Reorganization of Nursing and Medical Care to Reduce the Incidence of Postoperative Delirium and Improve Rehabilitation Outcome in Elderly Patients Treated for Femoral Neck Fractures

A bibliometric analysis of orthogeriatric care: top 50 articles

Background

Population is ageing and orthogeriatric care is an emerging research topic.

Purpose

This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature.

Methods

From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review.

Results

The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%).

Conclusion

This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.

The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation

Post-operative delirium after lung transplantation is common. Its associations with health-related quality of life (HRQL), depression, and mortality remains unknown. In 236 lung transplant recipients, HRQL and depressive symptoms were assessed as part of a structured survey battery before and after transplantation. Surveys included the Geriatric Depressive Scale (GDS) and Short Form 12 (SF12). Delirium was assessed throughout the post-operative intensive care unit (ICU) stay with Confusion Assessment Method for ICU. Delirium and mortality data were extracted from electronic medical records. We examined associations between delirium and changes in depressive symptoms and HRQL using linear mixed effects models and association between delirium and mortality with Cox-proportional hazard models. Post-operative delirium occurred in 34 participants (14%). Delirium was associated with attenuated improvements in SF12-PCS (difference ₋4.0; 95%CI: -7.4, -0.7) but not SF12-MCS (difference 2.2; 95%CI: -0.7,5.7) or GDS (difference ₋0.4; 95%CI: -1.5,0.7). Thirty-two participants died during the study period. Delirium was associated with increased adjusted hazard risk of mortality (HR 17.9, 95%CI: 4.4,72.5). Delirium after lung transplantation identifies a group at increased risk for poorer HRQL and death within the first post-operative year. Further studies should investigate potential causal links between delirium, and poorer HRQL and mortality risk after lung transplantation.

Textbook process as a composite quality indicator for in-hospital hip fracture care

Individual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay.

PURPOSE

The aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay.

METHODS

Hip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer.

RESULTS

Of the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52-0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78-1.30).

CONCLUSION

The textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.

A Multidisciplinary Approach to Expedite Surgical Hip Fracture Care

Introduction:

In 2014, we implemented a geriatric hip fracture patient care pathway at our institution which was designed to improve outcomes and decrease time to surgery.

Materials and Methods:

We analyzed retrospective data from 463 patients, aged greater than 50, who had surgical treatment for a closed hip fracture due to a low-energy injury between 2013 and 2016 at an academic institution. Objective outcome measures included time to surgery, mortality rate, and total hospital length of stay. Our primary goal was to decrease the time to surgery for definitive fracture fixation to within 24 hours of admission to the hospital for patients who were medically fit for surgery.

Results:

We implemented a multidisciplinary, collaborative approach to address the needs of this specific patient population. Prior to implementing the pathway in 2013, our baseline time to surgery within 24 hours was 74.67%. After implementation, we had incremental yearly increases in the percentage of patients operated on within 24 hours, 82.31% in 2014 (P = .10) and 84.14% in 2015 (P = .04). During the study period, our overall time to surgery was reduced by 27% with an initial average of 20.22 hours in 2013, decreasing to 15.33 hours in 2014, and 14.63 hours in 2015. Our mortality rate at 1 year was 16% in 2013, 17% in 2014, and 15% in 2015.

Conclusion:

With implementation of the pathway, we were able to expedite surgical care for our patients and demonstrate a 10% improvement in the percentage of patients able to have surgery within 24 hours over a 3-year period. Our mortality and hospital length of stay, however, remained the same. Through this collaborative process and system standardization, we believe we have significantly improved not only direct patient care but their overall hospital experience. We continue to make improvements in our pathway.

Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

BACKGROUND

Older people represent a risk group for acquiring or further development of delirium during hospitalization, therefore requiring suitable nonpharmacological delirium interventions.

OBJECTIVE

This scoping review analyzed nonpharmacological intervention programs for older inpatients with or without cognitive decline on regular or acute geriatric wards to present the range of interventions.

METHODS

A systematic literature search was conducted using scientific databases. A total of 4652 records were screened by two independent reviewers, leaving 81 eligible articles for full-text screening and 25 studies were finally included. Inclusion criteria were older patients ≥65 years in regular or acute geriatric wards and nonpharmacological multicomponent interventions.

RESULTS

More than a half of the included studies (14, 56%) recruited patients with pre-existing cognitive decline as part of the study population and 12% focused exclusively on patients with cognitive decline. On average 11 intervention components were integrated in the programs and two programs included full coverage of all 18 identified components.

CONCLUSION

Only few programs were described for older inpatients and even fewer regarding pre-existing cognitive decline. The low numbers of interventions and data heterogeneity restricted the assessment of outcomes; however, delirium incidence, as reported by two thirds of the studies was reduced by nonpharmacological multicomponent interventions.

Effectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review

ABSTRACTBackground:Delirium is the most frequent complication among the hospitalized elderly with hip fracture. Although, delirium is associated with longer hospital stay, higher mortality rates, worse functional outcomes, and higher institutionalization rates yet health service planners have hugely ignored its existence. This review aims to identify the effectiveness of multicomponent interventions to prevent delirium in hospitalized elderly patients with hip fracture.

METHODS

This review includes experimental, non-experimental, and observational studies. Electronic searches were conducted in MEDLINE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Embase, and Web of science.

RESULTS

After inclusion and exclusion criteria were applied, nine full text articles were included in the review. The studies reported the following effect on delirium: We pooled data regarding incidence of delirium from the three RCTs. The effect was in favor of the intervention group (odds ratio 0.64, 95% CI 0.46-0.87). All three RCTs reported that duration of delirium was shorter in the intervention group than in the usual care group (mean 2.9 vs. 3.1 days, median 3 vs. 4 days, median 5.0 vs. 10.2 days). Four other studies reported on the duration of delirium with Milisen and colleagues reported shorter duration of delirium within the intervention group. Four studies reported on severity of delirium with two research groups reporting significant results.

CONCLUSION

Early engagement of multidisciplinary staff who addresses the risk factors of delirium as soon as the patient presents to the acute care environment is the key element of a successful delirium prevention program. Once delirium had developed, the multicomponent interventions did not appear to make a difference to the duration or severity of delirium.

Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial

OBJECTIVES

To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted postoperative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders.

DESIGN

Pragmatic clinical trial to evaluate a quality improvement intervention.

SETTING

Tertiary care hospital.

PARTICIPANTS

Individuals aged 65 and older admitted for hip fracture repair (N = 283).

INTERVENTION

PPOs with delirium-friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements.

MEASUREMENTS

Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini-Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in-hospital mortality were recorded.

RESULTS

Orthopedic nurses adhered reasonably well with delirium-friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between-group difference in these outcomes.

CONCLUSION

It is possible to introduce delirium-friendly PPOs into routine post-hip fracture care in a representative elderly population including individuals with dementia. Delirium-friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.

Orthogeriatrics in the management of frail older patients with a fragility fracture

This review article examines the role of orthogeriatric management for frail older patients with a fragility fracture. The history of orthogeriatrics and its application in clinical practice around the world is reported, and an evidence-based evaluation for the effect of orthogeriatric management on patient morbidity and mortality is also provided. It has been more than 50 years since the role of the geriatrician in the management of patients with a hip fracture was first described. The evidence that supports an orthogeriatric model of care has grown exponentially over the last decade. This evidence base is primarily related to hip fractures and demonstrates reduced morbidity and mortality rates amongst patients managed with a recognised model of orthogeriatric care. The societal and economic burden of hip fracture has led to health economic evaluations within this field, many of which have concluded that orthogeriatric management results in cost-effective clinical practice. Based on existing clinical and economic research, national clinical practice guidelines have been developed in several countries which recommend orthogeriatric participation in the management of older patients with a hip fracture. Compliance with such guidance has already demonstrated improved patient outcomes. Although the pathogenesis and prognosis of other types of fragility fracture may be as poor, there is a dearth of clinical research that evaluates the effect of orthogeriatric management on such injuries. Looking to the future, orthogeriatric management is likely to become more widespread, and the robust collection and reporting of patient outcomes from national registries will provide a greater understanding of the impact of orthogeriatric models in the care of all frail older patients with any type of fragility fracture.

What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? A systematic review

The aim of this study was to conduct a systematic literature review of research-based studies to identify practices designed to meet the specific care needs of older cognitively impaired patients in emergency departments (ED). A systematic literature review of studies was completed using PRIMSA methodology. The search criteria included articles from both emergency and acute care settings. A total of 944 articles were screened, and a total of 43 articles were identified as eligible. The review found a number of intervention studies to improve quality of care for older persons with cognitive impairment carried out or commenced in emergency settings, including interventions to improve cognitive impairment recognition (n = 9) and clinical approaches to reduce falls (n = 1) and both delirium incidence and prevalence (n = 2). Relevant studies carried out in acute care settings regarding cognitive impairment recognition (n = 4) and primary and secondary prevention of delirium (n = 18) and intervention studies that reduced the prescription of deliriogenic drugs (n = 1), reduced behavioral symptoms and discomfort (n = 7), and improved nutritional intake (n = 1) in hospitalized older persons with dementia were also identified. There is limited research available that reports interventions that improve the quality of care of older ED patients with cognitive impairment. Although this review found evidence obtained from the acute care setting, additional research is needed to identify whether these interventions are beneficial in fast-paced emergency settings.

The effect of a pre- and post-operative orthogeriatric service on cognitive function in patients with hip fracture. The protocol of the Oslo Orthogeriatrics Trial

BACKGROUND

Hip fractures mainly affect older people. It is associated with high morbidity and mortality, and in particular a high frequency of delirium. Incident delirium following hip fracture is associated with an increased risk of dementia in the following months, but it is still not firmly established whether this is an association or a causal relationship. Orthogeriatric units vary with respect to content and timing of the intervention. One main effect of orthogeriatric care may be the prevention of delirium, especially if preoperative and postoperative care are provided. Thus, the aim of Oslo Orthogeriatric Trial, is to assess whether combined preoperative and postoperative orthogeriatric care can reduce the incidence of delirium and improve cognition following hip fracture.

METHODS/DESIGN

Inclusion and randomisation will take place in the Emergency Department, as soon as possible after admission. All patients with proximal femur fractures are eligible, irrespective of age, pre-fracture function and accommodation, except if the fracture is caused by a high energy trauma or the patient is terminally ill. The intervention is pre-and post-operative orthogeriatric care delivered on a dedicated acute geriatric ward. The primary outcome measure is a composite endpoint combining the Clinical Dementia Rating Scale (CDR) and the 10 word memory task at four months after surgery. Secondary outcomes comprise incident delirium, length of stay, cognition, mobility, place of residence, activities of daily living and mortality, measured at 4 and 12 months after surgery. We have included 332 patients in the period 17th September 2009 to 5th January 2012.

DISCUSSION

Our choice of outcome measures and our emphasis of orthogeriatric care in the preoperative as well as the postoperative phase will enable us to provide new knowledge on the impact of orthogeriatric care on cognition.

TRIALS REGISTRATION

ClinicalTrials.gov NCT01009268.

Older hip fracture patients: three groups with different needs

Background

Norway, and particularly Oslo, has the highest reported incidence of hip fractures in the world. It is increasingly common to care for older hip fracture patients in orthogeriatric units where orthopaedic care is combined with interdisciplinary geriatric care. The characteristics and needs of older hip fracture patients are poorly described. The aim of this paper is to describe the characteristics of these patients in order to better understand their need for care and rehabilitation.

Methods

This is an observational study based on a quality register for all patients 65+ years in an orthogeriatric unit who are operated for a hip fracture. The unit covers 250,000 inhabitants in Oslo. Patient data were collected in the aim of quality control. The quality database includes demographic, medical, and functional data collected from routine assessment by the interdisciplinary team.

Results

From January 2007 to September 2009, 1010 patients, included 241 (24%) from long-term care institutions, were enrolled in the database. Mean age was 85.1 years (SD 7.1), 76% were female, and 83% had experienced an indoor fall. Chronic diseases were registered in 88%, and 38% of the community-dwelling patients had pre-fracture cognitive impairment defined as IQCODE-SF > 3.6. Complications were observed in 51% of the patients, of which the most common were a need for blood transfusion, delirium, and urinary tract infections. Post-operative orthopaedic infections were rare (3.1%). Patients from long-term care were older, (87 vs. 84 years, p < 0.001), more had American Society of Anaesthesiologists (ASA) score >/= 3 (67% vs. 48%, p < 0.001) and a higher number of chronic medical conditions (mean 2.2 vs. 1.6, p < 0.001). Among community-dwelling patients, those who had fallen indoors were older, more often female, had ASA score >/= 3, chronic medical conditions, impairment in pre-fracture ADL and cognitive function, and more complications during hospital stay.

Conclusions

Older hip fracture patients in this orthogeriatric unit may be divided into three groups; patients who are relatively fit and have experienced outdoors falls (17%), frail community-dwelling patients who have fallen indoors (59%), and patients from long-term care institutions (24%). Different caring pathways are needed for these groups.

Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture

OBJECTIVES

To evaluate risk factors for preoperative and postoperative delirium.

DESIGN

Prospective cohort study.

SETTING

Departments of orthopedic surgery in two Norwegian hospitals.

PARTICIPANTS

Three hundred sixty-four patients with and without cognitive impairment, aged 65 and older.

MEASUREMENTS

Patients were screened daily for delirium using the Confusion Assessment Method. Established risk factors and risk factors regarded as clinically important according to expert opinion were explored in univariate analyses. Variables associated with the outcomes (P<.05) were entered into multivariate logistic regression models.

RESULTS

Delirium was present in 50 of 237 (21.1%) assessable patients preoperatively, whereas 68 of 187 (36.4%) patients developed delirium postoperatively (incident delirium). Multivariate logistic regression identified four risk factors for preoperative delirium: cognitive impairment (adjusted odds ratio (AOR)=4.7, 95% confidence interval (CI)=1.9-11.3), indoor injury (AOR=3.6, 95% CI=1.1-12.2), fever (AOR=3.4, 95% CI=1.5-7.7), and preoperative waiting time (AOR=1.05, 95% CI=1.0-1.1 per hour). Cognitive impairment (AOR=2.9, 95% CI=1.4-6.2), indoor injury (AOR=2.9, 95% CI=1.1-6.3), and body mass index (BMI) less than 20.0 (AOR=2.9, 95% CI=1.3-6.7) were independent and statistically significant risk factors for postoperative delirium.

CONCLUSION

Time from admission to operation is a risk factor for preoperative delirium, whereas low BMI is an important risk factor for postoperative delirium in hip fracture patients. Cognitive impairment and indoor injury are independent risk factors for preoperative and postoperative delirium.

Evaluation and management of the elderly patient at risk for postoperative delirium

Geriatric patients are at a high risk for the development of postoperative delirium. By recognizing predisposing and precipitating risk factors, preventive measures can be undertaken to reduce this risk. Accurate and timely diagnosis is essential, and we offer therapeutic strategies to help reduce the high morbidity and mortality of this important condition.

Orthogeriatric care for the elderly with hip fractures: where are we?

Hip fracture (HF) is a major health care problem in the Western world, associated with significant morbidity, mortality and loss of function. Its incidence is expected to increase as the population ages. The authors discuss the role of a coordinated multidisciplinary team in the management of patients during hospital stay, at discharge and during rehabilitation. Orthogeriatric care should not just be viewed as a multidisciplinary activity, but as a radical alternative to the traditional model of care, an alternative based on all those strategies in which evidence shows an improvement in outcomes in the fractured elderly. Therefore, key points of the care are early surgery, immediate mobilization, prevention and management of delirium, pain and malnutrition, as well as an integrated and multidisciplinary approach. Comprehensive geriatric assessment is useful in identifying frail elderly and in providing information that is essential in formulating clinical recommendations and making care plans. In each hospital, the orthogeriatric unit should represent a center of excellence for treating elderly patients with major fractures. However, when an orthogeriatric project is implemented, it is essential that detailed data about the case-mix of patients, process of care and outcomes are collected, to compare the results with historical data and to be able to participate in audit processes.

Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study

BACKGROUND AND AIMS

Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures.

METHODS

One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria.

RESULTS

The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028).

CONCLUSIONS

Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.

Delirium in older patients admitted to general internal medicine

Delirium on the day of admission to general internal medicine wards was studied in 400 consecutive patients aged 70 years and above regarding occurrence, associated factors, clinical profile, length of hospital stay, and mortality. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination, and delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day of admission occurred in 31.3% of the patients and was independently associated with old age, fever on the day of admission (> or = 38 degrees C), treatment with neuroleptics, impaired vision, male sex, and previous stroke. Delirious patients had longer hospital stay (15.4 vs 9.5 days, P < .001), a higher mortality rate during hospitalization (11/125 vs 5/275, P < .001), and a higher 1-year mortality rate (45/125 vs 55/275, P = .001). Delirium is a common complication with often easily identified causes, and it has a serious impact on outcome for older medical patients.

The Organic Brain Syndrome (OBS) scale: a systematic review

BACKGROUND/OBJECTIVE

The Organic Brain Syndrome (OBS) Scale was developed to determine elderly patients' disturbances of awareness and orientation as to time, place and own identity, and assessment of various emotional and behavioural symptoms appearing in delirium, dementia and other organic mental diseases. The aim of the study was to examine the OBS Scale, using the eight criteria and guidelines formulated by the Scientific Advisory Committee of the Medical Outcomes Trust (SAC), and to investigate its relevance and suitability for use in various clinical settings.

METHOD

Systematic search and analysis of papers (30) on the OBS Scale were carried out using the criteria suggested by the SAC.

RESULTS

The OBS Scale in many aspects satisfies the requirements suggested by the SAC: conceptual and measurement model, reliability, validity, responsiveness, interpretability, respondent and administrative burden, alternative forms of administration, and cultural and language adaptations, but there is a need for additional evaluation, especially with regard to different forms of reliability, and the translation and adaptation to other languages.

CONCLUSIONS

The OBS Scale is a sensitive scale which is clinically useful for the description and long-term follow-up of patients showing symptoms of acute confusional state and dementia. Although the OBS Scale has been used in several clinical studies there is need for further evaluation.

Delirium in elderly people: an update

PURPOSE OF REVIEW

To review recent studies on epidemiology, diagnosis, pathophysiology, treatment and prevention of delirium in elderly people.

RECENT FINDINGS

There is no evidence that the clinical picture of delirium in elderly people differs from that in younger patients, although it may run a more chronic course. Diagnosing delirium in demented patients, however, may be difficult due to overlap in symptoms of delirium and dementia. Systematic use of screening and diagnostic instruments may help to diminish the common underdiagnosis of delirium. Delirium is best understood as the result of multiple interacting predisposing and precipitating factors. In the elderly, predisposing factors that make patients more susceptible for delirium include cognitive dysfunction and older age, while important precipitating factors that directly cause delirium are any somatic events and the use of anticholinergic drugs. Delirium has a significant negative prognostic impact on functional and cognitive outcome, as well as on morbidity and mortality. Haloperidol remains the standard treatment for delirium, while there is some evidence for the efficacy of risperidone. Other atypical antipsychotics, as well as cholinesterase inhibitors, have not yet been sufficiently studied. Results of studies on the effectiveness of systematic screening of populations at risk and standardized interventions to prevent delirium have been inconclusive.

SUMMARY

In recent years, the emphasis in the approach to delirium has shifted from ad hoc treatment to systematic screening and prevention. Interest has been raised in treatment options other than haloperidol, such as atypical antipsychotics and procholinergic drugs.

A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients

OBJECTIVES

To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients.

DESIGN

Prospective intervention study.

SETTING

Department of General Internal Medicine, Sundsvall Hospital, Sweden.

PARTICIPANTS

Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward.

INTERVENTION

The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care.

MEASUREMENTS

The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

RESULTS

Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03).

CONCLUSION

This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.

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

BACKGROUND

Postoperative delirium is a frequent and serious complication in elderly patients following operation for hip fracture, leading to an increased risk of complications. The pathophysiological mechanisms are unresolved, but probably multifactorial. The purpose of this review is to summarize current knowledge about the pathogenesis of postoperative delirium with a view to finding strategies for prevention and management.

METHOD

We conducted an Internet search through the Medline database (1966-March 2003) and supplemented it with a manual search. We included 12 studies which specifically discussed pathogenic factors or interventions against postoperative delirium following operation for hip fracture.

RESULTS

1,823 patients were included with an average incidence of delirium of 35%. We concentrated on pre-, intra-, and postoperative risk factors. Only advanced age and dementia met our fixed criterion of "strong evidence" for a significant association. Hence, from the studies that we reviewed we were unable to find intraoperative or postoperative factors with "strong evidence" for a significant association with delirium.

INTERPRETATION

Postoperative delirium is a serious complication. The pathophysiology leading to delirium after hip fracture surgery still remains to be clarified and no single drug or surgical regimen has proven to be preventive. This calls for more detailed investigations of the differential role of different pathogenic mechanisms, as well as an aggressive multimodal approach to enhance recovery and reduce morbidity, as has proven to be successful in a variety of elective surgical procedures. Such multimodal interventional studies represent a major task for orthopedic departments in collaboration with anesthesiologists, geriatricians, physiotherapists and nursing staff.

Cognitive Function and Health-Related Quality of Life After Delirium in Connection With Hip Surgery

NEED

Delirium is a serious psychiatric disorder, and elderly patients who undergo hip surgery are at higher risk for delirium development.

PURPOSE

The purpose was to compare change in cognitive function and health-related quality of life 6 months after hip surgery in patients who experienced postoperative delirium with those who did not.

SAMPLE

A total of 115 patients 75 years or older were included.

MEASURES

Screening for delirium was done using the Diagnostic and Statistical Manual, 4th ed criteria. Cognitive function was measured with the Mini Mental State Examination and health-related quality of life with the SF-36.

RESULTS

Of the 115 patients, 32 became delirious during hospital stay (D group), whereas the remaining patients did not (NonD group). Both D and NonD groups scored lower on the Mini Mental State Examination at follow-up than during hospital stay, but the deterioration was significantly greater in the D group. At follow-up, health-related quality of life was improved in patients who were destined for hip replacement surgery but unchanged or impaired for those with hip fracture. Delirium onset in connection with hip fracture lowered the health-related quality of life even more. At follow-up, low cognitive function correlated with lower scoring in physical function. Greater knowledge about delirious patients' vulnerable positions related to lower cognition and life quality can improve rehabilitation and support for these patients.

Dementia after delirium in patients with femoral neck fractures

OBJECTIVES

To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate.

DESIGN

A 5-year prospective follow-up study.

SETTING

Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden.

PARTICIPANTS

Seventy-eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years.

MEASUREMENTS

The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre- and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini-Mental State Examination in their homes 5 years after the fracture.

RESULTS

Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5-year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P <.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P =.001).

CONCLUSION

Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.

Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips

100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

Nutritional status and functional capacity after femoral neck fractures: a prospective randomized one-year follow-up study

The primary aim of this study was to evaluate the effect of two different surgical methods on nutritional status and functional capacity during the first postoperative year in patients with displaced femoral neck fractures. A further aim was to evaluate the effect of nutritional support. One hundred patients were randomly assigned to treatment with either primary total hip arthroplasty (THA) or osteosynthesis. Half of the patients in each treatment group received protein- and energy-enriched food in the hospital in addition to individual nutritional advice in order to optimize their intake of protein- and energy-rich food. Nutritional state and functional capacity were examined at baseline, one and three months, and one year after the operation. Pain was examined at three months and one year. The effect of nutritional intervention was equal within both surgical groups. Logistic regression showed that the dependent variable "living at one year" was significantly associated with serum albumin levels at one month. Advanced age, mental impairment and deteriorated nutritional status were predominant in the non-survivors. Overall, the primary THA group performed better compared with the osteosynthesis group concerning weight change over time, locomotion and pain. This study also showed that primary THA could safely be performed in the elderly without an increased postoperative mortality rate.