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Agar MR, Quinn SJ, Crawford GB, Ritchie CS, Phillips JL, Collier A, Currow DC. Predictors of Mortality for Delirium in Palliative Care. J Palliat Med 2016; 19:1205-1209. [PMID: 27309842 DOI: 10.1089/jpm.2015.0416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Delirium has a high mortality rate. Understanding predictors of prognosis in patients with delirium will aid treatment decisions and communication. This study aimed to explore variables associated with death during an established episode of delirium in palliative care when haloperidol treatment had been commenced. METHODS A consecutive cohort of palliative care patients, from 14 centers across four countries, is reported. The outcome of interest was death within 14 days from commencement of haloperidol treatment for delirium. Clinicodemographic variables explored were delirium severity, age, gender, primary life limiting illness, body mass index (BMI), total daily haloperidol dose at baseline (mg), functional status, and comorbidities. RESULTS One hundred and sixteen palliative care patients where vital status was known were included in the analysis; 45% (n = 52) died within 10 days, and 56% (n = 65) died within 14 days. In multivariate analyses no clinical or demographic variables predicted death, apart from lower BMI in noncancer patients. CONCLUSION This study has shown a very high mortality rate within two weeks of commencing haloperidol for delirium in palliative care, with no clear clinical predictors for those with a higher chance of dying. Having a higher BMI offered some benefit in survival, but only in noncancer patients. When delirium occurs in advanced illness, discussion should be initiated about the gravity of the clinical situation.
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Affiliation(s)
- Meera R Agar
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia.,2 South West Sydney Clinical School, University of New South Wales , Sydney Australia .,3 Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney , Ultimo, Australia .,4 Ingham Institute of Applied Medical Research , Sydney, Australia
| | - Stephen J Quinn
- 5 Flinders Clinical Effectiveness, Flinders University , Adelaide, Australia
| | - Gregory B Crawford
- 6 Discipline of Medicine, University of Adelaide , Adelaide, Australia .,7 Northern Adelaide Local Health Network , Adelaide, Australia
| | - Christine S Ritchie
- 8 Department of Medicine, Division of Geriatrics, University of California San Francisco , San Francisco, California.,9 The Jewish Home of San Francisco, San Francisco, California
| | - Jane L Phillips
- 3 Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney , Ultimo, Australia
| | - Aileen Collier
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia
| | - David C Currow
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia.,5 Flinders Clinical Effectiveness, Flinders University , Adelaide, Australia
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Koskderelioglu A, Onder O, Gucuyener M, Altay T, Kayali C, Gedizlioglu M. Screening for postoperative delirium in patients with acute hip fracture: Assessment of predictive factors. Geriatr Gerontol Int 2016; 17:919-924. [DOI: 10.1111/ggi.12806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/22/2016] [Accepted: 03/11/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Asli Koskderelioglu
- Department of Neurology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
| | - Ozlem Onder
- Department of Neurology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
| | - Melike Gucuyener
- Department of Neurology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
| | - Taskin Altay
- Department of Orthopedics and Traumatology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
| | - Cemil Kayali
- Department of Orthopedics and Traumatology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
| | - Muhtesem Gedizlioglu
- Department of Neurology; Izmir Bozyaka Education and Research Hospital; Izmir Turkey
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Fansa A, Huff S, Ebraheim N. Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures. Clin Orthop Surg 2016; 8:140-5. [PMID: 27247737 PMCID: PMC4870315 DOI: 10.4055/cios.2016.8.2.140] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/06/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality. METHODS Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery. RESULTS Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036). CONCLUSIONS Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.
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Affiliation(s)
- Ashraf Fansa
- Department of Orthopedics, University of Toledo Medical Center, Toledo, OH, USA
| | - Scott Huff
- College of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Nabil Ebraheim
- Department of Orthopedics, University of Toledo Medical Center, Toledo, OH, USA
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Restrepo Bernal D, Niño García JA, Ortiz Estévez DE. [Delirium Prevention]. REVISTA COLOMBIANA DE PSIQUIATRIA 2016; 45:37-45. [PMID: 26896403 DOI: 10.1016/j.rcp.2015.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/06/2015] [Accepted: 06/30/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Delirium is the most prevalent neuropsychiatric syndrome in the general hospital. Its presence is a marker of poor prognosis for patients. Its prevention could be the most effective strategy for reducing its frequency and its complications. OBJECTIVE To review recent findings and strategies for the prevention of delirium. METHODOLOGY A non-systematic review of scientific articles published in the last ten years in Spanish and English. A search was made in databases such as MEDLINE, Cochrane, EMBASE, Ovid, and ScienceDirect, for articles that included the terms, delirium and prevention. RESULTS Identification of predisposing and precipitating factors for delirium and a better understanding of the pathophysiological mechanisms underlying the onset of delirium have enabled the implementation of various pharmacological and non-pharmacological strategies in patients at high risk to develop hospital delirium. The studies to prevent delirium have focused on surgical patients. The current evidence supports the daily implementation of non-pharmacological measures to prevent delirium, as they are easy and cost effective. The available evidence is still limited to recommend the daily use of pharmacological strategies in delirium prophylaxis, and there is a consensus against the modest use of antipsychotic drugs in surgical patients and dexmedetomidine in patients in intensive care. CONCLUSIONS New high-quality clinical trials and studies involving non-surgical patients are needed to provide more evidence about this subject.
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Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CAN J EMERG MED 2015; 18:245-52. [DOI: 10.1017/cem.2015.94] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveHip fractures are a common source of acute pain amongst the frail elderly. One potential technique to adequately manage pain in this population is the femoral nerve block. The objective of this systematic review was to provide updated evidence for the use of femoral nerve blocks as a pain management technique for older hip fracture patients in the emergency department (ED).Data SourcesSearches of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were conducted between December 2010 and May 2014. The reference list of a previous systematic review was also searched.Study SelectionWe included randomized control trials examining the use of femoral nerve blocks in the ED among older adults (65 years of age or older) with acute hip fracture.Data ExtractionAmong 93 citations reviewed, seven trials were included. Four studies employed a single femoral nerve block, while three studies employed continuous (catheter-placed) femoral blocks. All but one of the studies were found to have a high risk of bias.Data SynthesisAll studies reported reductions in pain intensity with femoral nerve blocks. All but one study reported decreased rescue analgesia requirements. There were no adverse effects found to be associated with the femoral block procedure; rather, two studies found a decreased risk of adverse events such as respiratory and cardiac complications.ConclusionsFemoral nerve blocks appear to have benefits both in terms of decreasing the pain experienced by older patients, as well as limiting the amount of systemic opioids administered to this population.
