Association between postoperative delirium and mortality in elderly patients undergoing hip fractures surgery: a meta-analysis

Association between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery: A large-scale cohort study

AIM

This cohort study aimed to explore the connection between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery.

METHODS

Elderly patients aged 65 years and older undergoing emergency hip fracture surgery were included in the study. The presence of postoperative hyperactive delirium was assessed, and logistic regression analysis, following propensity score matching, was conducted to investigate the association between postoperative hyperactive delirium and major complications occurring 30 and 90 days post-surgery. The analysis controlled for potential confounding factors.

RESULTS

After propensity score matching, the analysis included 13 590 patients, equally distributed with 6795 in each group. The group experiencing postoperative hyperactive delirium exhibited a significantly elevated risk of 30-day postoperative complications, including acute renal failure, pneumonia, septicemia, and stroke, with adjusted odds ratios ranging from 1.64 to 2.39. Furthermore, this group displayed notably higher rates of 90-day postoperative complications, encompassing mortality, acute renal failure, pneumonia, septicemia, and stroke, with a significantly increased incidence of mortality within 90 days.

CONCLUSION

Postoperative hyperactive delirium in elderly patients undergoing emergency hip fracture surgery is significantly linked to an increased risk of major complications at both 30 and 90 days post-surgery. These findings underscore the critical importance of delirium prevention and management in this patient population, offering the potential to reduce the occurrence of postoperative complications. Geriatr Gerontol Int 2024; 24: 730-736.

Registered nurses' experiences of caring for patients with hypoactive delirium after cardiac surgery - A qualitative study

OBJECTIVES

Delirium is a common post-cardiac surgery complication that presents as acute changes in mental abilities with confused thinking and a lack of awareness of the surroundings. Delirium symptoms present in hyperactive- and hypoactive forms. Hypoactive delirium is often overlooked. Although nursing interventions are important in preventing and treating hypoactive delirium, studies focusing on nurses' experiences of hypoactive delirium are scarce. This study describes registered nurses' experiences of caring for patients with hypoactive delirium after cardiac surgery.

RESEARCH METHODOLOGY/DESIGN

This was a qualitative descriptive study with an inductive approach. Data was collected through focus group interviews with 12 registered nurses with experience in caring for cardiac surgery patients with hypoactive delirium. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

SETTING

A cardiac surgery department at a Swedish University Hospital.

FINDINGS

The analysis resulted in one main category; "Navigating the complexities of care when caring for patients with hypoactive delirium" and three sub-categories: "Challenges, "Nursing interventions" and "Promoting a team approach".

CONCLUSION

Delirium assessment and nursing interventions are perceived as essential yet demanding. when caring for patients with hypoactive delirium. Nursing interventions like maintaining the circadian rhythm and offering emotional support need to be prioritised by the nurses, in line with the autonomy of the registered nurse's profession. Moreover, the team around the patient is crucial for detecting and treating hypoactive delirium, and it is important to involve other professionals as well as the patient's relatives. Future research is needed to develop assessment instruments that more accurately capture hypoactive delirium in the postoperative setting.

IMPLICATIONS FOR CLINICAL PRACTICE

Despite the use of screening tools, nurses still experience challenges in detecting the symptoms of hypoactive delirium, indicating a need for more clinically effective screening tools for hypoactive delirium. Nursing interventions are emphasised in the care of patients with hypoactive delirium.

The Effect of Dexmedetomidine as a Local Anesthetic Adjuvant for Iliac Fascia Compartment Block on Postoperative Delirium in Elderly Patients Undergoing Elective Hip Surgery

INTRODUCTION

We analyzed the effect of dexmedetomidine (DEX) as a local anesthetic adjuvant on postoperative delirium (POD) in elderly patients undergoing elective hip surgery.

METHODS

In this study, 120 patients undergoing hip surgery were enrolled and randomly assigned to two groups: fascia iliaca compartment block with DEX + ropivacaine (the Y group, n = 60) and fascia iliaca compartment block with ropivacaine (the R group, n = 60). The primary outcomes: presence of delirium during the postanesthesia care unit (PACU) period and on the first day (D1), the second day (D2), and the third day (D3) after surgery. The secondary outcomes: preoperative and postoperative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), occurrence of insomnia on the preoperative day, day of operation, D1 and D2; HR values of patients in both groups before iliac fascia block (T1), 30 min after iliac fascia block (T2), at surgical incision (T3), 20 min after incision (T4), when they were transferred out of the operating room (T5) and after leaving the recovery room (T6) at each time point; VAS for T1, PACU, D1, D2; the number of patients requiring remedial analgesics within 24 h after blockade and related complications between the two groups.

RESULTS

A total of 97 patients were included in the final analysis, with 11 and 12 patients withdrawing from the R and Y groups, respectively. The overall incidence of POD and its incidence in the PACU and ward were all lesser in the Y group than in the R group (p < 0.05). Additionally, fewer cases required remedial analgesia during the PACU period, and more vasoactive drugs were used for maintaining circulatory system stability in the Y group as compared to the R group (p < 0.05). At the same time, the incidence of intraoperative and postoperative bradycardia in the Y group was higher than that in the R group, accompanied by lower postoperative CRP and ESR (all p < 0.05).

