Pathogenesis of and management strategies for postoperative delirium after hip fracture: a review

Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review

The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.

Efficiency of probiotics in elderly patients undergoing orthopedic surgery for postoperative cognitive dysfunction: a study protocol for a multicenter, randomized controlled trial

BACKGROUND

Postoperative cognitive dysfunction (POCD) refers to a neurological dysfunction after a major surgery and anesthesia. It is common in elderly patients and is characterized by impairment in consciousness, orientation, thinking, memory, and executive function after surgical anesthesia. However, at present, there is no definite preventive or treatable strategy for it. Previous animal experiments showed that giving probiotics to mice before operation can prevent POCD, but there is a lack of clinical evidence. This study aims to intervene with the intestinal flora imbalance using probiotics during the perioperative period to reduce the incidence of POCD in elderly patients after orthopedic surgery and to provide new ideas and methods for the clinical prevention and treatment of POCD.

METHODS

A multicenter, double-blind, placebo-controlled clinical trial will be performed to evaluate the efficacy of probiotics in elderly patients undergoing orthopedic surgery. Participants (n = 220) will receive probiotics (Peifeikang, Live Combined Bifidobacterium, 210 mg per capsule, twice a day, four capsules each time, which contains Bifidobacterium longum, Lactobacillus acidophilus and Streptococcus faecalis no less than 1.0 × 10⁷ CFU viable bacteria respectively) or placebo from 1 day before surgery to 6 days after surgery. Neuropsychological tests will be performed 1 day before surgery and 1 week and 1 month after surgery. The main outcome of this study is the incidence of POCD 7 days after surgery. Our secondary objective is to assess the incidence of POCD 1 month after surgery; the cognitive status will be determined based on a telephone interview and will be evaluated via TICS-m; postoperative delirium will be assessed 7 days after surgery using the Confusion Assessment Method (CAM).

DISCUSSION

Discovering the correlation between the intestinal microbiota and POCD is an important breakthrough. Based on the key role of the intestinal microbiota in other cognitive disorders, we hope that probiotics can reduce its incidence in elderly orthopedic patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04017403. Registered on August 15, 2019.

Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.

METHODS AND ANALYSIS

PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022313895.

The effect of regional nerve block on perioperative delirium in hip fracture surgery for the elderly: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

With minimal systemic toxicity, an analgesic effect of regional nerve block (RNB) has been proved in hip fracture cases. Analgesia was expected to reduce delirium by controlling pain, a known predisposing factor for delirium. We performed a meta-analysis to investigate the effect of RNB on delirium after hip fracture surgery in elderly patients. We aimed to answer the question: Can regional nerve block reduce postoperative delirium in hip fracture patients?

HYPOTHESIS

Our hypothesis was that RNB could reduce postoperative delirium after hip fracture surgery in elderly patients.

PATIENTS AND METHODS

MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 9, 2020, investigating the effect of RNB on perioperative delirium after hip fracture in elderly patients. We performed synthetic analyses for overall RNB compared to a control group both in 1) overall elderly patients, including the cognitively impaired, and 2) for patients without cognitive impairment (CoI). Also, we performed subgroup analyses for each of the block techniques, such as fascia-iliac block (FIB) and femoral nerve block (FNB).

RESULTS

Eight randomized controlled trials compared the incidence of perioperative delirium between the RNB and control groups. A pooled analysis showed no differences in delirium incidence between the RNB and control groups (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.36-1.22; p=0.18; I²=58%) in overall elderly patients. However, there was a significant reduction of delirium in the RNB group in patients without CoI (OR: 0.44; 95% CI: 0.21-0.94; p=0.03; I²=51%). In the subgroup analyses, we were unable to discern any differences in delirium incidence between the groups for FIB (OR, 0.89; 95% CI: 0.19-4.19; p=0.88; I²=78%) and FNB (OR 0.61; 95% CI: 0.31-1.20, p=0.15, I²=47%).

CONCLUSIONS

In cases of hip fracture in elderly, RNB demonstrated a preventive effect on perioperative delirium for patients without preoperative CoI. No significant reduction in perioperative delirium was observed when cognitively impaired patients were included.

5-HT3 receptor antagonists decrease the prevalence of postoperative delirium in older patients undergoing orthopedic lower limb surgery

BACKGROUND

Delirium is an important postoperative complication. Recent research suggested that 5-hydroxytryptamine 3 (5-HT₃) receptor antagonists may have clinical effect in the treatment and prevention of delirium. We investigated the association between 5-HT₃ receptor antagonists and the occurrence of postoperative delirium (POD).

METHODS

Retrospectively, the electronic medical records were reviewed in patients aged ≥ 65 years who underwent orthopedic lower limb surgery under regional anesthesia (spinal or combined spinal-epidural anesthesia) and administered intravenous 0.075 mg palonosetron or 0.3 mg ramosetron prior to the end of surgery between July 2012 and September 2015. POD incidence and anesthesia-, surgery-, and patient-related factors were evaluated. To investigate the association between 5-HT₃ receptor antagonists and the occurrence of POD, multivariable logistic regression analysis was performed.

RESULTS

Of the 855 patients included, 710 (83%) were administered 5-HT₃ receptor antagonists. POD was confirmed in 46 (5.4%) patients. 5-HT₃ receptor antagonists reduced the POD incidence by 63% (odds ratio [OR] 0.37; 95% confidence interval [CI], 0.15-0.94; P = 0.04). Moreover, the POD incidence decreased by 72% (OR 0.28, 95% CI 0.10-0.77, P = 0.01) when palonosetron was administered. Other identified risk factors for POD were emergency surgery, older age, hip surgery, lower body mass index, and intraoperative propofol sedation.

CONCLUSION

5-HT₃ receptor antagonists may be related with a significantly reduced risk for POD in older patients undergoing orthopedic lower limb surgery. Notably, palonosetron was more effective for POD prevention.

Neurocognitive decline in cardiac surgery-Distraction rather than destruction?

BACKGROUND

A neurocognitive decline is an undesirable event that can be observed in patients after cardiac surgery. It has been related to the use of cardiopulmonary bypass (CPB). Minor embolic or hyperinflammatory mechanisms are thought to be responsible. In this issue of the Journal of Cardiac Surgery, the neurocognitive decline was observed in 22 of 30 patients after cardiac surgery with CPB. Repeatable neuropsychological status tests were used and scores 4 days after surgery were 5%-15% lower than before. Mechanistic investigations with glycemic control and transcriptomic and cytokine analyses failed to provide an explanation but the frequency of this observation is worrisome.