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Bollinger AJ, Butler PD, Nies MS, Sietsema DL, Jones CB, Endres TJ. Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures? Geriatr Orthop Surg Rehabil 2015; 6:202-8. [PMID: 26328237 PMCID: PMC4536513 DOI: 10.1177/2151458515588560] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander J. Bollinger
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Paul D. Butler
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Matthew S. Nies
- Department of Orthopaedic Surgery, University of Wisconsin, Madison, WI, USA
| | - Debra L. Sietsema
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Clifford B. Jones
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Terrence J. Endres
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
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Jones CA, Jhangri GS, Feeny DH, Beaupre LA. Cognitive Status at Hospital Admission: Postoperative Trajectory of Functional Recovery for Hip Fracture. J Gerontol A Biol Sci Med Sci 2015; 72:61-67. [DOI: 10.1093/gerona/glv138] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 07/20/2015] [Indexed: 11/13/2022] Open
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Khadaroo RG, Padwal RS, Wagg AS, Clement F, Warkentin LM, Holroyd-Leduc J. Optimizing senior's surgical care - Elder-friendly Approaches to the Surgical Environment (EASE) study: rationale and objectives. BMC Health Serv Res 2015; 15:338. [PMID: 26293153 PMCID: PMC4546177 DOI: 10.1186/s12913-015-1001-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 08/11/2015] [Indexed: 01/08/2023] Open
Abstract
Background It is estimated that seniors (≥65 years old) account for >50 % of acute inpatient hospital days and are presenting for surgical evaluation of acute illness in increasing numbers. Unfortunately, conventional acute care models rarely take into account needs of the elderly population. The failure to consider these special needs have resulted in poor outcomes, longer lengths of hospital stay and have likely increased the need for institutional care. Acute Care for the Elderly models on medical wards have demonstrated decreased cost, length of hospital stay, readmissions and improved cognition, function and patient/staff satisfaction. We hypothesize that specific Elder-friendly Approaches to the Surgical Environment (EASE) interventions will similarly improve health outcomes in a cost-effective manner. Methods/design Prospective, before-after study with a concurrent control group. Four cohorts of 140 consecutively-screened older patients (≥65 years old) will be enrolled (560 patients in total). The EASE interventions involves co-locating all older surgical patients on a single unit, involving an interdisciplinary care team (including a geriatric specialist) in the development of individual care plans, implementing evidence-informed elder-friendly practices, use of a reconditioning program, and optimizing discharge planning. Subjects will be followed via chart review for their hospital stay, and will then complete in-person or telephone interviews at 6 weeks and 6 months after discharge. Measured outcomes include clinical (postoperative major in-hospital complication or death [primary composite outcome]; death or readmission within 30-days of initial discharge; length of hospital stay), humanistic (quality of life; functional, cognitive, and nutritional status) and economic (health care resource utilization and costs) endpoints. Within-site mean change scores will be computed for the composite primary outcome and the overall covariate-adjusted between-site pre-post difference will be the dependent variable analyzed using generalized linear mixed model procedures including adjustment for clustering. Discussion Our findings will generate new knowledge on outcomes from acute surgical care in older patients and validate a novel elder-friendly surgical model including assessment of both clinical and economic benefits. If effective, we expect the EASE initiatives to be generalizable to other surgical centres. Trial registration Clinicaltrials.govidentifier:NCT02233153
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Affiliation(s)
- Rachel G Khadaroo
- Department of Surgery, University of Alberta, Edmonton, AB, Canada. .,2D3.77 Walter C. Mackenzie Health Sciences Centre, 8440-112th Street, Edmonton, T6G 2B7, AB, Canada.
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Alberta Diabetes Institute, Edmonton, AB, Canada.
| | - Adrian S Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Alberta Seniors Health Strategic Clinical Network, Calgary, AB, Canada.
| | - Fiona Clement
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada. .,Alberta Seniors Health Strategic Clinical Network, Calgary, AB, Canada.
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Chen J, Zhu W, Zhang Z, Zhu L, Zhang W, DU Y. Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial. Exp Ther Med 2015; 10:737-742. [PMID: 26622385 DOI: 10.3892/etm.2015.2512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 05/01/2015] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to determine whether celecoxib is able to ameliorate pain intensity, provide a narcotic-sparing effect, achieve early ambulation and improve rehabilitation following total hip arthroplasty (THA) in elderly patients. Peri- and post-operative oral celecoxib was administered to verify the efficacy of celecoxib for acute pain management in a multimodal analgesic strategy. All 64 eligible patients were randomly allocated to either the celecoxib group, who took an oral 400 mg capsule of celecoxib peri-operatively and 200 mg per 12 h post-operatively for the first 5 days, or the control group, who were orally treated with a placebo capsule having the same appearance. A multimodal analgesic technique was used in which oral celecoxib or placebo capsule was combined with intravenous patient-controlled analgesia (PCA) morphine pump for peri- and post-operative pain management. Pain assessments were recorded at 6, 12, 24, 48 and 72 h, and 7 and 14 days after THA using the visual analog scale (VAS). PCA morphine consumption; 6, 12, 24 and 48-h post-operative Harris hip score (HHS); time interval until initial ambulation; rates of urinary retention and post-operative nausea and vomiting (PONV) within 72 h; and intra- and post-operative blood loss were also documented. The celecoxib and control groups comprised 34 and 30 patients, respectively. Baseline demographics were comparable between the two groups. The post-operative VAS in the celecoxib group was significantly lower than that in the control group at 12, 24, 48 and 72 h after THA. The post-operative HHS had no significant difference between the two groups, while the time interval until initial ambulation in the celecoxib group (4.5±1.2 days) was significantly less than that in the control group (5.83±2.04 days; P<0.05). Morphine consumption was significantly decreased in the celecoxib group when compared with the control group at 6, 12, 24 and 24 h. Although the 72-h post-operative rates of urinary retention and PONV were lower in the celecoxib group than in the control group, there were no significant differences in these rates between the two groups. The intra- or post-operative blood loss was not significantly different between groups. In conclusion, pre-and post-operative oral celecoxib in a multimodal analgesic strategy can achieve favorable pain relief, reduce opioid consumption, and provide earlier ambulation and improved rehabilitation when compared with PCA morphine alone following THA in elderly patients.
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Affiliation(s)
- Jia Chen
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
| | - Wei Zhu
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
| | - Zhenxiang Zhang
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
| | - Lixian Zhu
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
| | - Wenjie Zhang
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
| | - Yaqing DU
- Orthopedic Department, The Affiliated Taizhou People's Hospital of Nantong University, Taizhou, Jiangsu 225300, P.R. China
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Blom MT, Jansen S, de Jonghe A, van Munster BC, de Boer A, de Rooij SE, Tan HL, van der Velde N. In-Hospital Haloperidol Use and Perioperative Changes in QTc-Duration. J Nutr Health Aging 2015; 19:583-9. [PMID: 25923490 DOI: 10.1007/s12603-015-0465-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Haloperidol may prolong ECG QTc-duration but is often prescribed perioperatively to hip-fracture patients. We aimed to determine (1) how QTc-duration changes perioperatively, (2) whether low-dose haloperidol-use influences these changes, and (3) which clinical variables are associated with potentially dangerous perioperative QTc-prolongation (PD-QTc; increase >50 ms or to >500 ms). DESIGN Prospective cohort study. SETTING Tertiary university teaching-hospital. PARTICIPANTS Patients enrolled in a randomized controlled clinical trial of melatonin versus placebo on occurrence of delirium in hip-fracture patients. MEASUREMENTS Data from ECGs made before and after hip surgery (1-3 days and/or 4-6 days post-surgery) were analyzed. QTc-duration was measured by hand, blinded for haloperidol and pre/post-surgery status. Clinical variables were measured at baseline. Mixed model analysis was used to estimate changes in QTc-duration. Risk-factors for PD-QTc were estimated by logistic regression analysis. RESULTS We included 89 patients (mean age 84 years, 24% male); 39 were treated with haloperidol. Patients with normal pre-surgery QTc-duration (male ≤430 ms, female ≤450 ms) had a significant increase (mean 12 ms, SD 28) in QTc-duration. A significant decrease (mean 19 ms, SD 34) occurred in patients with prolonged pre-surgery QTc-duration (male >450ms, female >470 ms). Haloperidol-use did not influence the perioperative course of the QTc-interval (p=0.351). PD-QTc (n=8) was not associated with any of the measured risk-factors. CONCLUSION QTc-duration changed differentially, increasing in patients with normal, but decreasing in patients with abnormal baseline QTc-duration. PD-QTc was not associated with haloperidol-use or other risk-factors. Low-dose oral haloperidol did not affect perioperative QTc-interval.