CONCLUSION

Ultrasound-guided high fascia iliaca compartment block with a combination of ropivacaine and DEX can reduce the incidence of POD, the use of intraoperative opioids and postoperative remedial analgesics, and postoperative inflammation in elderly patients who have undergone hip surgery, indicating that this method could be beneficial in the prevention and treatment of POD.

Butyrylcholinesterase activity in patients with postoperative delirium after cardiothoracic surgery or percutaneous valve replacement- an observational interdisciplinary cohort study

BACKGROUND AND OBJECTIVES

Postoperative delirium is a frequent and severe complication after cardiac surgery. Activity of butyrylcholinesterase (BChE) has been discussed controversially regarding a possible role in its development. This study aimed to investigate the relevance of BChE activity as a biomarker for postoperative delirium after cardiac surgery or percutaneous valve replacement.

METHODS

A total of 237 patients who received elective cardiothoracic surgery or percutaneous valve replacement at a tertiary care centre were admitted preoperatively. These patients were tested with the Montreal Cognitive Assessment investigating cognitive deficits, and assessed for postoperative delirium twice daily for three days via the 3D-CAM or the CAM-ICU, depending on their level of consciousness. BChE activity was measured at three defined time points before and after surgery.

RESULTS

Postoperative delirium occurred in 39.7% of patients (n = 94). Univariate analysis showed an association of pre- and postoperative BChE activity with its occurrence (p = 0.037, p = 0.001). There was no association of postoperative delirium and the decline in BChE activity (pre- to postoperative, p = 0.327). Multivariable analysis including either preoperative or postoperative BChE activity as well as age, MoCA, type 2 diabetes mellitus, coronary heart disease, type of surgery and intraoperative administration of red-cell concentrates was performed. Neither preoperative nor postoperative BChE activity was independently associated with the occurrence of postoperative delirium (p = 0.086, p = 0.484). Preoperative BChE activity was lower in older patients (B = -12.38 (95% CI: -21.94 to -2.83), p = 0.011), and in those with a history of stroke (B = -516.173 (95% CI: -893.927 to -138.420), p = 0.008) or alcohol abuse (B = -451.47 (95% CI: -868.38 to -34.55), p = 0.034). Lower postoperative BChE activity was independently associated with longer procedures (B = -461.90 (95% CI: -166.34 to -757.46), p = 0.002), use of cardiopulmonary bypass (B = -262.04 (95% CI: -485.68 to -38.39), p = 0.022), the number of administered red cell-concentrates (B = -40.99 (95% CI: -67.86 to -14.12), p = 0.003) and older age (B = -9.35 (95% CI: -16.04 to -2.66), p = 0.006).

CONCLUSION

BChE activity is not independently associated with the occurrence of postoperative delirium. Preoperative BChE values are related to patients' morbidity and vulnerability, while postoperative activities reflect the severity, length and complications of surgery.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study

BACKGROUND

Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited.

AIMS

To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation.

METHODS

A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken.

RESULTS

A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes.

CONCLUSIONS

Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Suffering in silence - Cardiac surgery patients recalling hypoactive delirium a qualitative descriptive study

OBJECTIVES

Postoperative delirium affects up to 50% of patients undergoing cardiac surgery. Delirium phenotypes are commonly divided into hyperactive and hypoactive, with hypoactive symptoms (reduced motor activity and withdrawal) often being overlooked due to their discreet character. Although the consequences of hypoactive delirium are severe, studies focusing on patients' experiences of hypoactive delirium are scarce. The aim of the study was to describe cardiac surgery patients' experiences of hypoactive delirium.

RESEARCH METHODOLOGY/DESIGN

We used qualitative descriptive semi-structured interviews with an inductive, latent approach. Twelve patients with hypoactive symptoms of delirium after cardiac surgery were purposefully selected. Interview data were analysed by qualitative content analysis.

FINDINGS

Two themes based on eight sub-themes emerged. "Dream or reality in parallel worlds" included disturbing experiences of existing in parallel realities with cognitive effects, residual nightmares, and illusions that occasionally persisted after hospital discharge. "Managing the state of hypoactive delirium" included experiences of intellectually dealing with hypoactive delirium with assumptions of causes and cures, and through interactions like communicating with others.

CONCLUSION

Participants experienced hypoactive delirium as extensive and long-lasting with perceptions of existing in parallel realities. The findings emphasize the need for healthcare professionals to have expertise in hypoactive delirium and its fluctuating course, as the delirium of many patients may be undetected and undiagnosed. Improving the use of screening tools for clinical practice is essential for the detection of hypoactive delirium, and a person-centred approach is needed to properly care for this group of patients.

