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Itami T, Yamamoto K, Kurokawa Y, Saito T, Takahashi T, Momose K, Yamashita K, Tanaka K, Makino T, Yasunobe Y, Akasaka H, Fujimoto T, Yamamoto K, Nakajima K, Eguchi H, Doki Y. Assessing the Risk of Postoperative Delirium Through Comprehensive Geriatric Assessment and Eastern Cooperative Oncology Group Performance Status of Elderly Patients With Gastric Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-16034-w. [PMID: 39373928 DOI: 10.1245/s10434-024-16034-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 07/29/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Postoperative delirium is especially common and often problematic among elderly patients undergoing surgery. This study aimed to explore factors that can predict postoperative delirium in elderly patients undergoing gastric cancer surgery. METHODS This cohort study included 255 patients age 75 years or older who underwent gastric cancer surgery between July 2010 and December 2020. All the patients underwent preoperative comprehensive geriatric assessment (CGA) evaluation by a geriatrician. In addition to the CGA items, this study investigated the association between postoperative delirium and clinicopathologic factors, including Eastern Cooperative Oncology Group performance status (ECOG-PS). RESULTS The most common postoperative complication was delirium, present in 31 patients (12.2%). The group with delirium was significantly more likely to have ECOG-PS ≥ 2, diabetes mellitus, cardiovascular disease, or cerebral infarction. The CGA showed frailty in the Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), the Vitality Index (VI), and the Geriatric Depression Scale 15 (GDS-15). In the multivariate analysis, the independent risk factors for delirium were ECOG-PS ≥ 2 (P = 0.002) and MMSE-frailty (P < 0.001). Using an MMSE score of ≤ 23 and an ECOG-PS score of ≥ 2 as cutoffs, postoperative delirium was predicted with a sensitivity of 80.7% and a specificity of 74.1%. CONCLUSION Postoperative delirium might be more easily predicted based on the combination of MMSE and ECOG-PS for elderly patients with gastric cancer undergoing gastrectomy.
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Affiliation(s)
- Takefumi Itami
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuyoshi Yamamoto
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuro Saito
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kota Momose
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yukiko Yasunobe
- Department of Geriatric and General Medicine, The University of Osaka Graduate School of Medicine, Osaka, Japan
- Department of Rehabilitation Science, Osaka Health Science University, Osaka, Japan
| | - Hiroshi Akasaka
- Department of Geriatric and General Medicine, The University of Osaka Graduate School of Medicine, Osaka, Japan
- Department of Hygiene and Preventive Medicine, Iwate Medical University, Idaidori, Yahaba, Iwate, Japan
| | - Taku Fujimoto
- Department of Geriatric and General Medicine, The University of Osaka Graduate School of Medicine, Osaka, Japan
- Department of Hygiene and Preventive Medicine, Iwate Medical University, Idaidori, Yahaba, Iwate, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, The University of Osaka Graduate School of Medicine, Osaka, Japan
- Department of Hygiene and Preventive Medicine, Iwate Medical University, Idaidori, Yahaba, Iwate, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Sontag AF, Kiselev J, Schaller SJ, Spies C, Rombey T. Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review. BMC Health Serv Res 2024; 24:192. [PMID: 38350947 PMCID: PMC10863196 DOI: 10.1186/s12913-024-10665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/31/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why. METHODS Following Pawson's realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated. RESULTS From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients' needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision. CONCLUSIONS Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention's goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients. TRIAL REGISTRATION PROSPERO (CRD42022335282).
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Affiliation(s)
- Anna Frederike Sontag
- Berlin School of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jörn Kiselev
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan J Schaller
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Ismaninger Str.22, 81675, München, Germany
| | - Claudia Spies
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.