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Affiliation(s)
- M T Blom
- Nathalie van der Velde, MD, PhD, Department of Internal Medicine, section of Geriatric Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands, Phone: 31-20-5663066, Fax: 31-20-5669325;
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Luk TTH, Jia B, Pang EYT, Lau VNM, Lam CKM, Chu MHM, Han R, Chan MTV. Depth of Anesthesia and Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0088-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Hip fracture after stroke is a frequently occurring and costly complication. The bone quality of stroke survivors is affected by decreased mobility, asymmetric weight bearing, and impaired vitamin D stores. Simultaneously, the risk of falling after stroke is often increased by various impairments. Yet, attempts to limit falls are not enough to prevent fractures. Closer attention to bone health is also needed. Bone markers, which reflect the dynamics of bone remodeling, are becoming more available. Activity is necessary for bone health, but there are no clear guidelines for the type and amount of therapeutic exercise. New metrics for studying bone mineral density and exercise are on the horizon. Finally, there appears to be a role for bisphosphonate prophylaxis in a yet-to-be-defined at-risk population of stroke survivors. The purpose of this review is to discuss the setting for hip fracture after stroke and assess emerging treatments and technologies that may be used to combat the problem.
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Affiliation(s)
- Brian A Bast
- Department of Orthopaedics, Sports and Spine Rehabilitation, Beth Israel Medical Center, New York, USA
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Liang CK, Chu CL, Chou MY, Lin YT, Lu T, Hsu CJ, Chen LK. Interrelationship of postoperative delirium and cognitive impairment and their impact on the functional status in older patients undergoing orthopaedic surgery: a prospective cohort study. PLoS One 2014; 9:e110339. [PMID: 25402484 PMCID: PMC4234211 DOI: 10.1371/journal.pone.0110339] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/15/2014] [Indexed: 11/19/2022] Open
Abstract
Background The impact of postoperative delirium on post-discharge functional status of older patients remains unclear, and little is known regarding the interrelationship between cognitive impairment and post-operative delirium. Therefore, the main purpose was to evaluate the post-discharge functional status of patients who experience delirium after undergoing orthopaedic surgery and the interrelationship of postoperative delirium with underlying cognitive impairment. Method This prospective cohort study, conducted at a tertiary care medical center from April 2011 to March 2012, enrolled all subjects aged over 60 years who were admitted for orthopaedic surgery. The baseline characteristics (age, gender, BMI, and living arrangement), surgery-related factors (ASA class, admission type, type of surgery, and length of hospital stay), results of geriatric assessment (postoperative delirium, cognition, depressive mood, comorbidity, pain, malnutrition, polypharmacy, ADL, and instrumental [I]ADL) and 1–12-month postoperative ADL and IADL functional status were collected for analysis. Results Overall, 9.1% of 232 patients (mean age: 74.7±7.8 years) experienced postoperative delirium, which was significantly associated with IADL decline at only 6 and 12 months postoperatively (RR: 6.22, 95% CI: 1.08–35.70 and RR: 12.54, 95% CI: 1.88–83.71, respectively). Delirium superimposed on cognitive impairment was a significant predictor for poor functional status at 6 and 12 months postoperatively (RR: 12.80, 95% CI: 1.65–99.40 for ADL at the 6th month, and RR: 7.96, 95% CI: 1.35–46.99 at the 12th month; RR: 13.68, 95% CI: 1.94–96.55 for IADL at the 6th month, and RR: 30.61, 95% CI: 2.94–318.54 at the 12th month, respectively). Conclusion Postoperative delirium is predictive of IADL decline in older patients undergoing orthopaedic surgery, and delirium superimposed on cognitive impairment is an independent risk factor for deterioration of ADL and IADL functional status. Early identification of cognitive function and to prevent delirium are needed to improve functional status following orthopaedic surgery.
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Affiliation(s)
- Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital Kaohsiung, Taiwan
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | - Chin-Liang Chu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital Kaohsiung, Taiwan
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- * E-mail: (YTL); (LKC)
| | - Ti Lu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Jen Hsu
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- * E-mail: (YTL); (LKC)
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Walke LM, Rosenthal RA, Trentalange M, Perkal MF, Maiaroto M, Jeffery SM, Marottoli RA. Restructuring Care for Older Adults Undergoing Surgery: Preliminary Data from the Co-Management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) Model of Care. J Am Geriatr Soc 2014; 62:2185-90. [DOI: 10.1111/jgs.13098] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa M. Walke
- Department of Medicine; School of Medicine; Yale University; New Haven Connecticut
| | - Ronnie A. Rosenthal
- Department of Surgery; School of Medicine; Yale University; New Haven Connecticut
- Department of Surgery; Veterans Affairs Connecticut Healthcare System; West Haven Connecticut
| | | | - Melissa F. Perkal
- Department of Medicine; School of Medicine; Yale University; New Haven Connecticut
- Department of Surgery; School of Medicine; Yale University; New Haven Connecticut
| | - Maria Maiaroto
- Geriatrics and Extended Care; Veterans Affairs Connecticut Healthcare System; West Haven Connecticut
| | - Sean M. Jeffery
- School of Pharmacy; University of Connecticut; Storrs Connecticut
| | - Richard A. Marottoli
- Department of Medicine; School of Medicine; Yale University; New Haven Connecticut
- Geriatrics and Extended Care; Veterans Affairs Connecticut Healthcare System; West Haven Connecticut
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65
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The approach to patients with cognitive impairment and hip fracture: the role of orthogeriatric care. ACTA ACUST UNITED AC 2014. [DOI: 10.1017/s0959259814000100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SummaryHip fracture is very common among older patients, who are characterized by increased co-morbidities, including cognitive impairment. These patients have an increased risk of falls and fractures, poorer functional recovery and lower survival both in hospital and 12 months after discharge. We review the survival and functional outcomes of older patients with cognitive impairment and hip fracture managed in orthogeriatric units, and highlight the gaps in our knowledge of the efficacy and efficiency of specific orthogeriatric programmes for such patients and the future research perspectives in this field.
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Wong JC, Goyal N, McBride WC, Austin MS, Deirmengian GK. Head computed tomography is not useful for evaluating patients change in mental status following total joint arthroplasty. J Arthroplasty 2014; 29:1114-8. [PMID: 24524774 DOI: 10.1016/j.arth.2013.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 12/20/2013] [Accepted: 12/21/2013] [Indexed: 02/01/2023] Open
Abstract
We retrospectively reviewed 187 patients who presented with neurologic abnormality after total joint arthroplasty to establish the incidence of diagnosed organic brain disorders in these patients and determine the utility of advanced head imaging studies. 139 of 187 (74.3%) patients underwent imaging for altered mental status (AMS) and 48 patients for a focal neurologic deficit (FND). Acute findings on head imaging were more common in the FND group. The incidence of stroke and transient ischemic attack was significantly lower in the AMS group compared to FND group (Stroke: 0% vs 12.5%, p < 0.001; TIA: 0% vs. 16.7%, P < .001). Advanced head imaging for evaluation of TJA patients with a change in mental status is of low yield. An algorithm for evaluation of these patients is proposed.
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Affiliation(s)
- Justin C Wong
- Thomas Jefferson University Department of Orthopaedic Surgery, Philadelphia, Pennsylvania
| | - Nitin Goyal
- Anderson Orthopaedic Research Institute and the Inova Center for Joint Replacement at Mount Vernon Hospital, Alexandria, Virginia
| | - William C McBride
- Department of Neurology, Cerebrovascular Division at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Matthew S Austin
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory K Deirmengian
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? A systematic review. Adv Emerg Nurs J 2013; 35:154-69. [PMID: 23636047 DOI: 10.1097/tme.0b013e31828c7f4a] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The aim of this study was to conduct a systematic literature review of research-based studies to identify practices designed to meet the specific care needs of older cognitively impaired patients in emergency departments (ED). A systematic literature review of studies was completed using PRIMSA methodology. The search criteria included articles from both emergency and acute care settings. A total of 944 articles were screened, and a total of 43 articles were identified as eligible. The review found a number of intervention studies to improve quality of care for older persons with cognitive impairment carried out or commenced in emergency settings, including interventions to improve cognitive impairment recognition (n = 9) and clinical approaches to reduce falls (n = 1) and both delirium incidence and prevalence (n = 2). Relevant studies carried out in acute care settings regarding cognitive impairment recognition (n = 4) and primary and secondary prevention of delirium (n = 18) and intervention studies that reduced the prescription of deliriogenic drugs (n = 1), reduced behavioral symptoms and discomfort (n = 7), and improved nutritional intake (n = 1) in hospitalized older persons with dementia were also identified. There is limited research available that reports interventions that improve the quality of care of older ED patients with cognitive impairment. Although this review found evidence obtained from the acute care setting, additional research is needed to identify whether these interventions are beneficial in fast-paced emergency settings.