DISCUSSION

However, available evidence suggests that neurocognitive dysfunction disappears within a few months, and later on no difference to controls that did not undergo surgery can be detected. In addition, similar degrees of neurocognitive dysfunction can be observed after noncardiac surgery and even after percutaneous coronary intervention (PCI). A most recent comparison of memory decline after CABG and PCI also suggests no difference between the two invasive treatment options for coronary artery disease. All these findings argue against a primarily CPB-associated mechanism. Interestingly, test subjects from a consumer investigation showed a 10% decline in their working memory just by placing their cell phone on the table, suggesting that being distracted may also affect neurocognitive function. Given the reversibility of surgery- and intervention-associated neurocognitive dysfunction, we question destructive, embolic, or inflammatory-associated mechanisms. Distractive aspects of intervention-associated stress may also play a role.

CONCLUSION

In any case, neurocognitive decline after cardiac surgery does not appear to be surgery-specific.

Neurocognitive disorders in the elderly: altered functional resting-state hyperconnectivities in postoperative delirium patients

Postoperative delirium (POD) represents a confusional state during days/weeks after surgery and is particularly frequent in elderly patients. Hardly any fMRI studies were conducted to understand the underlying pathophysiology of POD patients. This prospective observational cohort study aims to examine changes of specific resting-state functional connectivity networks across different time points (pre- and 3-5 months postoperatively) in delirious patients compared to no-POD patients. Two-hundred eighty-three elderly surgical patients underwent preoperative resting-state fMRI (46 POD). One-hundred seventy-eight patients completed postoperative scans (19 POD). For functional connectivity analyses, three functional connectivity networks with seeds located in the orbitofrontal cortex (OFC), nucleus accumbens (NAcc), and hippocampus were investigated. The relationship of POD and connectivity changes between both time points (course connectivity) were examined (ANOVA). Preoperatively, delirious patients displayed hyperconnectivities across the examined functional connectivity networks. In POD patients, connectivities within NAcc and OFC networks demonstrated a decrease in course connectivity [max. F = 9.03, p = 0.003; F = 4.47, p = 0.036, resp.]. The preoperative hyperconnectivity in the three networks in the patients at risk for developing POD could possibly indicate existing compensation mechanisms for subtle brain dysfunction. The observed pathophysiology of network function in POD patients at least partially involves dopaminergic pathways.

Elderly hip fracture patients: surgical timing and factors to consider

PURPOSE OF REVIEW

Hip fractures of the elderly population are a common trauma and numbers are increasing due to ageing societies. Although this is an ordinary low energy impact injury and surgical repair techniques show good results, the perioperative course is characterized by an unparalleled disproportionate perioperative morbidity and mortality.

RECENT FINDINGS

Most studies focus on outcome-related data. Little is known on how to prevent and treat adverse sequelae, ranging from mild physical challenges to neurobiological disorders and death.

SUMMARY

Although the contribution of the anaesthetic technique per se seems to be small, the role of the anaesthesiologist as a perioperative physician is undisputed. From focusing on comorbidities and initiating preoperative optimization to intraoperative and postoperative care, there is a huge area to be covered by our faculty to ensure a reasonable outcome defined as quality of postoperative life rather than merely in terms of a successful surgical repair. Protocol-driven perioperative approaches should be employed focusing on pre, intraoperative and postoperative optimization of the patient to facilitate early repair of the fracture that may then translate into better outcomes and hence alleviate the individual patient's burden as well as the socioeconomic load for society.

[Evidence-based non-pharmacological delirium prevention on general wards - A systematic literature review]

BACKGROUND

Delirium is a disturbance of attention and consciousness and a serious complication, especially in older hospitalized patients. For non-pharmacological delirium prevention, mainly so-called multicomponent programmes are described, which have to be adapted to the individual risk profile. The aim of this systematic review was to summarize the current status of the available evidence on non-pharmacological delirium prevention in general wards.

METHOD

The databases MEDLINE via Pubmed, CINAHL, EMBASE, PsycINFO and Cochrane Library were searched for the period from 1990 to November 2018; the methodological quality of the systematic reviews and meta-analyses was evaluated with AMSTAR 2. In order to reflect the broad spectrum of delirium prevention, international guidelines were included in the systematic review.

RESULTS

A total of 77 titles were read in full text, nine reviews and six guidelines were included in the analysis. Eight meta-analyses demonstrated that non-pharmacological multicomponent programmes for delirium prevention reduce the incidence of delirium compared to standard care (RR 0.65 to 0.73; OR 0.47 to 0.64, with varying methodological quality). The effect size was similar in the surgical (RR 0.63 to 0.71; OR 0.64) and non-surgical (RR 0.65 to 0.73; OR 0.47) general ward setting. The multicomponent programmes for delirium prevention each consisted of a different number of interventions. In addition to twelve person-related interventions, e. g. promotion of orientation, mobility, day-night rhythm, environmental adjustments and staff training programmes, were considered.

CONCLUSION

Non-pharmacological multicomponent programmes for the prevention of delirium in general wards effectively reduce the incidence of delirium and must be adapted to the individual risk factors of each patient.

The effect of gait training with low-intensity neuromuscular electrical stimulation of hip abductor muscles in two patients following surgery for hip fracture: Two case reports

Background: The rate of force development (RFD) is an indicator of muscle strength. A previous study reported that the RFD of hip abductor muscles was increased by neuromuscular electrical stimulation (NMES) to gluteus medius (GM) during gait in healthy adults. However, the effects for patients following femoral head replacement for hip fracture are unclear.Purpose: The aim of this case report was to investigate the effects of gait training with sub-motor threshold NMES on RFD of hip abductor muscles in two patients following femoral head replacement for hip fracture compared to gait training without NMES.Case description: Two elderly patients following femoral head replacement for hip fracture received both interventions of gait training with sub-motor threshold NMES to GM and without NMES. Intervention phases involved 14 sessions each, for 28 sessions total.Outcomes: The RFD of hip abductor muscles, maximum walking speed, six-minute walk distance (6MWD), Berg Balance Scale, one-leg standing time (OLST), functional independence measure, and Numeric Pain Rating Scale (NPRS) were used as outcome measures. In both patients, RFD, 6MWD, OLST, and NPRS were improved by gait training with NMES compared to without NMES.Conclusion: Our results suggest the potential of NMES as a treatment methodology for these two patients undergoing femoral head replacement for hip fracture.

Analgesic and psychoactive medications and the risk of falls in relation to delirium in single-bed rooms compared to multiple-bed rooms in geriatric inpatients

BACKGROUND

Previously, we demonstrated a substantial reduction of delirium incidence among geriatric patients after relocating from old hospital buildings with multiple-bed rooms to a new hospital with single-bed rooms.

