0.01).

CONCLUSIONS

Patients who are older, with worse physical status, worse cognitive function and depression are more likely to develop delirium after hip fracture. Incident delirium has negative independent effects on short-term outcomes in elderly patients after hip fracture.

Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture

OBJECTIVE

The aim of this study was to determine the association between functional recovery and neuropsychiatric symptoms in hip fracture patients undergoing in-hospital rehabilitation. Very few studies have extensively evaluated neuropsychiatric symptoms in hip fracture patients, and the relationship between these symptoms and rehabilitation outcome is not yet clearly defined.

DESIGN

This study was conducted on 200 patients with hip fracture who underwent a rehabilitation program. The Neuropsychiatric Inventory was used to identify neuropsychiatric symptoms. Efficiency and effectiveness in terms of the motor-Functional Independence Measure and length of stay were considered as outcome measures.

RESULTS

At admission, 74% of the patients had neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms had a lower motor-Functional Independence Measure effectiveness (P = 0.015) and efficiency (P = 0.002) and a longer length of stay (P = 0.008) than those without neuropsychiatric symptoms. However, after adjustment for the Mini-Mental State Examination, the patients with neuropsychiatric symptoms differed from those without symptoms only in terms of longer length of stay (P = 0.006) and lower motor-Functional Independence Measure efficiency (P = 0.008).

CONCLUSIONS

Neuropsychiatric symptoms make the rehabilitation process slower and less efficient in hip fracture patients. Understanding the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients.

Predictors of severe pain in the immediate postoperative period in elderly patients following hip fracture surgery

INTRODUCTION

The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery.

PATIENTS AND METHODS

Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists' preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥ 7 one hour after surgery indicated severe pain.

RESULTS

Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (> 12 yr in school) (P < 0.05). Higher cognitive function was associated with higher postoperative pain (P < 0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P < 0.05, P < 0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery.

CONCLUSION

Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.

Perioperative management of elderly patients suffering a hip fracture

Preparing elderly patients for emergency hip fracture surgery is a significant challenge for hospital staff. This article discusses the principles of preoperative care in these patients, and the rationale for such strategies, based on evidence and current guidelines. Such guidance increasingly reflects a national standard of care.

Improving delirium care through early intervention: from bench to bedside to boardroom

Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.

Screening for delirium in the emergency department: a systematic review

Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult's visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults' mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.

Onset, risk factors, and impact of delirium in patients with traumatic spinal cord injury

Delirium is a commonly reported acute care adverse event in patients with traumatic spinal cord injury (TSCI), but studies specifically investigating it in this population are lacking. The purpose of this study was to characterize the onset, risk factors, and impact of delirium in patients with TSCI. Patients discharged between 2008 and 2010 were identified from a prospective registry in an acute SCI center. Controls were matched to delirium cases based on date of discharge from acute care. Patient characteristics, risk factors, and the hospital unit (intensive care, spine step-down, spine ward) in which delirium occurred were collected retrospectively. Length of stay (LOS) was calculated and compared between cases and controls. A predictive model was built for patient characteristics and risk factors associated with delirium using logistical regression. There were 192 patients identified from the study group; 34 (17.7%) were delirium cases and 34 were selected as controls. Most delirious episodes were reported during high acuity care (76.5%). The median time interval between injury and delirium identification was 8.5 days (interquartile range=5-31). Age at injury (p<0.01) and initial motor score (p<0.05) were significantly associated with delirium. Patients with delirium had significantly greater LOS than controls (median LOS=46.9 vs. 15.3 days respectively, p<0.0001). Elderly patients who sustain a TSCI and have a low motor score on admission are at increased risk of delirium. These results could contribute to the development of a screening program to address the problem of delirium in the TSCI population.

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium

The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.

Cognitive dysfunction in hip fracture patients

Hip fractures represent a widespread morbidity among the geriatric population. In North America, more than 320,000 hip fractures are sustained annually, a number that is expected to increase dramatically as the population continues to age. Disorders of cognition, primarily dementia and delirium, also have a higher-than-average incidence and prevalence among the geriatric population. The co-occurrence of cognitive dysfunction and hip fracture is an important entity for orthopedic surgeons and other clinicians involved in hip fracture care to recognize. This article provides an overview of the currently available evidence regarding cognitive dysfunction, specifically dementia and delirium, in patients with hip fractures.

Delirium in the fast-track surgery setting

Postoperative delirium (PD) and postoperative cognitive dysfunction (POCD) are two separate syndromes of cognitive decline after major surgery, especially in the elderly. Pathogenesis is multifactorial with some common risk factors, and to reduce the risk, a multimodal approach is necessary. The fast-track methodology is becoming a well-established perioperative care regime with possible preventive effects for postoperative cognitive decline, including reduced pain and use of opioids, and early mobilisation with early discharge (≤3 days) to preoperative environment after total hip/knee arthroplasty (THA/TKA). The fast-track set-up seems to be associated with a lower frequency of PD and early POCD after THA/TKA. Thus, in a series of 225 patients ≥60 years, no cases of PD were seen and the incidence of POCD was reduced by more than 50% at 1 week postoperatively compared to previous studies. In conclusion, the fast-track methodology may reduce the incidence of postoperative cognitive decline after surgery.