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68
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Godfrey M, Smith J, Green J, Cheater F, Inouye SK, Young JB. Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study. BMC Health Serv Res 2013; 13:341. [PMID: 24004917 PMCID: PMC3766659 DOI: 10.1186/1472-6963-13-341] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. METHODS We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. RESULTS Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. CONCLUSIONS Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly. STUDY REGISTRATION ISRCTN65924234.
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Affiliation(s)
- Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - Jane Smith
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - John Green
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - Francine Cheater
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, Edith Cavell Building, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, UK
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Roslindale, MA 02131, USA
| | - John B Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
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Mézière A, Paillaud E, Belmin J, Pariel S, Herbaud S, Canouï-Poitrine F, Le Thuaut A, Marty J, Plaud B. Delirium in older people after proximal femoral fracture repair: Role of a preoperative screening cognitive test. ACTA ACUST UNITED AC 2013; 32:e91-6. [DOI: 10.1016/j.annfar.2013.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/06/2013] [Indexed: 11/30/2022]
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Dubljanin-Raspopović E, Marković-Denić L, Marinković J, Nedeljković U, Bumbaširević M. Does early functional outcome predict 1-year mortality in elderly patients with hip fracture? Clin Orthop Relat Res 2013; 471:2703-10. [PMID: 23546850 PMCID: PMC3705055 DOI: 10.1007/s11999-013-2955-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/20/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hip fractures in the elderly are followed by considerable risk of functional decline and mortality. QUESTIONS/PURPOSES The purposes of this study were to (1) explore predictive factors of functional level at discharge, (2) evaluate 1-year mortality after hip fracture compared with that of the general population, and (3) evaluate the affect of early functional outcome on 1-year mortality in patients operated on for hip fractures. METHODS A total of 228 consecutive patients (average age, 77.6 ± 7.4 years) with hip fractures who met the inclusion criteria were enrolled in an open, prospective, observational cohort study. Functional level at discharge was measured with the motor Functional Independence Measure (FIM) score, which is the most widely accepted functional assessment measure in use in the rehabilitation community. Mortality rates in the study population were calculated in absolute numbers and as the standardized mortality ratio. Multivariate regression analysis was used to explore predictive factors for motor FIM score at discharge and for 1-year mortality adjusted for important baseline variables. RESULTS Age, health status, cognitive level, preinjury functional level, and pressure sores after hip fracture surgery were independently related to lower discharge motor FIM scores. At 1-year followup, 57 patients (25%; 43 women and 14 men) had died. The 1-year hip fracture mortality rate compared with that of the general population was 31% in our population versus 7% for men and 23% in our population versus 5% for women 65 years or older. The 1-year standardized mortality rate was 341.3 (95% CI, 162.5-520.1) for men and 301.6 (95% CI, 212.4-391.8) for women, respectively. The all-cause mortality rate observed in this group was higher in all age groups and in both sexes when compared with the all-cause age-adjusted mortality of the general population. Motor FIM score at discharge was the only independent predictor of 1-year mortality after hip fracture. CONCLUSIONS Functional level at discharge is the main determinant of long-term mortality in patients with hip fracture. Motor FIM score at discharge is a reliable predictor of mortality and can be recommended for clinical use.
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Affiliation(s)
- Emilija Dubljanin-Raspopović
- />Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000 Belgrade, Serbia
| | - Ljiljana Marković-Denić
- />Institute of Epidemiology, School of Medicine, Faculty of Medicine, University of Belgrade, Višegradska 26, 11000 Belgrade, Serbia
| | - Jelena Marinković
- />Institute of Medical Statistics and Medical Informatics, Faculty of Medicine, University of Belgrade, Dr Subotića 15, 11000 Belgrade, Serbia
| | - Una Nedeljković
- />Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Marko Bumbaširević
- />Clinic for Orthopaedic Surgery and Traumatology, Clinical Center Serbia, Faculty of Medicine, University of Belgrade, Višegradska 26, 11000 Belgrade, Serbia
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Gruber-Baldini AL, Marcantonio E, Orwig D, Magaziner J, Terrin M, Barr E, Brown JP, Paris B, Zagorin A, Roffey DM, Zakriya K, Blute MR, Hebel JR, Carson JL. Delirium outcomes in a randomized trial of blood transfusion thresholds in hospitalized older adults with hip fracture. J Am Geriatr Soc 2013; 61:1286-95. [PMID: 23898894 DOI: 10.1111/jgs.12396] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine whether a higher blood transfusion threshold would prevent new or worsening delirium symptoms in the hospital after hip fracture surgery. DESIGN Ancillary study to a randomized clinical trial. SETTING Thirteen hospitals in the United States and Canada. PARTICIPANTS One hundred thirty-nine individuals hospitalized with hip fracture aged 50 and older (mean age 81.5 ± 9.1) with cardiovascular disease or risk factors and hemoglobin concentrations of less than 10 g/dL within 3 days of surgery recruited in an ancillary study of the Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair. INTERVENTION Individuals in the liberal treatment group received one unit of packed red blood cells and as much blood as needed to maintain hemoglobin concentrations at greater than 10 g/dL; those in the restrictive treatment group received transfusions if they developed symptoms of anemia or their hemoglobin fell below 8 g/dL. MEASUREMENTS Delirium assessments were performed before randomization and up to three times after randomization. The primary outcome was severity of delirium according to the Memorial Delirium Assessment Scale (MDAS). The secondary outcome was the presence or absence of delirium defined according to the Confusion Assessment Method (CAM). RESULTS The liberal group received a median two units of blood and the restrictive group zero units of blood. Hemoglobin concentration on Day 1 after randomization was 1.4 g/dL higher in the liberal group. Treatment groups did not differ significantly at any time point or over time on MDAS delirium severity (P = .28) or CAM delirium presence (P = .83). CONCLUSION Blood transfusion to maintain hemoglobin concentrations greater than 10 g/dL alone is unlikely to influence delirium severity or rate in individuals with hip fracture after surgery with a hemoglobin concentration less than 10 g/dL.
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Affiliation(s)
- Ann L Gruber-Baldini
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, 660 W. Redwood St., Howard Hall Suite 200, Baltimore, MD 21201, USA.
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Use of early indicators in rehabilitation process to predict one-year mortality in elderly hip fracture patients. Hip Int 2013; 22:661-7. [PMID: 23233176 DOI: 10.5301/hip.2012.10142] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2012] [Indexed: 02/04/2023]
Abstract
Hip fractures remain one of the most devastating injuries in the elderly. Early prediction of outcome following hip fracture potentially results in more efficient health care. The aims of this study were to explore predictors of ambulation status at hospital discharge in patients ≥65 years of age operated on for fracture of the hip, and to investigate the impact of ambulation status at hospital discharge on 1-year mortality after hip fracture. We studied 344 patients who underwent surgery for hip fracture during a 12 month period. Multivariate regression analysis was used to explore predictive factors for ambulatory status at discharge, and 1-year mortality adjusted on important baseline variables. Cumulative 1-year mortality was significantly lower for patients in the ambulatory group when compared to patients in the non-ambulatory group. Patients who were older, had severe cognitive impairment, lower functional level before injury, and in whom postoperative delirium and pressure ulcers occurred had a higher chance of not recovering their gait ability at hospital discharge, and being dead 1 year after hip fracture. Inability to walk at hospital discharge and presence of delirium are independent predictors of 1-year mortality. Every effort should be made to assure early mobilisation after hip fracture surgery, and prevention, prompt recognition and treatment of postoperative complications is important in order to facilitate better short-and long-term outcome.