AIMS

To investigate whether (1) the reduced incidence of delirium in single-bed rooms was associated with a simultaneous change in medication use, (2) the relocation had affected the incidence of falls, (3) the use of analgesics and psychoactive medications was associated with the risk of delirium and falls.

METHODS

We included 461 admissions to the old wards and 553 admissions to the new wards. Delirium was assessed by the Confusion Assessment Method. Data on drug use and falls during hospitalization were extracted from medical records.

RESULTS

There was no difference in drug use between the wards. In the new wards, patients who had experienced delirium had a much higher risk of falls than patients without delirium, while in the old wards this contrast was small. The risk of delirium was increased among patients who received antipsychotic drugs and anti-dementia drugs, Patients who received these drugs had an insignificantly increased risk of falls.

CONCLUSION

Medication of analgesics and psychoactive drugs was similar in the old and new wards. In single-bed rooms, but not in multiple-bed rooms there was a much higher risk of falls among inpatients that developed delirium than among other patients. Patients who had used antipsychotics and anti-dementia drugs during hospitalization had increased risk of developing delirium and an insignificantly higher risk of falls.

Validation of two nurse-based screening tools for delirium in elderly patients in general medical wards

Background

Delirium is an acute disturbance characterized by fluctuating symptoms related to attention, awareness and recognition. Especially for elderly patients, delirium is frequently associated with high hospital costs and resource consumption, worse functional deterioration and increased mortality rates. Early recognition of risk factors and delirium symptoms enables medical staff to prevent or treat negative effects. Most studies examining screening instruments for delirium were conducted in intensive care units and surgical wards, and rarely in general medical wards. The aim of the study is to validate the Nursing Delirium Screening Scale (Nu-DESC) and the Delirium Observation Screening Scale (DOS) in general medical wards in a German tertiary care hospital, considering predisposing delirium risk factors in patients aged 65 and older.

Methods

The prospective observational study including 698 patients was conducted between May and August 2018 in two neurological and one cardiology ward. During their shifts, trained nurses assessed all patients aged 65 or older for delirium symptoms using the Nu-DESC and the DOS. Delirium was diagnosed according to the DSM-5 criteria by neurologists. Patient characteristics and predisposing risk factors were obtained from the digital patient management system. Descriptive and bivariate statistics were computed.

Results

The study determined an overall delirium occurrence rate of 9.0%. Regarding the DOS, sensitivity was 0.94, specificity 0.86, PPV 0.40 NPV 0.99 and regarding the Nu-DESC, sensitivity was 0.98, specificity 0.87, PPV 0.43, NPV 1.00. Several predisposing risk factors increased the probability of delirium: pressure ulcer risk OR: 17.3; falls risk OR: 14.0; immobility OR: 12.7; dementia OR: 5.38.

Conclusions

Both screening instruments provided high accuracy for delirium detection in general medical wards. The Nu-DESC proved to be an efficient delirium screening tool that can be integrated into routine patient care. According to the study results, pressure ulcer risk, falls risk, and immobility were risk factors triggering delirium in most cases. Impaired mobility, as common risk factor of the before mentioned risks, is well known to be preventable through physical activity programmes.

Postoperative cognitive dysfunction in elderly patients undergoing hip arthroplasty

Even after successful hip arthroplasty, elderly patients who have undergone this procedure remain subject to cognitive decline and may collectively develop postoperative cognitive dysfunction (POCD). However, no consensus exists as to the risk factors resulting in a higher likelihood that a patient may present with this complication, and the aetiology of POCD is not well understood. We conducted a systematic review of papers concerning the influence of POCD-related risk factors in patients undergoing hip arthroplasty but limited the literature search to papers in English. A systematic and electronic search for manuscripts in the PubMed database was performed in order to identify all studies in which the risk factors for POCD were investigated. Articles were also obtained from the authors' files. Keywords for the search were postoperative cognitive dysfunction/change/impairment/decline/deficit, elderly/older/aged patients, and hip arthroplasty/replacement surgery. The evidence published to date suggests that POCD is a multifactorial disease, which includes an individual patient's characteristics, surgery, type of anaesthesia, and pain levels. All of these factors can increase the risk of POCD incidence. There are a number of factors that appear to influence the risk of early cognitive dysfunction after hip arthroplasty. Nevertheless, the specific mechanism and explicit risk factors associated with this cognitive dysfunction are not completely understood. Hip arthroplasty has made it possible for older patients to find relief from pain and improve their function, whereas it also increases the risk for suffering POCD that may affect these patients' quality of life and increase their mortality. Therefore, it is worthwhile investigating the mechanism of POCD in future studies in order to prevent and treat this condition.

Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture

BACKGROUND

Post-hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed.

METHODS

The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model.

RESULTS

Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78-10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05-2.76], 3 points); (3) age (reference, 60-69 years of age) (age 70-79: aOR, 1.60 [95% CI, 1.20-2.12], 2 points; age 80-89: aOR, 2.09 [95% CI, 1.59-2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82-3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13-1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III-V (aOR, 1.40 [95% CI, 1.14-1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17-1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07-1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09-1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14-1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76-0.78) and 0.77 (95% CI, 0.76-0.78), respectively, with similar results in the validation cohort.

CONCLUSIONS

A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy.

Postoperative Delirium Is Associated with Long-term Decline in Activities of Daily Living

BACKGROUND

Postoperative delirium is one of the most common complications in the elderly surgical population. However, its long-term outcomes remain largely to be determined. Therefore a prospective cohort study was conducted to determine the association between postoperative delirium and long-term decline in activities of daily living and postoperative mortality. The hypothesis in the present study was that postoperative delirium was associated with a greater decline in activities of daily living and higher mortality within 24 to 36 months after anesthesia and surgery.

METHODS

The participants (at least 65 yr old) having the surgeries of (1) proximal femoral nail, (2) hip replacement, or (3) open reduction and internal fixation under general anesthesia were enrolled. The Confusion Assessment Method algorithm was administered to diagnose delirium before and on the first, second, and fourth days after the surgery. Activities of daily living were evaluated by using the Chinese version of the activities of daily living scale (range, 14 to 56 points), and preoperative cognitive function was assessed by using the Chinese Mini-Mental State Examination (range, 0 to 30 points). The follow-up assessments, including activities of daily living and mortality, were conducted between 24 and 36 months after anesthesia and surgery.

RESULTS

Of 130 participants (80 ± 6 yr, 24% male), 34 (26%) developed postoperative delirium during the hospitalization. There were 32% of the participants who were lost to follow-up, resulting in 88 participants who were finally included in the data analysis. The participants with postoperative delirium had a greater decline in activities of daily living (16 ± 15 vs. 9 ± 15, P = 0.037) and higher 36-month mortality (8 of 28, 29% vs. 7 of 75, 9%; P = 0.009) as compared with the participants without postoperative delirium.

CONCLUSIONS

Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.

Post-acute Use of Opioids and Psychotropics in Patients after Hip Fracture: Unintended Consequences of Implementing Diagnosis-Related Grouping Payment

OBJECTIVE

How implementing diagnostic-related grouping (DRG) payment affected the use of opioids and psychotropics by hip fracture patients following hospitalization remained unknown.

DESIGN

A retrospective, pre-post design, cohort study of data excerpted from Taiwan's National Health Insurance Research database (NHIRD).

SETTING AND PARTICIPANTS

Adults aged ≥ 65 years first admitted for hip fracture surgery from 2007 to 2012 were identified and divided into two 1:1 propensity-score matched groups: pre-DRG (2007-2009); DRG (2010-2012).

MEASUREMENTS

The outcome measures were use of opioid and/or psychotropic drugs within 30 days, 90 days, 180 days, and 365 days after discharge.

RESULTS

Data of 16,522 subjects were excerpted, and 8,261 propensity-score matched subjects each classified into the pre-DRG and DRG groups. After adjustment, the DRG group was significantly more likely than the pre-DRG group to have used antipsychotics after discharge from hip fracture surgery (≤30 days, ≤90 days, ≤180 days and ≤365 days). The DRG group also had significantly higher prescription rates of benzodiazepines and antipsychotics during the observation period. Moreover, the DRG group was less likely to use non-steroidal anti-inflammatory drugs (≤30 days, ≤90 days, ≤180 days and ≤365 days) and more likely to use acetaminophen (≤30 days, ≤180 days, and ≤365 days).

CONCLUSIONS

In conclusion, DRG implementation in Taiwan substantially increased post-acute prescription of antipsychotic and psychotropic agents for hip fracture patients, and changed use of analgesics, which may result in suboptimal quality and safety for these patients. Further research is needed to evaluate the long-term outcomes of DRG implementation, and the potential benefits of appropriate post-acute care bundled with DRG payment.

Delay in detection and treatment of perioperative anemia in hip fracture surgery and its impact on postoperative outcomes

BACKGROUND

Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible delay in perioperative anemia detection, accumulated perioperative anemia-associated burden, peripheral perfusion, and their association with patient outcomes in elderly patients with hip fracture.

METHODS

Elderly patients with acute hip fracture scheduled for surgery were enrolled in this prospective study from August 2016 to December 2016. All patients were monitored continuously for hemoglobin concentration (SpHb) and perfusion index (PI) with the Radical-7® Pulse CO-Oximeter® and Rainbow® R1 Adhesive Multi-parameter Sensors (Masimo Corp., Irvine, CA, US) from 12 h presurgery to 24 h postsurgery.

RESULTS

Fifty-one patients were enrolled, and 41 were included in the final analyses. Mean delay in the detection of low Hb (<10 g/dL) using intermittent blood samples, when compared with SpHb, was 1.07 h (standard deviation, ±2.84 h). Median perioperative cumulated time with low SpHb (<10 g/dL for at least one min) was 25 min (interquartile range [IQR]: 21-690). There was a significant association between perioperative time with low SpHb and the occurrence of postoperative delirium (median cumulated time with low SpHb: 162 min in patients with delirium vs 22 min in patients without delirium, P = 0.034) and a nonsignificant trend for an association between perioperative time with low SpHb and 90-day mortality or medical complications (median cumulated time with low SpHb: 119 min for patients with mortality or severe complication vs 22 min for patients without mortality or severe complication, P = 0.104). PI values during the perioperative period were not significantly associated with patient outcomes. Cumulated time with low PI (<0.5) preoperatively (but not perioperatively) was significantly associated with the occurrence of postoperative delirium (P = 0.047).

CONCLUSIONS

This study showed a delay in transfusion threshold detection, and the presence of significant associations between low SpHb or time with low SpHb and postoperative outcomes.

Fascia iliaca compartment block as a preoperative analgesic in elderly patients with hip fractures - effects on cognition

BACKGROUND

Impaired cognition is a major risk factor for perioperative delirium. It is essential to provide good pain control in patients with hip fractures and especially important in patients with severely impaired cognitive status, as they receive less pain medication, have poorer mobility, poorer quality of life and higher mortality than patients with intact cognition. The purpose of this study was to examine the association between preoperative pain management with nerve blocks and cognitive status in patients with hip fractures during the perioperative period.

METHODS

One hundred and twenty-seven patients with hip fractures participating in a double-blind, randomised, controlled trial were included in this study. At hospital admission, a low-dose fascia iliaca compartment block (FICB) was administered as a supplement to regular analgesia. Cognitive status was registered on arrival at hospital before FICB and on the first postoperative day using the Short Portable Mental Status Questionnaire.

RESULTS

Changes in cognitive status from arrival at hospital to the first postoperative day showed a positive, albeit not significant, trend in favour of the intervention group. The results also showed that patients with no or a moderate cognitive impairment received 50% more prehospital pain medication than patients with a severe cognitive impairment. FICB was well tolerated in patients with hip fractures.

CONCLUSION

Fascia iliaca compartment block given to patients with hip fractures did not affect cognitive status in this study. Patients with a cognitive impairment may receive inadequate pain relief after hip fracture and this discrimination needs to be addressed in further studies.

TRIAL REGISTRATION

EudraCT number 2008-004303-59 date of registration: 2008-10-24.

Extracellular RNAs-TLR3 signaling contributes to cognitive decline in a mouse model of postoperative cognitive dysfunction

Postoperative cognitive dysfunction (POCD) is considered a severe complication after surgery among elderly patients. Toll-like receptor 3 (TLR3) has recently been reported to play an important role in hippocampus-dependent working memory. However, the role of TLR3 in the development of POCD remains unclear. In the current study, we hypothesized that increased extracellular RNAs (exRNAs) during anesthesia and surgical operation, especially double stranded RNAs (dsRNAs), would activate TLR3 signaling pathways and mediate POCD. Using a mouse model of POCD, 20-22 months wild-type (WT) mice were undergoing unilateral nephrectomy and increased TLR3 expression levels and co-localization with neuronal and microglial cells were found in the surgery group compared with the sham group. Compared with WT mice, TLR3 knockout (KO, ^-/-) mice had improved hippocampus-dependent memory and attenuated production of inflammatory cytokines and apoptosis. Increased exRNAs and/or co-localization with TLR3 were found in both in vitro and in vivo models. Of note, TLR3/dsRNA complex inhibitor administration reduced hippocampal dsRNA level and TLR3 expression, attenuated hippocampal inflammatory cytokines production and apoptosis, and thus improved hippocampus-dependent memory. Our results indicate that exRNAs, especially dsRNAs, present under stressful conditions may trigger TLR3 activation and initiate the downstream inflammatory and apoptotic signaling, and play a substantial role in the development of POCD.

Validation of orthopaedic surgeons' assessment of cognitive function in patients with acute hip fracture

BACKGROUND

About one fourth of patients with hip fracture have cognitive impairment. These patients are at higher risk of surgical and medical complications and are often excluded from participating in clinical research. The aim of the present study was to investigate orthopaedic surgeons' ability to determine the cognitive status of patients with acute hip fracture and to compare the treatment given to patients with and without cognitive impairment.

METHODS

The cognitive function of 1474 hip fracture patients reported by the orthopaedic surgeons to the nationwide Norwegian Hip Fracture Register was compared with data registered in quality databases in two hospitals with orthogeriatric service on the same patients. Cognitive function registered in the quality databases was determined either by the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or by pre-fracture diagnosis of dementia. The information registered in the quality databases was defined as the reference standard. Cognitive function in the Norwegian Hip Fracture Register was reported as: Chronic cognitive impairment? "Yes", "Uncertain" or "No" by the orthopaedic surgeons. Sensitivity, specificity, negative and positive predictive values for chronic cognitive impairment reported to the Norwegian Hip Fracture Register by the orthopaedic surgeons was calculated. Baseline data and treatment of hip fractures in patients with and without cognitive impairment in the Norwegian Hip Fracture Register were compared.

RESULTS

Orthopaedic surgeons reported chronic cognitive impairment in 31% of the patients. Using documented dementia or IQCODE > 4.0 as the reference, this assessment of cognitive impairment by the orthopaedic surgeons had a sensitivity of 69%, a specificity of 90%, a positive predictive value of 78%, and a negative predictive value of 84% compared to information registered in the two hospital quality databases. There were no differences in type of hip fracture or type of surgical treatment by cognitive function.

CONCLUSION

The treatment of hip fractures was similar in patients with chronic cognitive impairment and cognitively well-functioning patients. The surgeons had an acceptable ability to identify and report chronic cognitive impairment in the peri-operative period, indicating that the Norwegian Hip Fracture Register is a valuable resource for future registry-based research also on hip fracture patients with chronic cognitive impairment.

Association of joint replacement surgery with incident dementia diagnosis in German claims data

ABSTRACTBackground:Cognitive decline is an important complication of joint replacement surgeries in senior people.

METHODS

We determined incidence rates of dementia diagnosis following endoprosthetic joint replacement surgery (upper and lower extremities). The observation period covered up to 28 quarters using German claims data comprising 154,604 cases 65 years and older. Effects were controlled for cerebrovascular and vascular risk factors, age, sex, the presence of a diagnosis of delirium, and regular prescription of sedative or analgesic drugs (SAD).

RESULTS

The rate of incident dementia diagnoses in people without joint replacement surgery was 21.34 per 1,000 person years, compared with 80.76 incident cases when joint replacement surgery was conducted during the quarter of the incident dementia diagnosis; rates declined to 21.77 incident cases 7 and more quarters after joint replacement surgery had taken place. This pattern was maintained when controlling for delirium diagnosis and regular prescription of SAD. Among 10,563 patients with at least one joint replacement surgery, patients with a diagnosis of delirium in the quarter of the surgery were at increased risk of a dementia diagnosis compared to patients without such a diagnosis (HR=2.00, p < 0.001).

CONCLUSION

In people surviving the high-risk phase for dementia immediately after surgery, long-term risk of dementia may reach the level of those without surgery. These findings encourage consequent perioperative management to reduce the risk of dementia as well as prospective studies of potentially beneficial effects of joint replacement surgery on mid- to long-term recovery of mobility and cognition in geriatric patients.

Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery

BACKGROUND

The use of anaesthetics in the elderly surgical population (more than 60 years of age) is increasing. Postoperative delirium, an acute condition characterized by reduced awareness of the environment and a disturbance in attention, typically occurs between 24 and 72 hours after surgery and can affect up to 60% of elderly surgical patients. Postoperative cognitive dysfunction (POCD) is a new-onset of cognitive impairment which may persist for weeks or months after surgery.Traditionally, surgical anaesthesia has been maintained with inhalational agents. End-tidal concentrations require adjustment to balance the risks of accidental awareness and excessive dosing in elderly people. As an alternative, propofol-based total intravenous anaesthesia (TIVA) offers a more rapid recovery and reduces postoperative nausea and vomiting. Using TIVA with a target controlled infusion (TCI) allows plasma and effect-site concentrations to be calculated using an algorithm based on age, gender, weight and height of the patient.TIVA is a viable alternative to inhalational maintenance agents for surgical anaesthesia in elderly people. However, in terms of postoperative cognitive outcomes, the optimal technique is unknown.

OBJECTIVES

To compare maintenance of general anaesthesia for elderly people undergoing non-cardiac surgery using propofol-based TIVA or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthesia care unit (PACU), and hospital stay.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE (1946 to November 2017), Embase (1974 to November 2017), PsycINFO (1887 to November 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) with participants over 60 years of age scheduled for non-cardiac surgery under general anaesthesia. We planned to also include quasi-randomized trials. We compared maintenance of anaesthesia with propofol-based TIVA versus inhalational maintenance of anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesized findings.