IMPLICATIONS FOR CLINICAL PRACTICE

The challenges in the recognition of hypoactive delirium need to be emphasized because the syndrome is still overlooked. The use of screening tools in clinical practice is essential. A person-centred approach supports relationships between delirious patients and healthcare professionals.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Effect of Enhanced Recovery After Surgery on the Prognosis of Patients With Hip Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Hip fractures, predominantly occurring in the elderly, are a significant public health concern due to associated morbidity, disability, and mortality. Prolonged bed rest following the fracture often leads to complications, further threatening patient health. Enhanced recovery after surgery, a modern approach to postoperative care, is being explored for its potential to improve outcomes and quality of life in hip fracture patients.

OBJECTIVE

This study investigates the impact of enhanced recovery after surgery on hip fracture patients.

METHODS

In this systematic review, we addressed the PICO question: Does the enhanced recovery after surgery program reduce 1-year mortality, readmissions, and postoperative pain and improve Harris Hip Score compared with traditional care in elderly hip fracture patients? We searched key databases and gray literature and analyzed outcomes through a meta-analysis using RevMan, Stata, and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Nine studies involving 10,359 patients were included. Compared with the control group, the enhanced recovery after surgery group showed significant reduction in length of stay (mean difference [MD] = -2.00; 95% confidence interval [CI] [-2.87, -1.14]; p < .0001) and overall complication rate (risk ratio [RR] = 0.76; 95% CI [0.67, 0.85]; p < .0001), with a lower delirium rate (RR = 0.42; 95% CI [0.26, 0.68]; p = .004). No significant differences were observed in Harris Hip Score, pain score, 1-year mortality, readmission rate, or incidences of urinary tract infection, respiratory tract infection, and deep vein thrombosis.

CONCLUSION

Enhanced recovery after surgery is associated with reduced length of stay, complication rate, and delirium rate in hip fracture patients.

Preoperative cerebrospinal fluid biomarkers may be associated with postoperative delirium in patients undergoing knee/hip arthroplasty: the PNDABLE study

BACKGROUND

In the global aging population, the incidence of postoperative delirium (POD) is increasing. Therefore, finding its effective predictive tools becomes crucial. We aimed to identify potential Cerebrospinal fluid (CSF)biomarkers for POD.

METHODS

A total of 825 patients undergoing knee/hip arthroplasty under combined spinal-epidural anesthesia were selected. The patients were aged 40 to 90 years with American Society of Anesthesiologists physical status I~II. The Mini-Mental State Examination was completed 1 day before the operation. CSF was extracted after successful spinal-epidural combined puncture, and α-synuclein (α-syn), amyloid beta₄₀ (Aβ₄₀), amyloid beta₄₂ (Aβ₄₂), t-Tau, phosphorylated Tau (p-Tau), progranulin (PGRN) and soluble triggering receptor expressed on myeloid cells 2 (sTREM2) in the CSF were measured by enzyme-linked immunosorbent assays (ELISA). The patient's operation time, anesthesia time, intraoperative blood loss and fluid input were also recorded. After the operation, the occurrence rate and severity of POD were determined by the Confusion Assessment Method and the Memorial Delirium Assessment Scale (MDAS), respectively. Patients were categorized into POD group and non-POD group. Logistic regression analysis was performed on the indicators with statistically significant differences, and the area under the ROC curve (AUC) was used to estimate the predictive accuracy of the biomarkers for POD.

RESULTS

A total of 92 patients developed POD and the incidence of POD was 11.15%. The results of the multivariable logistic regression showed that CSF t-Tau (P = 0.004, OR = 1.006, 95%CI 1.002~1.009) and α-syn (P = 0.004, OR = 1.001, 95%CI 1.000~1.001) were positively associated with the occurrence rate of POD, while Aβ₄₂ (P < 0.001, OR = 0.989, 95%CI 0.986~0.993), CSF PGRN (P = 0.002, OR = 0.999, 95%CI 0.999~1.000), Aβ₄₂/ t-Tau (P < 0.001, OR = 0.181, 95%CI 0.102~0.319) and Aβ₄₂/p-Tau (P < 0.001, OR = 0.617, 95%CI 0.526~0.725) were inversely proportional to the occurrence of POD. ROC curve analysis indicated that Aβ₄₂/t-Tau (AUC = 0.823), CSF Aβ₄₂ (AUC = 0.813), Aβ₄₂/p-Tau (AUC = 0.810), α-syn (AUC = 0.644) and PGRN (AUC = 0.638) could predict the occurrence rate of POD. The combination of all these biomarkers showed a greater AUC(0.896) than using any of them alone.

CONCLUSIONS

CSF Aβ₄₂, PGRN, α-syn, Aβ₄₂/t-Tau and Aβ₄₂/p-Tau might be associated with the occurrence rate of POD in patients undergoing knee/hip arthroplasty.

TRIAL REGISTRATION

Clinical Registration No. ChiCTR2000033439.

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BACKGROUND

Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.

METHODS

Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.

RESULTS

A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).

CONCLUSION

Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.

Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes

Purpose

The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery.

Patients and Methods

A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria.

Results

The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)).

Conclusion

Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.

Association of C-reactive protein to albumin ratio with postoperative delirium and mortality in elderly patients undergoing hip fracture surgery: A retrospective cohort study in a single large center

BACKGROUND

Postoperative delirium is a common complication in elderly patients who have undergone hip fracture surgery. Since postoperative delirium is associated with poor outcomes and the treatment is very complicated, identifying the patients at high risk for delirium and providing more attentive care to prevent postoperative delirium is essential. In this study, we aimed to assess the association of an elevated C-reactive protein (CRP)/albumin ratio with the increased incidence of postoperative delirium in elderly people who had undergone hip fracture surgery.

METHODS

A total of 629 patients who underwent hip fracture surgery between January 2014 and December 2018 were retrospectively analyzed. Patients were classified into two groups according to preoperative CRP/albumin cut-off levels (<1.5 and ≥1.5). We performed a propensity score matching analysis to compare the incidence of postoperative delirium and overall mortality between the two groups. Multivariate logistic regression and Cox regression analyses were performed to examine the association of the preoperative CRP/albumin ratio with postoperative delirium and overall mortality.

RESULTS

There were significant differences in the incidence of postoperative delirium (18.0 % vs. 35.8 %, P < 0.001) and overall mortality (26.7 % vs. 46.9 %, P < 0.001) between the groups before matching. We also observed significant differences in the incidence of postoperative delirium (20.7 % vs. 32.7 %, P = 0.019) and overall mortality (34.7 % vs. 46.0 %, P = 0.046) between the groups after matching. A high CRP/albumin ratio (≥1.5) was significantly associated with a higher incidence of postoperative delirium (adjusted odds ratio [OR]: 2.11, 95 % confidence interval [CI]: 1.40-3.18, P < 0.001) and a higher rate of overall mortality (adjusted hazard ratio [HR]: 1.44, 95 % CI: 1.07-1.93, P = 0.015).

CONCLUSION

Preoperative CRP/albumin ratio might be an independent risk factor of postoperative delirium and surgical prognosis in elderly patients undergoing hip fracture surgery.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Data-driven development of the nationwide hip fracture registry in the Netherlands

Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators.

PURPOSE

Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA).

METHODS

An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made.

RESULTS

In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98).

CONCLUSION

This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

The hotspots and publication trends in postoperative delirium: A bibliometric analysis from 2000 to 2020

Background

Postoperative delirium (POD) is a common aging-associated postoperative complication that has received increasing attention in the context of the aging global population and the number of articles published on POD is gradually increasing. This study aimed to quantify the basic information of scholarly publications on POD and identify the most impactful literature, trends, and hotspots in POD research.

Materials and methods

We searched articles on POD through the Science Citation Index Expanded databases published from 2000 to 2020. Bibliographic information, including year, country, authorship, type, journal, funding, affiliations, subject areas, and hotspots, was collected for further analysis.

Results

A total of 2,114 articles on POD from 2000 to 2020 were identified. The highest number of studies (n = 748) were published in the United States, comprising the most total citations (13,928), followed by China (n = 278), and Germany (n = 209). Inouye, Sharon K. was the most productive author, with 66 publications on POD. The Journal of the American Geriatrics Society published the highest number of articles (n = 80), with the most total citations (4,561) and average (57.01), followed by Anesthesia and Analgesia (n = 52), and the British Journal of Anaesthesia (n = 43). Harvard University was the most productive institute, with the highest H-index (n = 46) and highest degree centrality (n = 191). The top hotspots in the field of POD during this period were “elderly,” “cardiac surgery,” “cognitive impairment,” “hip fracture,” and “intensive care unit.”

Conclusion

This study provides an overview of developments in the field of POD over the past 20 years using bibliometric analysis. Overall, research on POD has flourished worldwide. The United States (US) has a relatively high academic impact owing to its productive expertise and institutions in this field. Despite much research illustrating the diagnosis and management of POD in clinical practice, more basic research is needed.

Predictors of Postoperative Delirium in Older Patients Undergoing Elective Spine Surgery

Introduction

This prospective study was conducted to investigate the prevalence and predictors of postoperative delirium (POD) in a cohort of patients aged ≥65 years who were scheduled to undergo elective spine surgery.

Methods

Patients aged ≥65 years who were scheduled to undergo elective spine surgery from February 2018 to May 2019 were prospectively recruited for this study. Delirium was diagnosed according to the Confusion Assessment Method algorithm. Candidate predictors included patient characteristics, comorbidities, surgical time, blood loss, preoperative laboratory parameters, and preoperative cognitive function, as assessed by the Mini-Cog test. These variables were compared between patients with and without POD. Multivariate logistic regression was performed to identify the independent predictors of POD. For the continuous variables, a receiver operating characteristic curve was used to determine the optimal cutoff value for predicting POD.

Results

Of the 106 patients included in the study, 12 (11.3%) patients developed POD, with a median time to onset of 3 d and median duration of 2 d. After adjusting for confounders, the occurrence of POD was independently associated with older age, a higher blood urea nitrogen (BUN) concentration, and a lower Mini-Cog score. The optimal cutoff point of the Mini-Cog score for predicting the occurrence of POD was ≤3.