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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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Monaghan C, Kerr J, Ali A, Amer S, Ma J, Abraham C, Simpson K, Marcucci M, Carter A, Rizvi Z, Jones-Lim L, Peters ML, Versloot J. Improving the Prevention, Detection, and Management of Delirium in Adult Inpatients; an Interprofessional Consultative Team Pilot Project. Gerontol Geriatr Med 2023; 9:23337214231175044. [PMID: 37215402 PMCID: PMC10196527 DOI: 10.1177/23337214231175044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
Delirium is a common, often preventable fluctuating state of cognition associated with increased morbidity and mortality. This report describes the implementation of an interprofessional consultative Delirium Team formed to improve the prevention, detection, and management of delirium in a community hospital. Team members consulted refered inpatients with delirium to establish a care plan and provide recommendations for pharmacological and non-pharmacological management. The team also offered delirium-related education to unit staff, patients, and caregivers. Consultations were initially completed by the team Nurse Practitioner or Occupational Therapist, and complex patients were discussed with the team Geriatrician and Psychiatrist at rounds to optimize specialist input. Of the 160 patients managed by the team over the 8-month study period, two-thirds of referred patients did not require specialist consultation for their delirium management. Strategies most often recommended by experts for managing delirium were related to medical management, social/cognitive engagement, and functional mobility. Two-thirds of all recommendations made by the team were implemented. Barriers and facilitators to implementation and improving unit staff adherence are further described. The consultative Delirium Team is a promising model that should be further explored for managing an aging population in a capacity-limited medical system.
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Affiliation(s)
| | - Jason Kerr
- University of Toronto, ON, Canada
- Trillium Health Partners, Mississauga,
ON, Canada
| | - Amna Ali
- Trillium Health Partners, Mississauga,
ON, Canada
| | - Samia Amer
- Trillium Health Partners, Mississauga,
ON, Canada
| | - Julia Ma
- Trillium Health Partners, Mississauga,
ON, Canada
| | | | | | | | | | - Zainab Rizvi
- Trillium Health Partners, Mississauga,
ON, Canada
| | | | | | - Judith Versloot
- University of Toronto, ON, Canada
- Trillium Health Partners, Mississauga,
ON, Canada
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5
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Yan B, Sun W, Wang W, Wu J, Wang G, Dou Q. Prognostic significance of frailty in older patients with hip fracture: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2022; 46:2939-2952. [PMID: 36227383 DOI: 10.1007/s00264-022-05605-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Hip fracture (HF) has become a major healthcare concern associated with higher mortality in older patients. Frailty is one of the most important problems in aging population but its prognostic value in HF remains susceptible. This systematic review and meta-analysis aimed to evaluate the association between frailty and adverse outcomes in older patients with HF. METHODS We systematically searched electrical databases including PubMed and Embase to find eligible literature with end-search restriction of February 20, 2021. The main endpoints were all-cause mortality, peri-operative complications, abnormal discharge, and length of stay (LOS). Pooled effect size was calculated by random-effects or fixed-effect model according to study heterogeneity. Three subgroup analyses based on follow-up times, study design, and frailty criteria were conducted. RESULTS We screened 22 studies out of 1599 identified studies in our analysis. Compared with normal patients, frail ones had a higher risk of mortality both before (OR = 3.48, 95% CI: 2.50-4.85, I2 = 87.2%, P < 0.001) and after (OR = 1.87, 95% CI: 1.44-2.44, I2 = 85.5%, P < 0.001) adjustment. The incidence of peri-operative complications, abnormal discharge, and prolonged LOS also significantly increased in frail subjects. There was no publication bias observed and the pooled results were stable based on sensitivity analysis. CONCLUSION Overall, more attention needs to be paid to the prognostic effects caused by frailty in seniors with HF. Better understanding of the association between frailty and adverse outcomes in HF could help doctors perform co-management across orthopaedic and geriatric departments.
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Affiliation(s)
- Bingzi Yan
- West China School of Medicine, Sichuan University, Renmin South Road, No. 17, Wuhou District, Chengdu, 610041, China
| | - Wanting Sun
- West China School of Medicine, Sichuan University, Renmin South Road, No. 17, Wuhou District, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, Sichuan, China
| | - Jinhui Wu
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Guanglin Wang
- Department of Orthopedics, West China School of Medicine, West China Hospital, Sichuan University, No. 37, Wuhou Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Qingyu Dou
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Rd, Wuhou District, Chengdu, 610041, China.