MAIN RESULTS

We included 28 RCTs with 4507 randomized participants undergoing different types of surgery (predominantly cardiovascular, laparoscopic, abdominal, orthopaedic and ophthalmic procedures). We found no quasi-randomized trials. Four studies are awaiting classification because we had insufficient information to assess eligibility.All studies compared maintenance with propofol-based TIVA versus inhalational maintenance of anaesthesia. Six studies were multi-arm and included additional TIVA groups, additional inhalational maintenance or both. Inhalational maintenance agents included sevoflurane (19 studies), isoflurane (eight studies), and desflurane (three studies), and was not specified in one study (reported as an abstract). Some studies also reported use of epidural analgesia/anaesthesia, fentanyl and remifentanil.We found insufficient reporting of randomization methods in many studies and all studies were at high risk of performance bias because it was not feasible to blind anaesthetists to study groups. Thirteen studies described blinding of outcome assessors. Three studies had a high of risk of attrition bias, and we noted differences in the use of analgesics between groups in six studies, and differences in baseline characteristics in five studies. Few studies reported clinical trials registration, which prevented assessment of risk of selective reporting bias.We found no evidence of a difference in incidences of postoperative delirium according to type of anaesthetic maintenance agents (odds ratio (OR) 0.59, 95% confidence interval (CI) 0.15 to 2.26; 321 participants; five studies; very low-certainty evidence); we noted during sensitivity analysis that using different time points in one study may influence direction of this result. Thirteen studies (3215 participants) reported POCD, and of these, six studies reported data that could not be pooled; we noted no difference in scores of POCD in four of these and in one study, data were at a time point incomparable to other studies. We excluded one large study from meta-analysis because study investigators had used non-standard anaesthetic management and this study was not methodologically comparable to other studies. We combined data for seven studies and found low-certainty evidence that TIVA may reduce POCD (OR 0.52, 95% CI 0.31 to 0.87; 869 participants).We found no evidence of a difference in mortality at 30 days (OR 1.21, 95% CI 0.33 to 4.45; 271 participants; three studies; very low-certainty evidence). Twelve studies reported intraoperative hypotension. We did not perform meta-analysis for 11 studies for this outcome. We noted visual inconsistencies in these data, which may be explained by possible variation in clinical management and medication used to manage hypotension in each study (downgraded to low-certainty evidence); one study reported data in a format that could not be combined and we noted little or no difference between groups in intraoperative hypotension for this study. Eight studies reported length of stay in the PACU, and we did not perform meta-analysis for seven studies. We noted visual inconsistencies in these data, which may be explained by possible differences in definition of time points for this outcome (downgraded to very low-certainty evidence); data were unclearly reported in one study. We found no evidence of a difference in length of hospital stay according to type of anaesthetic maintenance agent (mean difference (MD) 0 days, 95% CI -1.32 to 1.32; 175 participants; four studies; very low-certainty evidence).We used the GRADE approach to downgrade the certainty of the evidence for each outcome. Reasons for downgrading included: study limitations, because some included studies insufficiently reported randomization methods, had high attrition bias, or high risk of selective reporting bias; imprecision, because we found few studies; inconsistency, because we noted heterogeneity across studies.

AUTHORS' CONCLUSIONS

We are uncertain whether maintenance with propofol-based TIVA or with inhalational agents affect incidences of postoperative delirium, mortality, or length of hospital stay because certainty of the evidence was very low. We found low-certainty evidence that maintenance with propofol-based TIVA may reduce POCD. We were unable to perform meta-analysis for intraoperative hypotension or length of stay in the PACU because of heterogeneity between studies. We identified 11 ongoing studies from clinical trials register searches; inclusion of these studies in future review updates may provide more certainty for the review outcomes.

An update on postoperative delirium: Clinical features, neuropathogenesis, and perioperative management

PURPOSE OF REVIEW

We present a focused review on postoperative delirium for anesthesiologists, encompassing clinical features, neuropathogenesis, and clinical identification and management strategies based on risk factors and current delirium treatments.

RECENT FINDINGS

The literature on postoperative delirium is dominated by non-experimental studies. We review delirium phenotypes, diagnostic criteria, and present standard nomenclature based on current literature. Disruption of cortical integration of complex information (CICI) may provide a framework to understand the neuropathogenesis of postoperative delirium, as well as risk factors and clinical modifiers in the perioperative period. We further divide risk factors into patient factors, surgical factors, and medical/pharmacological factors, and present specific considerations for each in the preoperative, intraoperative, and postoperative periods.

SUMMARY

Postoperative delirium is prevalent, poorly understood, and often missed with current screening techniques. Proper identification of risk factors is useful for perioperative interventions and can help tailor patient-specific management strategies.

Cerebral oximetry during preoperative resuscitation in elderly patients with hip fracture: a prospective observational study

This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO₂), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO₂ was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO₂ was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO₂ values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO₂ was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO₂ nadir values were also significant lower (p = 0.047). Low ScO₂ during initial resuscitation (defined as ScO₂ < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO₂ was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.

Interdependence in decision-making by medical consultants: implications for improving the efficiency of inpatient physician services

OBJECTIVES

Hospital administrators are seeking to improve efficiency in medical consultation services, yet whether consultants make decisions to provide more or less care is unknown. We examined how medical consultants account for prior consultants' care when determining whether to provide intensive consulting care or sign off in the treatment of complex surgical inpatients. We applied three distinct theoretical frameworks in the interpretation of our results.

METHODS

We performed a retrospective cohort study of consultants' care intensity, measured alternately using a dummy variable for providing two or more days consulting (versus one) and a continuous measure of total days consulting, with 100% Medicare claims data from 2007-2010. Our analytic samples included consults for beneficiaries undergoing coronary artery bypass grafting (n = 61,785) or colectomy (n = 33,460) in general acute care hospitals. We compared the care intensity of consultants who observed different patterns of consulting care before their initial consults using ordinary least squares regression models at the patient-physician dyad level, controlling for patient comorbidity and many other patient- and physician-level factors as well as hospital region and year fixed effects.

RESULTS

Consultants were less likely to provide intensive consulting care with each additional prior consultant on the case (1.2-1.7 percent) or if a prior consultant rendered intensive consulting care (20.6-21.5 percent) but more likely when prior consults were more concentrated across consultants (2.9-3.1 percent). Effects on consultants' total days consulting were similar.

CONCLUSION

On average, consultants appeared to calibrate their care intensity for individual patients to maximize their value to all patients. Interventions for improving consulting care efficiency should seek to facilitate (not constrain) consultants' decision-making processes.

Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial

OBJECTIVES

To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery.

METHODS

This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day.

RESULTS

The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001.

CONCLUSION

In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Risk factors of delirium in elderly patients with hip fracture

Background: Delirium is a leading cause of death and disability in the elderly with hip fracture. Identifying reliable risk factors for delirium is critical to support optimal outcomes for prevention and reducing delirium.

Objective: To quantify the reported factors associated to delirium for patients with hip fracture.

Methods: Electronic databases were searched (including Medline, Pub Med, CINAHL, EMBASE, Evidence Based Medicine Reviews, Cochrane Review, Web of Science, and PsycINFO) to identify all studies, published in English language that evaluated the risk factors of delirium hospitalized people with hip fracture. Two reviewers independently assessed methodology quality and extracted relevant data. The data from the included studies were summarized, and pooled estimates were calculated for 12 risk factors.

Results: Thirty-seven studies were included in the review and 25 in the meta-analysis. The incidence of delirium was 32.4% (95% confidence interval [CI] = 25.9%-39.5%). Six predisposing and four precipitating factors predicted delirium among older patients with hip fracture confirmed. The predisposing factors included advanced age (ES = 1.06, 95% CI = 1.03-1.09), male sex (ES = 1.34, 95% CI = 1.08-1.68), impairment of cognition (ES = 2.91, 95% CI = 1.91-4.42), and function (ES = 1.75, 95% CI = 1.39-2.2), comorbidity (ES = 1.59, 95% CI = 1.30-1.96), and health problems (ES = 2.64, 95% CI = 2.04-3.42). Precipitating factors were hypo- or hypernatremia (ES = 1.73, 95% CI = 1.14-2.64), depression (ES = 4.07, 95% CI = 1.95-8.49), more than three prescribed drugs (ES = 1.28, 95% CI = 1.10-1.49), and drugs including opioids (ES = 2.13, 95% CI = 1.42-3.18) and anticholinergic agents (ES = 2.10, 95% CI = 1.60-2.75).

Conclusion: This meta-analysis result provides evidence that these risk factors have a significant impact on delirium in elders with hip fracture during hospitalization. Developing formal screening, and effective preventive and management strategies for delirium is important.

Risk factors associated with outcomes of hip fracture surgery in elderly patients

Background

Hip fracture surgery on elderly patients is associated with a high incidence of morbidity and mortality. The aim of this study is to identify the risk factors related to the postoperative mortality and complications following hip fracture surgery on elderly patients.

Methods

In this retrospective study, the medical records of elderly patients (aged 65 years or older) who underwent hip fracture surgery from January 2011 to June 2014 were reviewed. A total of 464 patients were involved. Demographic data of the patients, American Society of Anesthesiologists physical status, preoperative comorbidities, type and duration of anesthesia and type of surgery were collected. Factors related to postoperative mortality and complications; as well as to intensive care unit admission were analyzed using logistic regression.

Results

The incidence of postoperative mortality, cardiovascular complications, respiratory complications and intensive care unit (ICU) admission were 1.7, 4.7, 19.6 and 7.1%, respectively. Postoperative mortality was associated with preoperative respiratory comorbidities, postoperative cardiovascular complications (P < 0.05). Postoperative cardiovascular complications were related to frequent intraoperative hypotension (P <0.05). Postoperative respiratory complications were related to age, preoperative renal failure, neurological comorbidities, and bedridden state (P < 0.05). ICU admission was associated with the time from injury to operation, preoperative neurological comorbidities and frequent intraoperative hypotension (P < 0.05).

Conclusions

Adequate treatment of respiratory comorbidities and prevention of cardiovascular complications might be the critical factors in reducing postoperative mortality in elderly patients undergoing hip fracture surgery.

Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review

OBJECTIVE

Systematically identify preoperative clinical risk factors for incident postoperative delirium in individuals undergoing hip fracture repair in order to guide clinicians in identifying high risk patients at admission.

METHODS

This is a systematic review of prospective observational studies with estimation of association between preoperative risk factors and incident postoperative delirium in multivariate models. Electronic searches were conducted in PubMed, Embase, PsycINFO, CINAHL, Cochrane Library, Proquest Dissertations and Theses, and WorldCatDissertations. Hand searches were conducted in selected journals and their supplements.

RESULTS

Search yielded 6380 titles and abstracts from electronic databases and 72 titles from hand searches, and 10 studies met inclusion criteria. The following risk factors were significant in bivariate models: cognitive impairment, age, gender, institutionalization, functional impairment, body mass index (BMI), albumin, comorbidities, American Society of Anesthesiologist classification, acute medical conditions, polypharmacy, and vision impairment. Among all of these risk factors, cognitive impairment most consistently remained statistically significant after adjusting for other risk factors in multivariate models, followed by BMI/albumin and multiple comorbidities.

CONCLUSION

In our systematic review, cognitive impairment was one of the strongest preoperative risk factors for postoperative delirium after hip fracture surgery. Preoperative cognitive assessment may be one of the most useful methods of identifying those who are at high risk for postoperative delirium and prioritizing delivery of delirium prevention measures.

Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series

Background

Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making.

Methods and Findings

We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I²=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I²=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium.

Conclusions

In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.

Sensitivity and specificity of the animal fluency test for predicting postoperative delirium

BACKGROUND

Preoperative cognitive impairment is a major risk factor for postoperative delirium. We therefore investigated the prognostic significance and feasibility of administering a brief cognitive screen before surgery.

METHODS

Patients > 65 yr of age undergoing hip, knee, or spine surgery were enrolled. A 60-sec cognitive screen, the animal fluency test (AFT), was administered preoperatively. Postoperative delirium was measured using a chart-based tool previously validated using criteria from the Confusion Assessment Method.

RESULTS

Of the 362 patients satisfying the inclusion/exclusion criteria, 199 (55%) underwent the AFT. Among them, 57 patients (29%) had an AFT score < 15, and 38 patients (19%, 95% confidence interval [CI]: 14 to 25%) developed postoperative delirium as measured by chart review. Patients with scores of < 15 were more likely to develop postoperative delirium than those who scored ≥ 15 (54% vs 5%, P < 0.01). A multiple logistic regression, with postoperative delirium as the dependent variable, identified an AFT score of < 15 (odds ratio 20.1, 95% CI: 7.9 to 51.4) and high American Society of Anesthesiologists classification (odds ratio 3.5, 95% CI: 1.3 to 9.2) as independent predictors.

CONCLUSIONS

The AFT is a potentially useful brief cognitive screen for identifying patients at risk of developing postoperative delirium. Limited participation by eligible participants in this study, however, raises questions about how useful and feasible systematic administration of the test is. Large studies using prospective measurement of postoperative delirium are indicated to validate our results.

Predictors of Postoperative Cognitive Decline in Very Old Patients With Hip Fracture: A Retrospective Analysis

BACKGROUND

To investigate incidence and predictors of the various postoperative cognitive declines in old patients with hip fracture.

METHODS

This retrospective chart study evaluated 411 patients (age ≥80 years, follow-up 5 years). After exclusion of 82 patients (preexisting dementia or delirium), 70 patients showing either diagnosed postoperative delirium (POD; group 1; N = 18, 5.5%) or an unspecified cognitive dysfunction and behavior (group 2; N = 52, 15.8%) were analyzed and compared with those without any acute postoperative cerebral impairment (control group; N = 259, 78.7%). Medical history, anesthesiological, orthopedic, and rehabilitation data were assessed using the medical database of the hospital information system. Relative ratio was calculated with Fisher exact test: P value Bonferroni corrected ≤.003.

RESULTS

Acute cognitive complications were observed in 70 (21.3%) patients. Our data in group 1 showed that patients with a medical history of stroke (relative risk [RR] = 16.2, P = .0001) or nicotine abuse (RR = 14.4, P = .001) and perioperative surgical bleeding (RR = 6.54, P = .002) are more likely to develop POD. Unspecified cognitive dysfunction and behavior (group 2) was significantly associated with a medical history of stroke (RR = 12.5, P = .0001) and postoperatively with depression (RR = 3.32, P = .001). In the follow-up, significantly more patients in group 1 (55.6%, RR = 21.8, P = .0001) and group 2 (13.5%, RR = 3.88, P = .001) developed dementia as compared to controls (1.9%). Mortality did not differ significantly between the groups (group 1: RR = 1.75, P = .5 and group 2: RR = 0.66, P = 1.0).

CONCLUSION

These data show that various predictors can identify a greater likelihood of developing postoperative cognitive decline in very old patients with hip fracture. Not identifying or labeling of POD limits the opportunity for evaluation, treatment, and planning. Thus, routine cognitive assessments need to be performed in the scope of multidisciplinary orthogeriatric comanagement.

Neuroanesthesiology update

We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.

The temporal relationship between early postoperative delirium and postoperative cognitive dysfunction in older patients: a prospective cohort study

BACKGROUND

Postoperative delirium and cognitive dysfunction are frequent phenomena in older patients; however, few studies have examined the temporal relationship between these two conditions in the early postoperative period. Therefore, this study aimed to determine if postoperative delirium and postoperative cognitive dysfunction (POCD) coexist after major noncardiac surgery.

METHODS

This was a prospective cohort study of patients who were ≥ 65 yr of age undergoing noncardiac surgery. Patients were evaluated preoperatively and for two days postoperatively for delirium and POCD. Delirium was determined using the Confusion Assessment Method, and POCD was measured by three cognitive tests addressing changes in executive function, memory, attention, and concentration. For each postoperative day, patients' neurologic status was categorized into three mutually exclusive categories: delirium, POCD, or neither condition.

RESULTS

Four hundred sixty-one patients aged ≥ 65 yr of age were studied, and 421 patients with complete postoperative cognitive testing were reported. Eighty percent of patients experienced either delirium or POCD on the first day after surgery. Seventy percent of patients who had delirium on the first postoperative day also had delirium on the second postoperative day. Sixty-three percent of patients who had POCD on postoperative day one continued to have POCD on the next day. Sixteen percent of patients with delirium on day one were non-delirious on day two but met criteria for POCD on day two. Conversely, 15% of patients with POCD on day one became delirious on day two. Only 13% of patients did not experience delirium or POCD on either day after surgery.

CONCLUSIONS

Eighty percent of surgical patients experienced some form of cognitive dysfunction the day after surgery, and few recovered by the second day after surgery.

Incidence and risk factors of delirium in patients post pancreaticoduodenectomy

BACKGROUND

Post-operative delirium is an important and common complication of major abdominal surgery characterized by acute confusion with fluctuating consciousness. The aim of this study was to establish the incidence of post-operative delirium in patients undergoing a pancreaticoduodenectomy and to determine the risk factors for its development.

METHODS

From a prospectively maintained database, a retrospective cohort analysis was performed of 50 consecutive patients who underwent a pancreaticoduodenectomy at the National Surgical Centre for Pancreatic Cancer in St. Vincent's University Hospital, Dublin and whose entire post-operative stay was in this institution, between July 2011 and December 2012. Two independent medical practitioners assessed all data and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder (DSM), fourth edition. Univariate and multivariate analyses were performed.

RESULTS

Seven patients (14%) developed post-operative delirium. The median onset was on the second post-operative day. Older age was predictive of an increased risk of delirium post-operatively. Those who developed delirium had a significantly increased length of stay (LOS) as well as a significantly increased risk of developing at least a grade 3 complication (Clavien-Dindo classification).

CONCLUSION

This study demonstrates that post-operative delirium is associated with a more complicated recovery after a pancreaticoduodenectomy and that older age is independently predictive of its development. Focused screening may allow targeted preventative strategies to be used in the peri-operative period to reduce complications and costs associated with delirium.

Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture

OBJECTIVE

The aim of this study was to determine the association between functional recovery and neuropsychiatric symptoms in hip fracture patients undergoing in-hospital rehabilitation. Very few studies have extensively evaluated neuropsychiatric symptoms in hip fracture patients, and the relationship between these symptoms and rehabilitation outcome is not yet clearly defined.

DESIGN

This study was conducted on 200 patients with hip fracture who underwent a rehabilitation program. The Neuropsychiatric Inventory was used to identify neuropsychiatric symptoms. Efficiency and effectiveness in terms of the motor-Functional Independence Measure and length of stay were considered as outcome measures.

RESULTS

At admission, 74% of the patients had neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms had a lower motor-Functional Independence Measure effectiveness (P = 0.015) and efficiency (P = 0.002) and a longer length of stay (P = 0.008) than those without neuropsychiatric symptoms. However, after adjustment for the Mini-Mental State Examination, the patients with neuropsychiatric symptoms differed from those without symptoms only in terms of longer length of stay (P = 0.006) and lower motor-Functional Independence Measure efficiency (P = 0.008).

CONCLUSIONS

Neuropsychiatric symptoms make the rehabilitation process slower and less efficient in hip fracture patients. Understanding the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients.

[Pain therapy in emergency medicine. Focus on emergency admissions]

With a prevalence of 50-80 % pain is one of the main symptoms of emergency admission patients worldwide; however, study results demonstrate that only 30-50 % of patients receive adequate analgesia. Therefore, in the USA quality indicators have been established by the Centers for Medicare & Medicaid Services (CMS) since 2010 within the framework of quality assurance of emergency admissions, e.g. the time window until the start of pain therapy. Despite the prescribed pain evaluation as part of many existing triage systems, e.g. the Manchester triage system (MTS), emergency severity index (ESI), Australasian triage scale (ATS), Canadian triage and acuity scale (CATS), in most emergency rooms there is no standardized, documented pain assessment and pain intensity is documented by using the appropriate pain scales in only 30 % of cases. Lack of knowledge and training and lack of awareness by the nursing and medical staff regarding pain perception and management represent the main causal factors. Studies on the situation of pain therapy in German emergency departments are not currently available. Due to the increasing number of central emergency departments and interdisciplinary teams of physicians and nurses, it seems sensible to introduce interdisciplinary standards of treatment to achieve the greatest possible safety in the use of analgesics in the emergency room. It is important to incorporate the experiences of the various clinical departments in the standards. This article aims to provide an overview of the situation in pain management in emergency departments and to serve as a basis for recommendations for pain therapy in German emergency departments. This article particularly discusses the possibilities of pain evaluation, treatment options with various medications and under specific conditions, e.g. for children, pregnant women or the elderly or alternative ways of pain management.

Can improved intra- and inter-team communication reduce missed delirium?

To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2 % of 47 cases compared to 41.3 and 43.6 % of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.