Frailty and post-operative delirium influence on functional status in patients with hip fracture: the GIOG 2.0 study

Unraveling the impact of frailty on postoperative delirium in elderly surgical patients: a systematic review and meta-analysis

BACKGROUND

Frailty has been consistently implicated as a pivotal factor in the onset of delirium following anesthesia and surgery. Nonetheless, a comprehensive understanding of the relationship between frailty and delirium remains to be elucidated. This study addresses that knowledge gap.

METHODS

A comprehensive search of literature databases identified 43 relevant studies involving 14,441 participants. The studies were subjected to a rigorous quality assessment using the Newcastle-Ottawa Scale. Statistical analysis was conducted using Review Manager (v5.4.1), including subgroup and sensitivity analyses.

RESULTS

Meta-analysis revealed a significant association between preoperative physical frailty and postoperative delirium (pooled odds ratio: 2.47; 95% confidence interval: 2.04-2.99; I2 = 46.7%). The baseline frailty rate was 34.0% (4,910/14,441), while the overall incidence of postoperative delirium was 20% (2,783/14,441). Subgroup analyses based on characteristics such as race, frailty-assessment tools, and surgical types were conducted to explore potential sources of heterogeneity. This meta-analysis provided compelling evidence supporting a notable link between preoperative physical frailty and an increased risk of postoperative delirium in older surgical patients. Early identification through frailty screening can enable targeted interventions, potentially enhancing overall management and individualized treatment. Integrating frailty assessment into preoperative evaluation may improve predictive accuracy in surgical planning and anesthesia management.

CONCLUSIONS

Future research could focus on optimizing the integration of frailty assessment into preoperative protocols for timely intervention and improved patient outcomes.

TRIAL REGISTRATION

The review protocol was registered with PROSPERO (CRD42023390486), date of registration: Aug 11, 2023.

Deprescribing psychoactive drugs in older orthogeriatric patients: findings from the GIOG2.0 Italian survey

BACKGROUND

Psychoactive drugs represent a major contributor to falls in older people. This study aims to evaluate the prescribing practice of psychoactive drugs in older people hospitalized for hip fracture (HF) and to explore independent correlates of deprescribing.

METHODS

Multicenter prospective observational study including patients with HF admitted to 13 Orthogeriatric wards of the Italian Group of Orthogeriatrics (July 2019-August 2022). Patients underwent a comprehensive geriatric assessment. The use of psychoactive drugs associated with a higher risk of falls was assessed using a dedicated checklist. Deprescribing was defined as any reduction in the number of psychoactive drugs upon discharge, and independent correlates of deprescribing were explored using logistic regression analyses. Cluster analysis by Partitioning around Medoids was also performed in the hypothesis that selected clusters of characteristics could be associated with deprescribing.

RESULTS

One thousand eight hundred fifty-four older individuals (mean age 84 years, 77% females) were studied; 1190 (64%) were not prescribed any psychoactive drug, while 474 (26%), 129 (7%), and 61 (3%) took 1, 2, 3 or more psychoactive drugs, respectively. Among 664 patients on psychoactive drugs on admission, 177 (27%) had fewer prescriptions at discharge, mainly anxiolytics from 89 to 10 (50-6%), antipsychotics from 49 to 12 (28-7%) and antidepressants from 98 to 28 (55-16%). On the other count, 51 (8%) were prescribed more psychoactive drugs, mostly antidepressants from 25 to 45 (49-88%) and antipsychotics from 7 to 17 (14-17%). Functional autonomy (ADL aOR 0.87 [95%CI 0.78-0.97] p < 0.001), polipharmacy (aOR 1.15 [95%CI 1.03-1.29] p < 0.001) and the occurrence of post-operative delirium (aOR 1.71 [95%CI 1.09-2.66] p < 0.017) were independent correlates of deprescribing. More specifically, the clustering procedure could not improve the characterization of deprescribing; conversely, the deprescribing propensity significantly depended upon the center-specific prescriptive practice, not explained by other clinical-epidemiological factors.

CONCLUSION

Only a small proportion of patients hospitalized for HF undergoes deprescribing of psychoactive drugs, with considerable heterogeneity among centers, suggesting that the physician's attitude rather than patient-related factors affects deprescribing.

The effect of delirium on the association between frailty and postoperative major complications in elderly patients: a mediation analysis

PURPOSE

Both preoperative frailty and postoperative delirium (POD) are associated with higher risk of postoperative complications. But it is unclear if the effect of preoperative frailty on postoperative complications was mediated by POD.

METHODS

This study was a mediation analysis of a pooled database. Patients aged ≥ 60 years who underwent elective non-cardiac surgery were enrolled. Preoperative frailty was defined as the modified frailty index (mFI) ≥ 0.27. POD was assessed twice daily within the first 3 days using the Confusion Assessment Method (CAM) for patients without intubation and the CAM for intensive care unit (CAM-ICU) for intubated patients. Major complications within postoperative 30 days were screened. Mediation analysis was employed to explore the relationships between frailty, POD, and postoperative complications.

RESULTS

A total of 4684 patients were included. The prevalence of frailty was 10.4% (489/4684). In comparison with non-frail patients, frail patients had a higher incidence of POD (12.7% [62/489] vs 6.5% [271/4195], RR = 2.102, 95% CI 1.568-2.819, P < 0.001) and more postoperative complications (21.5% [105/489] vs 16.7% [701/4195], RR = 1.363, 95% CI 1.082-1.716, P = 0.008). The adjusted total and direct associations between frailty and postoperative complications were 5.8% (adjusted β, 95% CI, 1.8-9.5%; P < 0.001) and 5.0% (adjusted β, 95% CI, 1.1-8.7%; P = 0.004), respectively. A significant indirect association via POD was observed (adjusted β = 0.8%; 95% CI, 0.3-1.4%; P < 0.001), accounting for 13.8% of the total effect.

CONCLUSION

Preoperative frailty is associated with an increased risk of postoperative complications, mediated in part by early POD, in elderly patients following non-cardiac surgery. Given the modest effect size, further research is warranted to confirm these findings.

Independent Association Between Frailty and Fear of Falling in Older Adults After Hip Fracture Surgery: A Cross-Sectional Study Using a Secondary Analysis

Purpose: This study aimed to investigate the independent association between the fear of falling (FOF) and frailty in Korean older adults after hip fracture surgery. Methods: The study included 149 participants. Participants were asked to provide general characteristics and complete walking speed, grip strength, frailty, and Short Falls Efficacy Scale-International assessments. A binary logistic regression model was used to investigate the independent association of the FOF with frailty. Results: Among the participants, 49% were found to be prefrail and 24.8% were frail. Additionally, 86.5% reported a moderate to severe FOF. Participants with a FOF were 1.23 times more likely to be frail, and those aged 85 years and older were 13.25 times more likely to be frail. Conclusion: This study's findings serve as a basis for developing and applying interventions to reduce frailty in older adults after hip fracture surgery. These interventions should consider the oldest-old (≥ 85 years) age group when they are designed.

Delirium and frailty in older adults: Clinical overlap and biological underpinnings

Frailty and delirium are two common geriatric syndromes sharing several clinical characteristics, risk factors, and negative outcomes. Understanding their interdependency is crucial to identify shared mechanisms and implement initiatives to reduce the associated burden. This literature review summarizes scientific evidence on the complex interplay between frailty and delirium; clinical, epidemiological, and pathophysiological commonalities; and current knowledge gaps. We conducted a PubMed systematic search in June 2023, which yielded 118 eligible articles out of 991. The synthesis of the results-carried out by content experts-highlights overlapping risk factors, clinical phenotypes, and outcomes and explores the influence of one syndrome on the onset of the other. Common pathophysiological mechanisms identified include inflammation, neurodegeneration, metabolic insufficiency, and vascular burden. The review suggests that frailty is a risk factor for delirium, with some support for delirium associated with accelerated frailty. The proposed unifying framework supports the integration and measurement of both constructs in research and clinical practice, identifying the geroscience approach as a potential avenue to develop strategies for both conditions. In conclusion, we suggest that frailty and delirium might be alternative-sometimes coexisting-manifestations of accelerated biological aging. Clinically, the concepts addressed in this review can help approach older adults with either frailty or delirium from a different perspective. From a research standpoint, longitudinal studies are needed to explore the hypothesis that specific pathways within the biology of aging may underlie the clinical manifestations of frailty and delirium. Such research will pave the way for future understanding of other geriatric syndromes as well.

Predictors of non-adherence to an early in-hospital rehabilitation program after surgery for hip fracture in a co-managed orthogeriatric unit

BACKGROUND

Hip fracture is a common event in older adults, leading to an increased risk of mortality, disability, and higher healthcare costs. Early in-hospital rehabilitation after surgery within orthogeriatric units may improve outcomes with limited incident complications even in the oldest old. We aimed to determine the prevalence and predictors of non-adherence to early rehabilitation in the orthogeriatric unit of an Italian tertiary hospital and its impact on outcomes and setting at discharge.

METHODS

Retrospective observational single-centered cohort study. Patients aged ≥ 65 years admitted to the orthogeriatric unit for hip fracture who underwent surgery between April 2019 and October 2020 were considered eligible if able to walk autonomously or with assistance and independent in at least 2 Basic Activities of Daily Living. Along with sociodemographic and geriatric variables, characteristics of surgery and rehabilitation, in-hospital complications and functional outcomes at discharge were collected. The primary outcome was non-adherence to the early in-hospital rehabilitation program.

RESULTS

Among 283 older patients (mean age 82.7 years, 28.6% male), non-compliance with physical therapy was assessed in 49 cases (17.3%), characterized by worse pre-fracture clinical, cognitive, and functional status and showing worse outcomes in terms of mobilization at discharge. After multivariable analysis, non-adherence was independently associated with the onset of delirium (OR 5.26, 95%CI 2.46-11.26; p < 0.001) or infections after surgery (OR 3.26, 95%CI 1.54-6.89; p < 0.001) and a systolic blood pressure at admission < 120 mmHg (OR 4.52, 95%CI 1.96-10.43, p < 0.001).

CONCLUSIONS

Pre-fracture poor cognitive and functional status, along with lower systolic blood pressure, seem to make some patients more vulnerable to in-hospital complications (mainly delirium and infections) and negatively affect the adherence to physical therapy and, by consequence, clinical outcomes of rehabilitation.

Factors associated with delirium in a real-world acute-care setting: analysis considering the interdependence of clinical variables with the frailty syndrome

PURPOSE

Delirium risk assessment in the acute-care setting generally does not account for frailty. The objective of this retrospective study was to identify factors associated with delirium, considering the interdependency of clinical variables with frailty syndrome in complex older patients.

METHODS

The clinical records of 587 participants (248 M, median age 84) were reviewed, collecting clinical, anamnestic and pharmacological data. Frailty syndrome was assessed with the Clinical Frailty Scale (CFS). Delirium was the main study endpoint. The correlations of the considered anamnestic and clinical variables with delirium and its subtypes were investigated selecting only those variables not showing a high overlap with frailty. Correlations associated with a 25% excess of frequency of delirium in comparison with the average of the population were considered as statistically significant.

RESULTS

Delirium was detected in 117 (20%) participants. The presence of one among age > 85 years old, CFS > 4 and invasive devices explained 95% of delirium cases. The main factors maximizing delirium incidence at the individual level were dementia, other psychiatric illness, chronic antipsychotic treatment, and invasive devices. The coexistence of three of these parameters was associated with a peak frequency of delirium, ranging from 57 to 61%, mostly hypoactive forms.

CONCLUSIONS

In acute-care wards, frailty exhibited a strong association with delirium during hospitalization, while at the individual level, dementia and the use of antipsychotics remained important risk factors. Modern clinical prediction tools for delirium should account for frailty syndrome.