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6
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Daum N, Kiselev J, Schaller SJ. Der fraile Patient: fiktives Fallbeispiel. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:674-681. [DOI: 10.1055/a-1760-8119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Neupane I, Mujahid N, Zhou EP, Monteiro JFG, Lueckel S, Cizginer S, Yildiz F, Raza S, Singh M, Gravenstein S, McNicoll L. A Model of Care to Improve Survival of Older Trauma Patients: Geriatrics Co-Management. J Gerontol A Biol Sci Med Sci 2022:6648764. [PMID: 35868000 DOI: 10.1093/gerona/glac146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics co-management on mortality in general trauma. METHODS Retrospective cohort study from 2015-2016 comparing overall and inpatient mortality in a geriatrics trauma co-management (GTC) program versus usual care (UC). Demographic and outcome measures were obtained from the trauma registry at an 11-bed trauma critical care unit within a 719-bed Level 1 Trauma Center. 1,572 patients, 80 years and older, with an admitting trauma diagnosis were evaluated. Primary outcome was in-hospital mortality and overall mortality (defined as inpatient death or discharge to hospice). Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, discharge location, and medical complications. RESULTS 346 patients (22%) were placed in the GTC program. Overall mortality was lower in the GTC (4.9%) when compared with UC (11.9%), representing a 57% reduction (95% OR CI 0.24-0.75, p-value = 0.0028). There was a 7.42% hospital mortality rate in the UC group compared to 2.6% in the GTC group (95% CI 0.21-0.92, p-value = 0.0285) representing a 56% decrease in in-hospital mortality. GTC patients had a longer mean LOS (6.4 days versus 5.3 days, p-value <0.0001). More GTC patients were sent to inpatient rehabilitation facilities or skilled nursing facilities (80% versus 60%, p-value <0.0001). CONCLUSIONS Geriatrics trauma co-management of trauma patients above the age of 80 may reduce mortality and deserves formal study.
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Affiliation(s)
- Iva Neupane
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Nadia Mujahid
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Eric P Zhou
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children Hospital, Harvard Medical School, Boston, MA, United States
| | - Joao Filipe Goncalves Monteiro
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Stephanie Lueckel
- Department of Surgery, Rhode Island Hospital, Providence, RI, United States
| | - Sevdenur Cizginer
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States.,Department of Surgery, Rhode Island Hospital, Providence, RI, United States.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Ferhat Yildiz
- Department of Surgery, Rhode Island Hospital, Providence, RI, United States
| | - Sakeena Raza
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Mriganka Singh
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Stefan Gravenstein
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, United States
| | - Lynn McNicoll
- Department of Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States
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Schaller SJ, Kiselev J, Loidl V, Quentin W, Schmidt K, Mörgeli R, Rombey T, Busse R, Mansmann U, Spies C. Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial. Trials 2022; 23:468. [PMID: 35668532 PMCID: PMC9167908 DOI: 10.1186/s13063-022-06401-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery. METHODS Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention. DISCUSSION Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.
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Affiliation(s)
- Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Jörn Kiselev
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Verena Loidl
- Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Katrin Schmidt
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany.
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Chen L, Au E, Saripella A, Kapoor P, Yan E, Wong J, Tang-Wai DF, Gold D, Riazi S, Suen C, He D, Englesakis M, Nagappa M, Chung F. Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis. J Clin Anesth 2022; 80:110883. [PMID: 35623265 DOI: 10.1016/j.jclinane.2022.110883] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients. DESIGN A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021. SETTING Preoperative assessment. PATIENTS Older patients (≥ 60 years) undergoing non-cardiac surgery. MEASUREMENTS Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies. RESULTS Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I2: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I2: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I2: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001). CONCLUSIONS Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.
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Affiliation(s)
- Lina Chen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Emily Au
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Paras Kapoor
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Gold
- Department of Psychiatry, Krembil Brain Institute, University of Toronto, Toronto, ON, Canada
| | - Sheila Riazi
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Colin Suen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
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Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes. J Surg Res 2022; 277:352-364. [PMID: 35567991 DOI: 10.1016/j.jss.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS). METHODS A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021. RESULTS Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition. CONCLUSIONS Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.