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73
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Mathillas J, Olofsson B, Lövheim H, Gustafson Y. Thirty-day prevalence of delirium among very old people: a population-based study of very old people living at home and in institutions. Arch Gerontol Geriatr 2013; 57:298-304. [PMID: 23711428 DOI: 10.1016/j.archger.2013.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
Abstract
Delirium has mainly been studied in various patient samples and in people living in institutions. The present study investigates the 30-day prevalence of delirium in a population-based sample of very old people in northern Sweden and Finland. Seven hundred and eight persons aged 85 years and older from the GErontological Regional DAtabase (GERDA) were assessed. Information was also collected from relatives, carers and medical records. Assessments performed were among others the Organic Brain Syndrome (OBS) scale, the Mini Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15). Delirium, depression and dementia diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The prevalence of delirium was 17% among 85 year-olds, 21% among 90 year-olds and 39% among participants aged 95 years and older (p<0.001). Delirium prevalence among individuals without dementia was lower than among those with dementia (5% vs. 52%, p<0.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression (Odds Ratio (OR)=2.0, 95% Confidence Interval (CI)=1.2-3.3), heart failure (OR=2.1, 95% CI=1.2-3.7), institutional living (OR 4.4, 95% CI=2.4-8.2) and prescribed antipsychotics (OR=3.0, 95% CI=1.5-6.0). Delirium is highly prevalent among very old people with dementia. Depression, heart failure, institutional living and prescribed antipsychotic medication seem to be associated with delirium.
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Affiliation(s)
- Johan Mathillas
- Geriatric Medicine, Department of Community Medicine and Rehabilitation, Umeå University, SE-901 85 Umeå, Sweden.
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74
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Rothberg MB, Herzig SJ, Pekow PS, Avrunin J, Lagu T, Lindenauer PK. Association Between Sedating Medications and Delirium in Older Inpatients. J Am Geriatr Soc 2013; 61:923-930. [DOI: 10.1111/jgs.12253] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Michael B. Rothberg
- Department of Internal Medicine, Medicine Institute; Cleveland Clinic; Cleveland Ohio
| | - Shoshana J. Herzig
- Division of General Medicine; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Penelope S. Pekow
- Center for Quality of Care Research; Baystate Medical Center; Springfield Massachusetts
- University of Massachusetts; Amherst Massachusetts
| | - Jill Avrunin
- Center for Quality of Care Research; Baystate Medical Center; Springfield Massachusetts
| | - Tara Lagu
- Center for Quality of Care Research; Baystate Medical Center; Springfield Massachusetts
- School of Medicine; Tufts University; Boston Massachusetts
| | - Peter K. Lindenauer
- Center for Quality of Care Research; Baystate Medical Center; Springfield Massachusetts
- School of Medicine; Tufts University; Boston Massachusetts
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Strömberg L, Öhlén G, Lindgren U, Svensson O. Continuity, Assessment and Feedback in Orthopaedic Nursing Care Practice is Cost-effective. Scand J Caring Sci 2013. [DOI: 10.1111/j.1471-6712.1999.tb00537.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lundström M, Edlund A, Lundström G, Gustafson Y. Reorganization of Nursing and Medical Care to Reduce the Incidence of Postoperative Delirium and Improve Rehabilitation Outcome in Elderly Patients Treated for Femoral Neck Fractures. Scand J Caring Sci 2013. [DOI: 10.1111/j.1471-6712.1999.tb00539.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Singler K, Biber R, Wicklein S, Sieber C, Bollheimer L. A plea for an early mobilization after hip fractures. The geriatric point of view. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2012.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Psychotic disorders due to a known medical illness or substance use are collectively termed secondary psychoses. In this paper, we first review the historic evolution of the concept of secondary versus primary psychosis and how this distinction supplanted the earlier misleading classification of psychoses into organic and functional. We then outline the clinical features and approach to the diagnosis of secondary psychotic disorders. Features such as atypical presentation, temporal relation to detectable medical cause, evidence of direct physiological causal relationship to the etiological agent, and the absence of evidence of a primary psychotic illness that may better explain the presentation suggest consideration of a secondary psychosis. Finally, we discuss how careful studies of secondary psychotic disorders can help elucidate the pathophysiology of primary, or idiopathic, psychotic disorders such as schizophrenia. We illustrate this issue through a discussion of three secondary psychotic disorders - psychoses associated with temporal lobe epilepsy, velocardiofacial syndrome, and N-methyl D-aspartate (NMDA) receptor encephalitis - that can, respectively, provide neuroanatomical, genetic, and neurochemical models of schizophrenia pathogenesis.
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Affiliation(s)
| | - Yoshio Kaneko
- Longwood Psychiatry Residency Training Program and Harvard Medical SchoolBoston, MA, USA
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79
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Abstract
Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Assistant Professor of Emergency Medicine, Vanderbilt University School of Medicine, Department of Emergency Medicine, 703 Oxford House, Nashville, TN 37232-4700, Phone: 615-936-1434, Fax: 615-936-1316
| | - Scott T. Wilber
- Emergency Medicine Research Center, Associate Professor of Emergency Medicine, Summa Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, Ohio 44309, Phone: 330-375-7530, Fax: 330-375-7564
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Ryan DJ, O'Regan NA, Caoimh RÓ, Clare J, O'Connor M, Leonard M, McFarland J, Tighe S, O'Sullivan K, Trzepacz PT, Meagher D, Timmons S. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open 2013; 3:bmjopen-2012-001772. [PMID: 23299110 PMCID: PMC3549230 DOI: 10.1136/bmjopen-2012-001772] [Citation(s) in RCA: 296] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To date, delirium prevalence and incidence in acute hospitals has been estimated from pooled findings of studies performed in distinct patient populations. OBJECTIVE To determine delirium prevalence across an acute care facility. DESIGN A point prevalence study. SETTING A large tertiary care, teaching hospital. PATIENTS 311 general hospital adult inpatients were assessed over a single day. Of those, 280 had full data collected within the study's time frame (90%). MEASUREMENTS Initial screening for inattention was performed using the spatial span forwards and months backwards tests by junior medical staff, followed by two independent formal delirium assessments: first the Confusion Assessment Method (CAM) by trained geriatric medicine consultants and registrars, and, subsequently, the Delirium Rating Scale-Revised-98 (DRS-R98) by experienced psychiatrists. The diagnosis of delirium was ultimately made using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. RESULTS Using DSM-IV criteria, 55 of 280 patients (19.6%) had delirium versus 17.6% using the CAM. Using the DRS-R98 total score for independent diagnosis, 20.7% had full delirium, and 8.6% had subsyndromal delirium. Prevalence was higher in older patients (4.7% if <50 years and 34.8% if >80 years) and particularly in those with prior dementia (OR=15.33, p<0.001), even when adjusted for potential confounders. Although 50.9% of delirious patients had pre-existing dementia, it was poorly documented in the medical notes. Delirium symptoms detected by medical notes, nurse interview and patient reports did not overlap much, with inattention noted by professional staff, and acute change and sleep-wake disturbance noted by patients. CONCLUSIONS Our point prevalence study confirms that delirium occurs in about 1/5 of general hospital inpatients and particularly in those with prior cognitive impairment. Recognition strategies may need to be tailored to the symptoms most noticed by the detector (patient, nurse or primary physician) if formal assessments are not available.
