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

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.