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11
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Civan Kahve A, Kaya H, Daylan Hİ, Ozpinar O, Goka E. Evaluation of Psychiatric Consultations of Elderly Hospitalized Patients: What are the Psychological Complaints and Diagnoses? ADVANCES IN GERONTOLOGY 2022. [DOI: 10.1134/s2079057022010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Van Heghe A, Mordant G, Dupont J, Dejaeger M, Laurent MR, Gielen E. Effects of Orthogeriatric Care Models on Outcomes of Hip Fracture Patients: A Systematic Review and Meta-Analysis. Calcif Tissue Int 2022; 110:162-184. [PMID: 34591127 PMCID: PMC8784368 DOI: 10.1007/s00223-021-00913-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/06/2021] [Indexed: 10/24/2022]
Abstract
Orthogeriatrics is increasingly recommended in the care of hip fracture patients, although evidence for this model is conflicting or at least limited. Furthermore, there is no conclusive evidence on which model [geriatric medicine consultant service (GCS), geriatric medical ward with orthopedic surgeon consultant service (GW), integrated care model (ICM)] is superior. The review summarizes the effect of orthogeriatric care for hip fracture patients on length of stay (LOS), time to surgery (TTS), in-hospital mortality, 1-year mortality, 30-day readmission rate, functional outcome, complication rate, and cost. Two independent reviewers retrieved randomized controlled trials, controlled observational studies, and pre/post analyses. Random-effects meta-analysis was performed. Thirty-seven studies were included, totaling 37.294 patients. Orthogeriatric care significantly reduced LOS [mean difference (MD) - 1.55 days, 95% confidence interval (CI) (- 2.53; - 0.57)], but heterogeneity warrants caution in interpreting this finding. Orthogeriatrics also resulted in a 28% lower risk of in-hospital mortality [95%CI (0.56; 0.92)], a 14% lower risk of 1-year mortality [95%CI (0.76; 0.97)], and a 19% lower risk of delirium [95%CI (0.71; 0.92)]. No significant effect was observed on TTS and 30-day readmission rate. No consistent effect was found on functional outcome. Numerically lower numbers of complications were observed in orthogeriatric care, yet some complications occurred more frequently in GW and ICM. Limited data suggest orthogeriatrics is cost-effective. There is moderate quality evidence that orthogeriatrics reduces LOS, in-hospital mortality, 1-year mortality, and delirium of hip fracture patients and may reduce complications and cost, while the effect on functional outcome is inconsistent. There is currently insufficient evidence to recommend one or the other type of orthogeriatric care model.
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Affiliation(s)
| | - Gilles Mordant
- Institute of Statistics, Biostatistics and Actuarial Sciences, UCLouvain, Louvain-la-Neuve, Belgium
| | - Jolan Dupont
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Centre for Metabolic Bone Diseases, UZ Leuven, Leuven, Belgium
- Department of Geriatrics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marian Dejaeger
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Centre for Metabolic Bone Diseases, UZ Leuven, Leuven, Belgium
- Department of Geriatrics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Michaël R Laurent
- Centre for Metabolic Bone Diseases, UZ Leuven, Leuven, Belgium
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium
| | - Evelien Gielen
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
- Centre for Metabolic Bone Diseases, UZ Leuven, Leuven, Belgium.
- Department of Geriatrics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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13
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Kappenschneider T, Meyer M, Maderbacher G, Parik L, Leiss F, Quintana LP, Grifka J. [Delirium-an interdisciplinary challenge]. DER ORTHOPADE 2022; 51:106-115. [PMID: 35037987 DOI: 10.1007/s00132-021-04209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients. DIAGNOSTIC Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential. TREATMENT In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.
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Affiliation(s)
- Tobias Kappenschneider
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Matthias Meyer
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Günther Maderbacher
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Lukas Parik
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Franziska Leiss
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Loreto Pulido Quintana
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Roberts ARA, Falank CR, Ontengco JB, Carter EL, Hallen SAM. Collaborative care when older adults fall: The benefits of geriatric consultation for trauma patients aged 75 years and older. J Am Geriatr Soc 2022; 70:1284-1286. [PMID: 34982468 DOI: 10.1111/jgs.17637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Emily L Carter
- Geriatric Medicine, Maine Medical Center, Portland, Maine, USA
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Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 11:CD013307. [PMID: 34826144 PMCID: PMC8623130 DOI: 10.1002/14651858.cd013307.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Handoll HH, Cameron ID, Mak JC, Panagoda CE, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2021; 11:CD007125. [PMID: 34766330 PMCID: PMC8586844 DOI: 10.1002/14651858.cd007125.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009. OBJECTIVES To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019). SELECTION CRITERIA We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain. DATA COLLECTION AND ANALYSIS Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. MAIN RESULTS The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months. AUTHORS' CONCLUSIONS In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.