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Affiliation(s)
- Daniel James Ryan
- Centre for Gerontology and Rehabilitation, University College Cork, St. Finbarr's Hospital, Cork, Ireland
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Frisch A, Miller T, Haag A, Martin-Gill C, Guyette FX, Suffoletto BP. Diagnostic Accuracy of a Rapid Checklist to Identify Delirium in Older Patients Transported by EMS. PREHOSP EMERG CARE 2013; 17:230-4. [DOI: 10.3109/10903127.2012.744785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Adam Frisch
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Thomas Miller
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Adam Haag
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Brian P. Suffoletto
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
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Abstract
BACKGROUND Involuntary psychiatric admission is a controversial issue with legislation varying from country to country. Research on elderly individuals being involuntary admitted has been limited. This study aims first at assessing whether elderly involuntary admitted patients (IAPs) differ with regard to demographic, psychopathological, and behavioral characteristics from voluntary admitted psychiatric patients (VAPs) and second to assess whether the former group should be treated in a different (special) way. METHODS Forty IAPs were compared to 39 VAPs with regard to sociodemographic data, DSM-IV diagnosis, as well as behavioral issues recorded by the Patient-Staff Conflict Checklist - Shift Report (PSCC-SR). All patients were aged 60 years and over and were admitted in the psychiatric departments of four general hospitals in Athens. The study period lasted 12 months. RESULTS VAPs were more likely to be suffering from mood disorders, while IAPs presented higher rates of delirium. From the 20 items of the PSCC-SR, differences were found only in two: IAPs presented more aggressive behavior during the first few days of admission whereas VAPs had committed recent suicide attempt just before admission. CONCLUSION From the clinical point of view, IAPs presented with delirium and more aggressive behavior, whereas, the VAPs presented with higher rates of mood disorder and suicidality. However, from the medicolegal point of view, our findings lend support to the argument of either setting a limited time frame for involuntary admission in elderly patients, and/or allowing for elderly individuals with acute organic conditions to be treated against their will.
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Abstract
SummaryPublished literature shows that evidence-based medical care can improve hip fracture outcomes. The orthogeriatrician plays a key role in providing this care, in collaboration with surgical and multidisciplinary professionals, managing pre-operative conditions and post-operative complications that may affect functional recovery, and ensuring co-ordinated effective management of hip fractures right from admission to discharge. Several management guidelines are available for this vulnerable group of elderly patients. Recent UK guidelines recommend that, from time of admission, hip fracture patients should be offered a formal acute orthogeriatric or orthopaedic ward-based ‘Hip Fracture Programme’, which includes orthogeriatric assessment as an essential key component.
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84
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Leeper AD, Brandon PT, Morgan AVM, Cutts S, Cohen AMM. Fascia iliaca compartment block reduces morphine requirement pre-operatively for patients with fractured neck of femur. Eur J Trauma Emerg Surg 2012; 38:673-7. [PMID: 26814555 DOI: 10.1007/s00068-012-0230-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 09/10/2012] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Fascia iliaca compartment block, performed in the emergency department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether fascia iliaca block (FIB) significantly reduced the requirement for systemic opiates in the pre-operative setting. MATERIALS AND METHODS Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a 9-month period were gathered prospectively. Fifty percent of patients had received FIB at diagnosis in the A&E, dependant on the expertise of the attending physician. Morphine administration between groups was analysed. RESULTS Over a 9-month period, 286 patients with complete documentation were admitted with fractured neck of femur. At the start of the study, an informal education programme in A&E was introduced, increasing the incidence of FIB provision at diagnosis (p = <0.0001, Fisher's exact test) and reducing the average amount of morphine administered (p = 0.027, linear regression analysis). The administration of FIB reduced the average morphine requirement for a patient in A&E by 41 % when compared with those who received systemic analgesia alone (p = 0.018, Mann-Whitney test). No adverse effects were reported with FIB. CONCLUSION Fascia iliaca compartment block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement.
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Affiliation(s)
- A D Leeper
- Orthopaedics, James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK.
| | - P T Brandon
- Orthopaedics, James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK
| | - A V M Morgan
- Orthopaedics, James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK
| | - S Cutts
- Orthopaedics, James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK
| | - A M M Cohen
- Orthopaedics, James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK
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85
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Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol 2012; 26:277-87. [PMID: 23040281 PMCID: PMC3580997 DOI: 10.1016/j.bpa.2012.07.003] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/25/2012] [Indexed: 10/27/2022]
Abstract
Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.
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Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, USA.
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86
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Schaller F, Sidelnikov E, Theiler R, Egli A, Staehelin HB, Dick W, Dawson-Hughes B, Grob D, Platz A, Can U, Bischoff-Ferrari HA. Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture. Bone 2012; 51:347-52. [PMID: 22705148 DOI: 10.1016/j.bone.2012.06.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 05/24/2012] [Accepted: 06/05/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is not well established if and to what extent mild to moderate cognitive impairment predicts mortality and risk of nursing home admission after hip fracture. OBJECTIVE To investigate prospectively whether and to what extent mild to moderate cognitive impairment, contributes to mortality and admission to nursing home in the first year after acute hip fracture. METHODS We enrolled 173 patients with acute hip fracture age 65 and older who reached a Mini-Mental State Examination (MMSE) score of at least 15 during acute care after hip fracture repair. An MMSE score of 15 to 24 (median) was classified as mild to moderate cognitive impairment. Primary outcomes were mortality in all and admission to nursing home among seniors who lived at home prior to their hip fracture. Follow-up was 12 months with clinical visits at baseline, 6, and 12 months, plus monthly phone calls. We used Cox proportional hazards models controlling for age, sex, body mass index, baseline number of comorbidities and 25-hydroxyvitamin D status, and severe incident infections to assess the risk of mortality and nursing home admission. Because the study population was enrolled in a factorial design clinical trial testing high dose vitamin D and/or an exercise home program, all analyses also controlled for these treatment strategies. RESULTS Of 173 acute hip fracture patients enrolled, 79% were women, 77% were admitted from home, and 80% were vitamin D deficient (<20ng/ml). Mean age was 84 years. 54% had mild to moderate cognitive impairment. Over the 12-month follow-up, 20 patients died (27% of 173) and 47 (35% of 134) were newly admitted to a nursing home. Mild to moderate cognitive impairment was associated with a more than 5-fold increased risk of mortality (HR=5.77; 95% CI: 1.55-21.55) and a more than 7-fold increased risk of nursing home admission (HR=7.37; 95% CI: 1.75-30.95). Additional independent risk factors of mortality were male gender (HR=3.55; 95% CI: 1.26-9.97), low BMI (HR=7.25; 95% CI: 1.61-33.74), and baseline 25-hydroxyvitamin D level (per 1ng/ml: HR=0.93; 95% CI: 0.87-0.998; p=0.04). CONCLUSIONS Mild to moderate cognitive impairment in patients with acute hip fracture is associated with a high risk of mortality and nursing home admission during the first year after hip fracture. Female gender, a greater BMI and a higher 25-hydroxyvitamin D status may protect against mortality after hip fracture independent of cognitive function.
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Affiliation(s)
- F Schaller
- Centre on Aging and Mobility, University of Zurich and City Hospital Waid, Zurich, Switzerland.
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87
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Lundström M, Stenvall M, Olofsson B. Symptom profile of postoperative delirium in patients with and without dementia. J Geriatr Psychiatry Neurol 2012; 25:162-9. [PMID: 23124010 DOI: 10.1177/0891988712455221] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This study compares the symptom profile of patients with postoperative delirium after femoral neck fracture surgery in those with and without dementia. In this study, 129 patients of age ≥70 years (mean age ±SD, 86±6 yr, 72% women) with postoperative delirium, were included. Delirium and dementia were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Of the 129 patients with delirium, 54 (42%) had a dementia disorder. Patients with delirium superimposed on dementia more often had any hyperactive and pure emotional delirium. Communication difficulties and symptoms such as restlessness/agitation, aggressive behavior, and irritability were more commonly found in the dementia group. In contrast, patients with delirium but without dementia were more often diagnosed with pure hypoactive and any psychotic delirium. The symptom profile of postoperative delirium varies according to whether it occurs in patients with or without dementia. This may indicate that postoperative delirium among patients with hip fracture differs based on the presence or absence of dementia.
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Affiliation(s)
- Maria Lundström
- Geriatric Medicine, Umeå University, SE-901 87 Umeå, Sweden.
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88
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Sasajima Y, Sasajima T, Azuma N, Akazawa K, Saito Y, Inaba M, Uchida H. Factors related to postoperative delirium in patients with lower limb ischaemia: a prospective cohort study. Eur J Vasc Endovasc Surg 2012; 44:411-5. [PMID: 22863895 DOI: 10.1016/j.ejvs.2012.06.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To preoperatively determine candidates at definitive risk of postoperative delirium (POD), we identified relevant factors in patients with arteriosclerosis obliterans who underwent bypass surgery. DESIGN A prospective cohort study. PATIENTS AND METHODS 299 patients (age ≥ 60 years) who underwent bypasses in 1995-2006 were enrolled. Cognitive impairment was assessed by the Revised Hasegawa Dementia Scale, the Confusion Assessment Method was also used, and severity was graded as Grade I-III (mild to severe) based on the Delirium Rating Scale. All patients were followed for 3 years. RESULTS POD occurred in 88 patients (29%), with a median age of 75 (10) years (IQR). Onset was 2 (1) days postoperatively, and a duration of 2 (2) days was observed. POD was hyperactive in 89% and was Grade I, II, and III in 11%, 68%, and 21% respectively. Multiple logistic regression analysis identified the following risk factors for POD: age ≥ 72 years (<0.0001), end-stage renal failure (0.001), multiple occlusive lesions (<0.0001), cognitive impairment (0.003), and critical limb ischaemia (0.034). The 3-year survival rate was similar when comparing POD and non-POD patients (84% vs. 88%, NS). CONCLUSIONS This study identified 5 risk factors for POD in patients undergoing bypasses for limb ischaemia. Long-term outcomes were similar when comparing the patients who experienced POD with those who did not.
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Affiliation(s)
- Y Sasajima
- Asahikawa College, Hokkaido Educational University, Asahikawa, Japan.
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89
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Abstract
Delirium (acute confusion) complicates 15% to 50% of major operations in older adults and is associated with other major postoperative complications, prolonged length of stay, poor functional recovery, institutionalization, dementia, and death. Importantly, delirium may be predictable and preventable through proactive intervention. Yet clinicians fail to recognize and address postoperative delirium in up to 80% of cases. Using the case of Ms R, a 76-year-old woman who developed delirium first after colectomy with complications and again after routine surgery, the diagnosis, prevention, and treatment of delirium in the postoperative setting is reviewed. The risk of postoperative delirium can be quantified by the sum of predisposing and precipitating factors. Successful strategies for prevention and treatment of delirium include proactive multifactorial intervention targeted to reversible risk factors, limiting use of sedating medications (especially benzodiazepines), effective management of postoperative pain, and, perhaps, judicious use of antipsychotics.
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Affiliation(s)
- Edward R Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts 02215, USA.
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90
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Groshaus H, Boscan A, Khandwala F, Holroyd-Leduc J. Use of clinical decision support to improve the quality of care provided to older hospitalized patients. Appl Clin Inform 2012; 3:94-102. [PMID: 23616902 DOI: 10.4338/aci-2011-08-ra-0047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 02/20/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence. OBJECTIVE The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients. METHODS A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool. RESULTS The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9-5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units. CONCLUSIONS Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users' engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.
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91
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Jain FA, Brooks JO, Larsen KA, Kelly SE, Bode RH, Sweeney GA, Stern TA. Individual risk profiles for postoperative delirium after joint replacement surgery. PSYCHOSOMATICS 2012; 52:410-6. [PMID: 21907058 DOI: 10.1016/j.psym.2011.03.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 03/25/2011] [Accepted: 03/25/2011] [Indexed: 10/26/2022]
Abstract
BACKGROUND Delirium occurs in nearly half of older patients after joint replacement surgery. However, risk profiles for developing delirium have not been established. OBJECTIVE We sought to identify risk profiles for delirium in patients following joint replacement surgery. METHOD Based on data from a randomized, double-blind, placebo-controlled trial of olanzapine (10 mg) as delirium prophylaxis in 400 patients (67-81 years old) undergoing hip or knee replacement surgery, we performed a signal detection analysis to develop risk profiles for postsurgical delirium (using baseline patient characteristics, iatrogenic factors, and physiologic response parameters). RESULTS Olanzapine reduced the incidence of delirium by 63% relative to placebo. Among patients receiving placebo, those with an ASA class = 3 and age ≥ 74 years had a 64% risk of delirium. Those with ASA class < 3 still had a 67% risk of delirium if postoperative oxygen saturation was < 95%. Patients who received olanzapine had an 83% risk of developing delirium if they received ≥ 42.5 mg equivalents of intra-operative morphine, were ≥ 74 years old, and had a mean arterial pressure (MAP) < 90 mm Hg at the presurgical screening visit. Patients with the lowest risk (6%) of developing delirium received olanzapine had a hematocrit ≥ 28%, and a presurgical MAP ≥ 90. CONCLUSION Although use of prophylactic olanzapine reduced the incidence of delirium, subsets of patients remained likely to develop delirium. The risk of developing delirium may be reduced through prophylactic dispensation of olanzapine, maintaining optimal perfusion and oxygenation, and limiting intra-operative opioids.
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Affiliation(s)
- Felipe A Jain
- Department of Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, CA, USA
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92
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Marcantonio ER, Palihnich K, Appleton P, Davis RB. Pilot randomized trial of donepezil hydrochloride for delirium after hip fracture. J Am Geriatr Soc 2012; 59 Suppl 2:S282-8. [PMID: 22091574 DOI: 10.1111/j.1532-5415.2011.03691.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair. DESIGN Pilot double-masked randomized placebo-controlled trial. SETTING Large academic medical center. PARTICIPANTS Sixteen individuals aged 70 and older with hip fracture. INTERVENTION Donepezil 5 mg or placebo was randomly allocated and initiated within 24 hours of surgery, preoperatively or postoperatively. Daily treatment was continued for 30 days or until side effects or the clinical situation required termination. MEASUREMENTS All outcomes were ascertained masked to treatment status. Information on drug tolerability and safety was obtained from the participant, nurse, and medical record. Delirium presence and severity were measured during daily hospital interviews and at 2, 4, and 6 weeks after surgery after a standardized assessment using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS). RESULTS Participants in the donepezil and placebo arms had similar baseline characteristics. Participants in the donepezil arm experienced significantly more side effects. In longitudinal models, there were no significant differences between the donepezil and placebo arms with regard to delirium presence over time (odds ratio = 0.9, 95% confidence interval (CI) = 0.4-2.3) or delirium severity over time (effect size = -0.2 on 30-point MDAS scale, 95%CI = -1.5-1.2). CONCLUSION Participants randomized to donepezil had no significant improvement in delirium presence or severity but experienced more side effects. Overall, sufficient evidence was not found from this pilot study to warrant a definitive Phase III trial.
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Affiliation(s)
- Edward R Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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93
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Abstract
Delirium presents clinically with differing subtypes ranging from hyperactive to hypoactive. The clinical presentation is not clearly linked to specific pathophysiological mechanisms. Nevertheless, there seem to be different mechanisms that lead to delirium; for example the mechanisms leading to alcohol-withdrawal delirium are different from those responsible for postoperative delirium. In many forms of delirium, the brain's reaction to a peripheral inflammatory process is considered to be a pathophysiological key element and the aged brain seems to react more markedly to a peripheral inflammatory stimulus than a younger brain. The effects of inflammatory mediators on the brain include changes in neurotransmission and apoptosis. On a neurotransmitter level, impaired cholinergic transmission and disturbances of the intricate interactions between dopamine, serotonin and acetylcholine seem to play an important role in the development of delirium. The risk factors for delirium are categorised as predisposing or precipitating factors. In the presence of many predisposing factors, even trivial precipitating factors may trigger delirium, whereas in patients without or with only a few predisposing factors, a major precipitating insult is necessary to trigger delirium. Well documented predisposing factors are age, medical comorbidities, cognitive, functional, visual and hearing impairment and institutional residence. Important precipitating factors apart from surgery are admission to an ICU, anticholinergic drugs, alcohol or drug withdrawal, infections, iatrogenic complications, metabolic derangements and pain. Scores to predict the risk of delirium based on four or five risk factors have been validated in surgical patients.
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94
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Tekin L, Ozçakar L, Işik AT. Delirium: a critical diagnosis for every member of the rehabilitation team. Rehabil Nurs 2011; 36:214-5. [PMID: 21882800 DOI: 10.1002/j.2048-7940.2011.tb00198.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Levent Tekin
- Department of Physical Medicine and Rehabilitation at Gülhane Military Medical Academy Haydarpaşa Training Hospital, Istanbul, Turkey
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95
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Lee KH, Ha YC, Lee YK, Kang H, Koo KH. Frequency, risk factors, and prognosis of prolonged delirium in elderly patients after hip fracture surgery. Clin Orthop Relat Res 2011; 469:2612-20. [PMID: 21327416 PMCID: PMC3148394 DOI: 10.1007/s11999-011-1806-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 02/01/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delirium in elderly patients after hip fracture surgery is believed to be a transient event, although it frequently lasts for more than 4 weeks. QUESTIONS/PURPOSES We determined the incidence, risk factors, morbidity, and mortality of prolonged delirium in elderly patients after hip fracture surgery. PATIENTS AND METHODS We evaluated 232 elderly patients (older than 65 years) (232 hips) who underwent hip fracture surgery for the development and duration of delirium and categorized them into three groups; nondelirium group, transient (≤ 4 weeks) delirium group, and prolonged (> 4 weeks) delirium group. Patients underwent a global geriatric evaluation, which included postoperative complications, mortality, and functional and mental status evaluations. The three groups were compared with respect to these variables. RESULTS Seventy patients (30.2%) had delirium develop, and among these, 14 (20%) had prolonged delirium with a total incidence of 6%. Multivariate analysis showed preinjury dementia was a risk factor of prolonged delirium. At the final followup, five (62.5%) of the eight patients who were ambulatory outdoors in the prolonged delirium group became housebound, whereas only 18 (16.4%) of the 110 patients who were ambulatory outdoors in the nondelirium group became housebound. Survival at 40 months was 81.0% (95% confidence interval, 72.6%-89.3%) in the nondelirium group and 63.6% (95% confidence interval, 35.2%-92.1%) in the prolonged delirium group. CONCLUSIONS Prolonged delirium was found to be associated with a poor functional outcome and increased mortality. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kyung-Hag Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul, 156-755 South Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyun Kang
- Department of Anesthesiology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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97
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Burkhart CS, Rossi A, Dell-Kuster S, Gamberini M, Möckli A, Siegemund M, Czosnyka M, Strebel SP, Steiner LA. Effect of age on intraoperative cerebrovascular autoregulation and near-infrared spectroscopy-derived cerebral oxygenation. Br J Anaesth 2011; 107:742-8. [PMID: 21835838 DOI: 10.1093/bja/aer252] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Age is an important risk factor for perioperative cerebral complications such as stroke, postoperative cognitive dysfunction, and delirium. We explored the hypothesis that intraoperative cerebrovascular autoregulation is less efficient and brain tissue oxygenation lower in elderly patients, thus, increasing the vulnerability of elderly brains to systemic insults such as hypotension. METHODS We monitored intraoperative cerebral perfusion in 50 patients aged 18-40 and 77 patients >65 yr at two Swiss university hospitals. Mean arterial pressure (MAP) was measured continuously using a plethysmographic method. An index of cerebrovascular autoregulation (Mx) was calculated based on changes in transcranial Doppler flow velocity due to changes in MAP. Cerebral oxygenation was assessed by the tissue oxygenation index (TOI) using near-infrared spectroscopy. End-tidal CO₂, O₂, and sevoflurane concentrations and peripheral oxygen saturation were recorded continuously. Standardized anaesthesia was administered in all patients (thiopental, sevoflurane, fentanyl, atracurium). RESULTS Autoregulation was less efficient in patients aged >65 yr [by 0.10 (se 0.04; P=0.020)] in a multivariable linear regression analysis. This difference was not attributable to differences in MAP, end-tidal CO₂, or higher doses of sevoflurane. TOI was not significantly associated with age, sevoflurane dose, or Mx but increased with increasing flow velocity [by 0.09 (se 0.04; P=0.028)] and increasing MAP [by 0.11 (se 0.05; P=0.043)]. CONCLUSIONS Our results do not support the hypothesis that older patients' brains are more vulnerable to systemic insults. The difference of autoregulation between the two groups was small and most likely clinically insignificant.
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Affiliation(s)
- C S Burkhart
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Switzerland
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98
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Adamis D, Meagher D. Insulin-like growth factor I and the pathogenesis of delirium: a review of current evidence. J Aging Res 2011; 2011:951403. [PMID: 21766035 PMCID: PMC3134253 DOI: 10.4061/2011/951403] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 04/26/2011] [Accepted: 05/12/2011] [Indexed: 01/28/2023] Open
Abstract
Delirium is a frequent complication in medically ill elderly patients that is associated with serious adverse outcomes including increased mortality. Delirium risk is linked to older age, dementia, and illness that involves activation of inflammatory responses. IGF-I is increasingly postulated as a key link between environmental influences on body metabolism with a range of neuronal activities and has been described as the master regulator of the connection between brain and bodily well-being. The relationships between IGF-I and ageing, cognitive impairment and inflammatory illness further support a possible role in delirium pathogenesis. Five studies of IGF-I in delirium were identified by a systematic review. These conflicting findings, with three of the five studies indicating an association between IGF-1 and delirium occurrence, may relate to the considerable methodological differences in these studies. The relevance of IGF-I and related factors to delirium pathogenesis can be clarified by future studies which account for these issues and other confounding factors. Such work can inform therapeutic trials of IGF-I and/or growth hormone administration.
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Affiliation(s)
- Dimitrios Adamis
- Research and Academic Institute of Athens, 27 Themistokleous Street and Akadimias, 10677 Athens, Greece
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99
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Slor CJ, de Jonghe JF, Vreeswijk R, Groot E, Ploeg TV, van Gool WA, Eikelenboom P, Snoeck M, Schmand B, Kalisvaart KJ. Anesthesia and Postoperative Delirium in Older Adults Undergoing Hip Surgery. J Am Geriatr Soc 2011; 59:1313-9. [DOI: 10.1111/j.1532-5415.2011.03452.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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100
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White JJE, Khan WS, Smitham PJ. Perioperative implications of surgery in elderly patients with hip fractures: an evidence-based review. J Perioper Pract 2011; 21:192-197. [PMID: 21823308 DOI: 10.1177/175045891102100601] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Hip fracture is a major cause of morbidity, mortality and loss of independence for the elderly. Surgical fixation of the fractured hip remains the standard of care to allow for early mobilisation and a return to independence. Operative management in this population carries its own set of problems. The altered physiological state of the older person, often coupled with significant comorbidity, can present challenges for the anaesthetist, the surgeon and the rest of the perioperative team. This article provides an evidence-based review of the important perioperative factors associated with hip fractures in the older person and their management.
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Affiliation(s)
- Jonathan J E White
- UCL Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP
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