Conclusions

POD was a common complication after spine surgery, showing an incidence of 11.3% in this study. Older age, a higher BUN concentration, and impaired cognition, as defined by the Mini-Cog, were independent predictors of POD. The current results may be useful for early identification of patients at risk of POD and facilitation of targeted interventions for preventing POD or mitigating its severity.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

A machine learning approach to identifying delirium from electronic health records

The identification of delirium in electronic health records (EHRs) remains difficult due to inadequate assessment or under-documentation. The purpose of this research is to present a classification model that identifies delirium using retrospective EHR data. Delirium was confirmed with the Confusion Assessment Method for the Intensive Care Unit. Age, sex, Elixhauser comorbidity index, drug exposures, and diagnoses were used as features. The model was developed based on the Columbia University Irving Medical Center EHR data and further validated with the Medical Information Mart for Intensive Care III dataset. Seventy-six patients from Surgical/Cardiothoracic ICU were included in the model. The logistic regression model achieved the best performance in identifying delirium; mean AUC of 0.874 ± 0.033. The mean positive predictive value of the logistic regression model was 0.80. The model promises to identify delirium cases with EHR data, thereby enable a sustainable infrastructure to build a retrospective cohort of delirium.

Delirium is a commonly observed complication in hospitalized patients, especially with intensive care. While signs and symptoms of delirium could be observed and well managed during the hospital stay, less is known about the long-term complication of delirium after discharge. In order to monitor the long-term sequelae of delirium, the correct identification of delirium patients is crucial. Currently, the retrospective identification of delirium patients is limited due to the under-coding of delirium diagnosis in electronic health records. We proposed a simple machine-learning model to retrospectively identify patients who experienced delirium during their intensive care unit stay. The model could be used to identify missed delirium cases and the establishment of a delirium cohort for long-term monitoring and surveillance.

Early Intervention of Perioperative Delirium in Older Patients (>60 years) with Hip Fracture: A Randomized Controlled Study

Objective

To explore the effect of early intervention for perioperative delirium in older (> 60 years) hip fracture patients.

Methods

This prospective study enrolled hip fracture patients aged ≥60 years who were admitted into our hospital between July 2011 and August 2019. Hip fractures were classified according to the Arbeitsgemeinschaft für Osteo‐synthesefragen (AO) classification. This study included patients with isolated hip fracture and excluded patients with pathological or peri prosthetic fracture or patients with multiple traumatic injuries and high‐energy trauma. They were randomized to receive conventional orthopedic care group (n = 65) or comprehensive orthopedic care group including preoperative psychological counseling and preventative risperidone (n = 63). Daily assessment was based on patient interview with the CAM‐CR, and delirium was diagnosed by the Delirium Rating Scale (DRS‐R‐98). The rate, severity and duration of perioperative delirium and the length of postoperative stay were analyzed.

Results

Totally 200 patients were screened for eligibility. Twenty patients were excluded due to alcohol abuse and 40 were excluded because of brain lesions on head CT. In addition, 12 patients were excluded because of impaired cognition. Finally 128 patients were enrolled. Their mean age was 75.3 ± 2.2 years for the comprehensive orthopedic care group and 73.5 ± 6.1 years for the conventional orthopedic care group, and 53.9% of the patients were female. Sixty‐eight (53.1%) patients had intertrochanteric fracture, 39.8% patients had femoral head fracture, and 7.0% patients had subtrochanteric fracture. In addition, 58.6% patients underwent internal fixation and 41.4% patients received arthroplasty. In this study, 63 patients were randomized to the comprehensive orthopedic care group and 65 patients to the conventional orthopedic care group. The two groups were comparable in demographic and baseline characteristics (P > 0.05). The rate of perioperative delirium was significantly lower in the comprehensive care group vs the conventional care group (15.9% vs. 30.8%; P < 0.05). The comprehensive care group had significantly reduced length of postoperative hospital stay vs the conventional care group (11.3 ± 2.5 days vs. 14.2 ± 2.2 days, P < 0.01). The mean DRS‐R‐98 score was 7.1 ± 2.7 for the comprehensive care group, and was significantly lower than that of the conventional orthopedic care group (11.2 ± 3.0; P < 0.05).

Conclusions

Our early intervention may reduce the incidence of perioperative delirium in elderly hip fracture patients (>60 years).

Perioperative platelet count in peripheral blood is associated with the early stage of PND after major orthopedic surgery: a prospective observational study

Background

Perioperative neurocognitive disorders (PND) are common complications of major surgery among elderly patients, remarkably decreasing patients’ life quality. Platelet count has been proved to be an essential factor in inflammation. However, as far as we know, the relationship between platelet count and PND is not clear yet in the orthopedic area. PND could be a long-term disease, which sometimes lasts for several years, and it is meaningful to find a biomarker of PND at the early stage. Thus, we designed this study to find out the association between perioperative platelet count and occurrence of PND, and determine whether preoperative platelet count could be a biomarker of the early stage of PND.

Methods

A prospective observational study was performed on the patients who would take total knee arthroplasty or total hip arthroplasty. Their peripheral platelets were counted by blood routine examination 1 day before and 3 days after the surgery. And we assessed their neurocognitive functions 1 day before and 3 days after the surgery. These data were recorded and analyzed to find out the relationship between platelet count and the occurrence of PND.

Results

Eventually, 70 patients finished the whole process, and 14 of them developed PND. The median preoperative platelet count in the PND group was significantly higher than that in the non-PND group (239 vs 168 × 10^9/L, p = 0.009). Preoperative platelet count was an independent risk factor for PND (odds ratio = 1.014, 95% confidence interval [CI] 1.000–1.027, P = 0.043) in the logistic multivariable regression, while the area under the curve of the receiver operating characteristic curve of the prediction model was 0.796 (95% CI 0.676–0.916).

Conclusions

The higher preoperative and postoperative level of platelet count in the peripheral blood were associated with the early stage of PND, and preoperative platelet count could be a potential predictor of the early stage of PND in patients undergoing major orthopedic surgeries.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2000033001, registration date: 17 May 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02899-7.

Factors associated with post-operative delirium in hip fracture patients: what should we care

Background

The postoperative delirium is a common yet serious complication in elderly patients with hip fracture. We aimed to evaluate the potential risk factors of delirium in patients with hip fracture, to provide reliable evidence to the clinical management of hip fracture.

Methods

This study was a retrospective design. Elderly patients who underwent hip fracture surgery in our hospital from June 1, 2019 to December 30, 2020 were selected. The characteristics and treatment data of delirium and no delirium patients were collected and compared. Multivariate logistic regression analysis was performed to analyze the influencing factors affecting postoperative delirium in elderly patients with hip fracture.

Results

A total of 245 patients with hip fracture were included, the incidence of postoperative delirium in patients with hip fracture was 13.06%. There were significant differences in the age, BMI, history of delirium, estimated blood loss and duration of surgery (all p  < 0.05). There were significant differences in the albumin and TSH between delirium and no delirium group (all p < 0.05), Logistics analyses indicated that age ≥ 75 years (OR 3.112, 95% CI 1.527–5.742), BMI ≥ 24 kg/m² (OR 2.127, 95% CI 1.144–3.598), history of delirium (OR 1.754, 95% CI 1.173–2.347), estimated blood loss ≥ 400 mL (OR 1.698, 95% CI 1.427–1.946), duration of surgery ≥ 120 min (OR 2.138, 95% CI 1.126–3.085), preoperative albumin ≤ 40 g/L (OR 1.845, 95% CI 1.102–2.835) and TSH ≤ 2 mU/L (OR 2.226, 95% CI 1.329–4.011) were the independent risk factors of postoperative delirium in patients with hip fracture(all p < 0.05).

Conclusions

Postoperative delirium is very common in elderly patients with hip fracture, and it is associated with many risk factors, clinical preventions targeted on those risk factors are needed to reduce the postoperative delirium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00660-9.

Potential Value of Serum Lipid in the Identication of Postoperative Delirium Undergoing Knee/Hip Arthroplasty: The Perioperative Neurocognitive Disorder and Biomarker Lifestyle Study

OBJECTIVE

We aimed to investigate the relationship between preoperative lipid level and postoperative delirium (POD) and explore whether lipid's effect on POD is mediated by POD core protein.

METHODS

A total of 635 patients who were planned to undergo knee/hip arthroplasty under combined spinal-epidural anesthesia, regardless of gender, were selected. The patients were aged 40-90 years with American Society of Anesthesiologists physical status I II. The Mini-Mental State Examination (MMSE) was completed 1 day before the operation. Five milliliter elbow venous blood was taken from the patients before anesthesia, and serum levels of total cholesterol (TG), triglyceride (TC), low-density lipoprotein (LDL-C), and high-density lipoprotein (HDL-C) were detected. Cerebrospinal fluid (CSF) was extracted after successful spinal-epidural combined puncture, and amyloid beta₄₀ (Aβ₄₀), amyloid beta₄₂ (Aβ₄₂), total Tau (t-Tau), and phosphorylated Tau (p-Tau) in the CSF were measured by enzyme-linked immunosorbent assays (ELISA). After the operation, the occurrence and severity of POD were assessed using the Confusion Assessment Method and the Memorial Delirium Assessment Scale (MDAS), respectively. Patients were categorized into POD group and NPOD group. Logistic regression was used to analyze the relationship between POD and TC, TG, LDL-C, and HDL-C, and the mediating effect was used to analyze the role of POD core proteins in the relationship between lipid and MDAS. We used the receiver operating characteristic (ROC) and the precision-recall curve (PRC) analysis to assess the ability of TC, TG, LDL-C, and HDL-C ability to predict POD. Finally, we performed a sensitivity analysis to assess the stability of the results.

RESULTS

A total of 562 patients were finally enrolled in this study, and 66 patients developed POD, with an incidence of 11.7%. Logistic regression analysis showed that high concentration of TC (OR = 3.148, 95%CI 1.858∼5.333, P < 0.001), TG (OR = 2.483, 95%CI 1.573∼3.918, P < 0.001), and LDL-C (OR = 2.469, 95%CI 1.310∼4.656, P = 0.005) in serum were risk factors for POD. A high concentration of HDL-C (OR = 0.258, 95%CI 0.112∼0.594, P = 0.001) was a protective factor for POD after adjusted for age, sex, education, and MMSE score. ROC curves showed that HDL-C have the highest sensitivity and specificity in predicting POD. For these four lipid markers, the PRC range from 0.602 to 0.731, respectively. The mediating analysis showed that POD core proteins could partially mediate the relationship between lipid and POD (effect value: 16.19∼91.04%). The results were barely changed in the sensitivity analysis, and the sensitivity analysis has shown that the results were stable.

CONCLUSION

The increase of serum TG, TC, and LDL-C concentration is a risk factor for POD development, while high HDL-C concentration is a protective factor for POD, and the occurrence of POD is caused by hyperlipidemia may be caused by POD core proteins.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [Chictr200033439].

Association between frailty and postoperative delirium: a meta-analysis of cohort study

BACKGROUND

Frailty has been suggested as a possible risk factor for postoperative delirium (POD). However, results of previous studies were not consistent. We performed a meta-analysis of cohort study to evaluate the above association.

METHODS

Relevant studies were obtained via systematic search of PubMed, Embase, SCOPUS, and Web of Science databases. Only studies with multivariate analysis were included. A random-effect model incorporating the potential heterogeneity was used to combine the results.

RESULTS

Fifteen cohort studies including 3250 adult patients who underwent surgery were included, and the prevalence of frailty was 27.1% (880/3250) before surgeries. Overall, POD occurred in 513 patients (15.8%). Pooled results showed that frailty was associated with a higher risk of POD (adjusted odds ratio [OR]: 3.23, 95% confidence interval [CI]: 2.56-4.07, P < 0.001) without significant heterogeneity (P for Cochrane's Q test = 0.25, I² = 18%). Subgroup analyses showed a more remarkable association between frailty and POD in prospective cohort studies (OR: 3.64, 95% CI: 2.95-4.49, P < 0.001) than that in retrospective cohort studies (OR: 2.32, 95% CI: 1.60-3.35, P < 0.001; P for subgroup difference = 0.04). Moreover, the association was not affected by country of the study, age group of the patient, elective or emergency surgeries, cardiac and non-cardiac surgeries, evaluation instruments for frailty, diagnostic methods for POD, or quality score of the study (P for subgroup difference all > 0.05).

CONCLUSIONS

Frailty may be associated with a higher risk of POD in adult population.

Is delirium associated with negative outcomes in older patients with hip fracture: analysis of the 4904 patients 2017-2018 from the Australian and New Zealand hip fracture registry

AIM

To determine associations between delirium and health outcomes using the Australia and New Zealand population-based hip fracture patient registry (ANZHFR).

METHODS

We performed a retrospective cohort study using data from the ANZHFR among hip-fracture surgery patients admitted to and discharged from hospital between 1 January 2017 and 31 December 2018.

RESULTS

Of the 4904 patients with complete data and included in the analysis, 1789 (36.5%) experienced delirium during their hospital stay. Patients with delirium also had a higher rate of in-hospital mortality (adjusted HR = 1.76; 95% CI = 1.24, 2.49; P < 0.001), a higher rate of long-term mortality (adjusted HR = 1.30; 95% CI = 1.15, 1.48; P < 0.001) and a higher odds of discharge to an aged care facility (adjusted OR = 1.24; 95% CI = 1.04, 1.48; P = 0.019).

CONCLUSION

A high rate of postoperative delirium exists among Australian and New Zealand hip fracture patients. Rates of hospital mortality, length of hospital stay and discharge to residential aged care are considerably worse in these patients.

Multicomponent nursing program to prevent delirium in critically ill patients: a randomized clinical trial

OBJECTIVES

To determine the efficacy of a multicomponent nursing program to prevent delirium in critically ill patients.

METHODS

Parallel controlled randomized clinical trial to prevent delirium in 81 critically ill patients: 41 in the control group and 40 in the intervention group (intervention: spatial and temporal guidance, visual stimulus, auditive stimulus, and family support). Participants were recruited from September 2017 to March 2018 in the university hospital Los Comuneros, Bucaramanga, Colombia. Clinical Trials record NCT03215745.

RESULTS

The incidence of delirium was 5% in the intervention group and 24% in the control group. The relative risk was 0.20 (95% CI 0.05 to 0.88). The absolute risk reduction was 19.39% (95% CI 4.61 to 34.17) and the number needed to treat was 5 (95 CI % 3 to 26%).

CONCLUSION

The multicomponent nursing program is efficient to prevent delirium in critically ill patients.

Evaluation of the effectiveness of delirium prevention care protocol for the patients with hip fracture: A randomised controlled study

AIMS AND OBJECTIVES

This study aimed to investigate the effectiveness of a delirium prevention care protocol on pain, functional status, sleep quality and delirium prevention in patients with hip fractures.

BACKGROUND

The development of delirium following hip fracture is common among older patients. According to the National Institute for Health and Care Excellence, 30% of delirium cases are preventable. The prevention of delirium, a multifactorial syndrome, can be achieved through a multicomponent care protocol that targets specific risk factors for delirium.

DESIGN

A randomised controlled study was conducted according to the CONSORT 2010 guidelines. The Clinical Trial Registry number is NCT04188795.

METHODS

A total of 84 patients were assigned to two groups by block randomisation. The intervention group (n = 41) received nursing care according to a protocol and the control group (n = 43) received standard nursing care. Study data were collected using the demographic information form, the Confusion Assessment Method-Intensive Care Unit (CAM-ICU), the Barthel Index, the Mini Nutritional Assessment-short form and the Richards-Campbell Sleep Questionnaire (RCSQ). The pain of the patients was assessed by using a Visual Analog Scale (VAS).

RESULTS

The mean age of the patients was 80.6 years (standard deviation 8.0; range 65.0- 97.5 years), and the percentage of the male patients were 36.3%. No statistically significant differences were found between the groups in terms of pain and functional status in the preoperative period, on the first postoperative day, or in the predischarge period (p > 0.05 for each). The sleep quality of patients in the intervention group was significantly better than in the control group for all three time measurements (p < 0.05 for each). While 15% of patients in the control group developed delirium, no patient in the intervention group developed delirium (x² =6.486, p = 0.026).

CONCLUSION

This study demonstrated that a delirium prevention care protocol may reduce the incidence of delirium and improve sleep quality.

RELEVANCE TO PRACTICE

The study highlighted that nurses can contribute to preventing patients' delirium using nonpharmacologic and independent nursing interventions.

Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients

BACKGROUND

Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients.

METHODS

This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality.

RESULTS

In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect.

CONCLUSIONS

Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.

The risk factors of postoperative delirium in general anesthesia patients with hip fracture: Attention needed

Delirium is a common postoperative complication of patients with hip fracture, yet the risk factors for postoperative delirium in patients with hip fracture remain unclear. We aimed to evaluate the associated risk factors of postoperative delirium in patients with hip fracture, to provide evidence for formulating coping measures of postoperative delirium prevention and treatment in clinical practice.Patients undergoing surgery for hip fracture from March 1, 2018 to September 30, 2020 in our hospital were included. The related characteristics and related lab examination results were reviewed and collected. The univariate and logistic regression analyses were performed to identify the potential risk factors.A total of 462 patients were included, the incidence of postoperative delirium in patients with hip fracture was 16.02%. Logistic regression analyses indicated that history of delirium (OR = 4.38, 1.15-9.53), diabetes mellitus (OR = 5.31, 1.23-10.75), hypoalbuminemia (OR = 4.97, 1.37-9.86), postoperative hypoxemia (OR = 5.67, 2.24-13.42), and body mass index (BMI) (kg/m2) (OR = 3.03, 1.36-6.18) were the independent risk factors for the delirium in patients with hip fracture surgery (all P < 0.05). The cutoff value of postoperative blood sugar, albumin, and BMI for delirium prediction was 8.05 (mmol/L), 32.26 (g/L), and 19.35 (kg/m2), respectively, and the area under curve of postoperative blood sugar, albumin, and BMI was 0.792, 0.714, and 0.703, respectively.Those patients with a history of delirium, postoperative hypoxemia, blood glucose ≥8.05 mmol/L, albumin ≤32.26 g/L, and BMI ≤19.35 kg/m2 particularly need the attention of healthcare providers for the prevention of delirium.

Artificial Neural Network and Cox Regression Models for Predicting Mortality after Hip Fracture Surgery: A Population-Based Comparison

This study purposed to validate the accuracy of an artificial neural network (ANN) model for predicting the mortality after hip fracture surgery during the study period, and to compare performance indices between the ANN model and a Cox regression model. A total of 10,534 hip fracture surgery patients during 1996–2010 were recruited in the study. Three datasets were used: a training dataset (n = 7374) was used for model development, a testing dataset (n = 1580) was used for internal validation, and a validation dataset (1580) was used for external validation. Global sensitivity analysis also was performed to evaluate the relative importances of input predictors in the ANN model. Mortality after hip fracture surgery was significantly associated with referral system, age, gender, urbanization of residence area, socioeconomic status, Charlson comorbidity index (CCI) score, intracapsular fracture, hospital volume, and surgeon volume (p < 0.05). For predicting mortality after hip fracture surgery, the ANN model had higher prediction accuracy and overall performance indices compared to the Cox model. Global sensitivity analysis of the ANN model showed that the referral to lower-level medical institutions was the most important variable affecting mortality, followed by surgeon volume, hospital volume, and CCI score. Compared with the Cox regression model, the ANN model was more accurate in predicting postoperative mortality after a hip fracture. The forecasting predictors associated with postoperative mortality identified in this study can also bae used to educate candidates for hip fracture surgery with respect to the course of recovery and health outcomes.