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Affiliation(s)
- Helen Hg Handoll
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Jenson Cs Mak
- Healthy Ageing, Mind & Body Institute, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Claire E Panagoda
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Terence P Finnegan
- Department of Aged Care and Rehabilitation Medicine, Royal North Shore Hospital of Sydney, St Leonards, Australia
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Pollmann CT, Mellingsæter MR, Neerland BE, Straume-Næsheim T, Årøen A, Watne LO. Orthogeriatric co-management reduces incidence of delirium in hip fracture patients. Osteoporos Int 2021; 32:2225-2233. [PMID: 33963884 PMCID: PMC8563591 DOI: 10.1007/s00198-021-05974-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/21/2021] [Indexed: 01/07/2023]
Abstract
UNLABELLED Hip fracture patients often display an acute confusional state (delirium) which is associated with worse outcomes. In this observational study, we found that co-management of hip fracture patients by a multidisciplinary team including a geriatrician and an orthopaedic surgeon could reduce the incidence of delirium. INTRODUCTION Delirium after hip fracture is common and is associated with negative outcomes. We investigated if orthogeriatric co-management reduced the incidence of delirium in hip fracture patients. METHODS In this single-centre, prospective observational study, we compared the incidence of delirium and subsyndromal delirium (SSD) before (usual care group, n = 94) and after (orthogeriatric group, n = 103) the introduction of orthogeriatric co-management as an integrated care model. The outcome measure 'no delirium/SSD/delirium' was treated as an ordinal variable and analysed using the chi-squared test and multivariable ordinal logistic regression. RESULTS The groups had similar baseline characteristics except for a higher proportion of patients with pre-existing cognitive impairment in the usual care group (51% vs. 37%, p = 0.045). Fewer patients in the orthogeriatric group developed SSD or delirium (no delirium: 59% vs. 40%/SSD: 6% vs. 13%/delirium: 35% vs. 47%; p = 0.021). The number needed to treat (NNT) to avoid one case of SSD or delirium was 5.3 (95% CI: 3.1 to 19.7). In a multivariable analysis adjusted for age, sex, ASA class, pre-existing cognitive impairment, time to surgery, type of surgery, and medical or surgical complications, the odds ratio for the development of SSD/delirium was lower in the orthogeriatric group (OR = 0.46, 95% CI: 0.23-0.89, p = 0.023). CONCLUSION Orthogeriatric co-management as an integrated care model reduced the incidence of SSD/delirium in hip fracture patients.
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Affiliation(s)
- C T Pollmann
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B E Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - T Straume-Næsheim
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway
- Oslo Sports Trauma Research Center (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway
| | - A Årøen
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
- Oslo Sports Trauma Research Center (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway
| | - L O Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
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Sura-Amonrattana U, Tharmviboonsri T, Unnanuntana A, Tantigate D, Srinonprasert V. Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings. BMC Geriatr 2021; 21:548. [PMID: 34641804 PMCID: PMC8513216 DOI: 10.1186/s12877-021-02509-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022] Open
Abstract
Background Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes. Methods A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation. Results Three hundred two patients were enrolled from the Siriraj hospital’s database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p < 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p < 0.001) and the length of stay was significantly shorter (11 days (8–17) VS 13 days (9–18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality. Conclusions The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.
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Affiliation(s)
- Unchana Sura-Amonrattana
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Theerawoot Tharmviboonsri
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Direk Tantigate
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Abstract
Delirium and frailty are prevalent geriatric syndromes and important public health issues among older adults. The prevalence of delirium among hospitalized older adults ranges from 15% to 75%, while that of frailty ranges from 12% to 24%. The exact pathophysiology of these two conditions has not been clearly identified, although several hypotheses have been proposed. However, these conditions are considered to be multifactorial in etiology and are associated with inflammation related to aging, alterations in vascular systems, genetics, and nutritional deficiency. Furthermore, clinically, they are significantly associated with frailty, which increases the risk of delirium by almost two- to three-fold among hospitalized older adults. With their multifactorial etiology and unknown pathophysiology, current evidence supports more practical multicomponent patient-centered approaches to prevent and manage delirium with frailty among hospitalized older adults. These comprehensive and organized bundled approaches can identify high-risk patients with frailty and more effectively manage their delirium.
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Affiliation(s)
- