Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Elderly adults with isolated hip fractures- orthogeriatric care versus standard care: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services.

METHODS

Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900, to August 31, 2017. A single Population, Intervention, Comparator and Outcome (PICO) question was generated with multiple outcomes: Should geriatric trauma patients 65 years or older with isolated hip fracture receive routine OG management, compared with no-routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay?

RESULTS

Forty-five articles were evaluated. Six randomized controlled trials and seven retrospective case-control studies met the criteria for quantitative analysis. For critical outcomes, retrospective case-control studies demonstrated a 30-day mortality benefit with OG (OR, 0.78 [0.67, 0.90]), but this was not demonstrated prospectively or at 1 year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at 4 months (mean difference [MD], 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Examination with OG at 12 months (MD, 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at 4 and 12 months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR, 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low.

CONCLUSION

In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Delay to Surgery of Less Than 12 Hours Is Associated With Improved Short- and Long-Term Survival in Moderate- to High-Risk Hip Fracture Patients

Introduction:

The effect of delays before surgery of 24 hours, 48 hours, and 72 hours on short- and long-term survival has been investigated comprehensively in hip fracture patients, but with controversial results. However, there is only limited evidence for how a threshold of 12-hour delay before hip fracture surgery affects survival.

Materials and Methods:

A prospective observational study of 884 consecutive hip fracture patients (age ≥ 65 years) undergoing surgery was carried out in terms of 30- and 365-day survival. A Cox hazard regression survival model was constructed for 724 patients with American Society of Anesthesiologists score ≥3 with adjustments of age, gender, cognition, number of medications on admission, hip fracture type, and prior living arrangements.

Results:

Patients who underwent surgery within 12 hours had better chances of survival than did those with 12 to 24 hours (hazard ratio [HR]: 8.30; 95% confidence interval [CI]: 1.13-61.4), 24 to 48 hours (HR: 7.21; 95% CI: 0.98-52.9), and >48 hours (HR: 11.75; 95% CI: 1.53-90.2) delay before surgery. Long-term survival was more influenced by nonadjustable patient features, but the adverse effect of >48 hours delay before surgery was noticed with HR: 2.02; 95% CI: 1.08-3.80. Increased age and male gender were significantly associated with worse short- and long-term survival.

Discussion/Conclusions:

Early hip fracture surgery within 12 hours of admission is associated with improved 30-day survival among patients with ASA score ≥3. Delay to surgery of more than 48 hours has an adverse effect on 365-day survival, but factors related to patients’ comorbidities have a great influence on long-term survival.

Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture

STUDY OBJECTIVE

To identify modifiable preoperative factors that might influence the morbidity and mortality associated with non-elective, inpatient hip fracture surgeries in the geriatric surgical population.

DESIGN

Retrospective database analysis from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project.

SETTING

Inpatient, perioperative.

PATIENTS

Geriatric patients undergoing surgery.

INTERVENTIONS

Non-elective hip repair surgery.

MEASUREMENTS

Preoperative demographic, medical, surgical, and anesthetic variables; post-operative rates of delirium, decline in functional status, and 30-day mortality.

MAIN RESULTS

The 1261 patients in this study were predominantly female (74%), white (89%), and non-Hispanic (92%). Ages were distributed across groups from 65 to over 90 years. Most patients were categorized as American Society of Anesthesiologists Physical Status class 3 (64%). General anesthesia (57%) was the most common anesthetic, followed by spinal (38%). Preoperative functional status was recorded in 79% as independent in activities of daily living (ADLs). About one third of patients had baseline dementia. Post-operatively, 42% experienced delirium, and most patients required partial or total assistance with ADLs (72% and 12%, respectively). Reoperation was required in 2.8% of cases. Mortality at 30 days was 5.0%. In the multivariable analysis, risk factors associated with post-operative delirium included dementia and lack of competency to sign consent. In the analysis for postoperative decline in functional status, the major risk factor was a history of falls, while emergently performed surgery was protective. The analysis for mortality at thirty days was under-powered.

CONCLUSIONS

Hip fractures remain a major source of morbidity in geriatric patients. Baseline dementia and inability to sign surgical consent are significant risk factors for adverse outcomes after hip fractures and should be considered in the informed consent process. Data from this study and currently ongoing randomized trials will help guide reductions in morbidity and mortality in this population.

Surgical delay is a risk factor of delirium in hip fracture patients with mild-moderate cognitive impairment

AIM

To investigate the relationship between onset of delirium and time to surgery in hip fracture (HF) patients with a different degree of cognitive impairment.

METHODS

Retrospective analysis of a prospective database of 939 older adults, aged ≥ 75 years admitted with a fragility HF. Subjects underwent a Comprehensive Geriatric Assessment on admission, evaluating health status, prefracture functional status in basic and instrumental activities of daily living, and walking ability. According to the Short Portable Mental Status Questionnaire score, patients were stratified into three categories: cognitively healthy (0-2 errors), mildly to moderately impaired (3-7 errors) and severely impaired (8-10 errors). Time to surgery (from admission) was expressed as days. The occurrence of delirium was ascertained daily by Confusion Assessment Method.

RESULTS

Two hundred ninety-two (31.1%) patients experienced delirium during in-hospital stay. They were older, with a higher degree of comorbidity and functional impairment compared to patients without delirium. In multivariate analysis, surgical delay resulted a significant independent risk factor for delirium (HR 1.11, 95% CI 1.01-1.24), along with age, prefracture functional disability and cognitive impairment. When the analysis was performed accounting for the cognitive categories, surgical delay demonstrated to increase the risk of delirium only in the subcategory of mildly to moderately impaired patients, while no significant effect was demonstrated in patients cognitively healthy or severely impaired.

CONCLUSIONS

The study supports the concept that older adults with HF should undergo surgery quickly. Patients with mild-to-moderate cognitive impairment should be primarily considered as the best target for interventions aiming to reduce time to surgery.

Incidence of postoperative delirium in elderly ambulatory patients: A prospective evaluation using the FAM-CAM instrument

BACKGROUND

While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery.

OBJECTIVE

To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit.

DESIGN

Prospective observational study.

PATIENTS

Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis.

INTERVENTIONS

Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery.

MAIN OUTCOME MEASURES

The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers.

RESULTS

Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days.

CONCLUSIONS

Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients.

Effects of a Medication Review on Delirium in Older Hospitalised Patients: A Comparative Retrospective Cohort Study

Background

Delirium in older hospitalised patients is a common and serious disorder. Polypharmacy and certain medications are risk factors for developing delirium. A medication review could benefit older hospitalised patients with delirium.

Objectives

(1) Evaluate the effects of medication review on length of delirium, length of hospital stay, mortality, and discharge destination; and (2) describe and analyse the proposed changes to medication and its implementation by the treating physician.

Setting

The study was conducted at Maastricht University Medical Centre+.

Methods

We compared two cohorts of older patients with delirium: the first cohort from before introducing the medication review, and a second cohort 5 months after introduction of the medication review. Data were extracted from the patients’ digital medical records.

Results

A significant interaction effect of cohort and number of medications taken by the patient was found for duration of delirium: patients from the second cohort taking between zero and six medications had significantly shorter delirious episodes than patients in the first cohort. This effect bordered on significance for patients taking between seven and 11 medications, but disappeared for patients taking 12 or more medications. No other statistically significant differences were found between the cohorts. The proposed changes in medication were implemented for 71% of the patients.

Conclusion

A medication review seems to significantly decrease the length of an older patient’s delirious episode. Given the clinical relevance of these findings, we advise medication reviews for all older patients who are delirious or are at risk of developing delirium.

Electronic supplementary material

The online version of this article (10.1007/s40266-018-0523-9) contains supplementary material, which is available to authorized users.

A Proactive Approach to High Risk Delirium Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Delirium is a common complication among elderly patients undergoing total joint arthroplasty (TJA). Its incidence has been reported from 4% to 53%. The Centers for Medicare and Medicaid Services consider delirium following TJA a "never-event." The purpose of this study is to evaluate a simple perioperative protocol used to identify delirium risk patients and prevent its incidence following TJA.

METHODS

Our group developed a protocol to identify and prevent delirium in patients undergoing TJA. All patients were screened and scored in the preoperative assessment, on criteria such as age, history of forgetfulness, history of agitation or visual hallucinations, history of falls, history of postoperative confusion, and inability to perform higher brain functions. Patients were scored on performance in a simple mental examination. The patients were classified as low, medium, or high risk. Patients who were identified as high risk were enrolled in a delirium avoidance protocol that minimized narcotics and emphasized nursing involvement and fluids administration.

RESULTS

Five of 7659 (0.065%) consecutive TJA patients from 2010 to 2015 developed delirium. A total of 422 patients were identified as high risk. All 5 patients who suffered delirium were within the high risk group. No low or medium risk patients suffered a delirium complication. Three (0.039%) patients suffered drug-induced delirium, 1 (0.013%) had delirium related to alcohol withdrawal, and 1 (0.013%) had delirium after a systemic infection.

CONCLUSION

This protocol is effective in identifying patients at high delirium risk and diminishing the incidence of this complication by utilizing a simple screening tool and perioperative protocol.

Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery

BACKGROUND

Postoperative delirium (POD) is a common disorder in the elderly patients, and neuroinflammation is the possible underlying mechanism. This study is designed to determine whether or not hypertonic saline (HS) pre-injection can alleviate POD in aged patients.

METHODS

This prospective study recruited 120 geriatric patients who underwent hip surgery. The patients were randomly divided into two groups: control group (NS group) and HS group. Patients in the NS group were pre-injected with 4 mL/kg isotonic saline, and those in the HS group were pre-injected with 4 mL/kg 7.5% HS. All 120 patients were then subjected to general anesthesia. Blood samples were extracted to detect the concentration of inflammatory factors, namely, IL-1β, IL-6, IL-10, and TNF-α, and the nerve injury factor S100β. Flow cytometry was used to detect the number of monocytes in peripheral venous blood and evaluate the relationship of inflammation to delirium. The nursing delirium screening scale (Nu-DESC) was used to determine cognitive function 1 to 3 days postoperatively.

RESULTS

Analysis using random-effect multivariable logistic regression indicated that HS administration before anesthesia was associated with a low risk of POD (odds ratio [OR], 0.13; 95% CI, 0.04 to 0.41; P = 0.001) and few CD14 + CD16+ monocytes (β = - 0.61; 95% CI, - 0.74 to - 0.48; P = 0.000) the following day. When the association between HS and delirium was controlled for CD14 + CD16+ monocytes, the effect size became nonsignificant (odds ratio [OR], 0.86; 95% CI, 0.14 to 5.33; P = 0.874). TNF-α was significantly associated with POD (odds ratio [OR], 1.10; 95% CI, 1.05 to 1.16; P = 0.000). However, IL-1β, IL-6, IL-10, and S100β were not significantly related to POD.

CONCLUSION

HS can alleviate POD in geriatric patients and may inhibit the secretion of inflammatory factors by monocytes.

Approaches to acute pain management in older people

Pain is a diverse, individual experience and is associated with distress and suffering. Uncontrolled acute pain has been linked to delayed recovery and prolonged hospital stay. Nurses have a duty of care to their patients and acute pain management is integral to this. However, acute pain in older people can be difficult to manage, often because of under-reporting or difficulties in assessment. Older people have altered physiology often compounded by multiple co-morbidities and polypharmacy, all of which affect the appropriateness of, and available, pharmacological pain management strategies. In addition, older people are at greater risk of adverse drug reactions, drug interactions and side effects from analgesia. Consequently, non-pharmacological strategies should also be integral to pain management.

Evaluation of the effectiveness of a care program for elderly patients with hip fractures: a network strategy

Abstract Objective: Evaluate the effectiveness of a care program for elderly persons with hip fractures due to a fall, based on a public network in Canoas, Rio Grande do Sul, Brazil. Methods: a prospective cohort study of quantitative character was carried out. A total of 182 elderly person above 60 years diagnosed with hip fractures were included. The sample was divided into two groups, one who underwent their usual treatment (n=91) and another who were included in a care program for elderly persons with hip fractures (n=91). The program had as its main axis a clinical Protocol and an Access Protocol. The treatment of choice was surgical in all cases. In statistical analysis, categorical variables were described by absolute and relative frequencies. The Mann-Whitney test was used to compare numeric variables. In the comparison of proportions, the Pearson's Chi-squared test or Fisher's exact test were applied. The significance level adopted was 5%. Results: The average age was 79.4 years, with a prevalence of the female gender. The most frequent morbidity was hypertension. After the implementation of the program there was a reduction in the average time between the fracture and the beginning of surgery, the average length of hospitalization, the urinary tract infection rate, the death rate and care costs. Conclusion: The care program of elderly persons with hip fractures modified the expected results as it reduced mortality, average hospital stay, postoperative complications and the costs of treatment during the hospitalization.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery

STUDY DESIGN

This study is a systematic review.

OBJECTIVE

Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery.

SUMMARY OF BACKGROUND DATA

Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available.

METHODS

A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015.

RESULTS

Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05).

CONCLUSIONS

An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed.

LEVEL OF EVIDENCE

Level II.

The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.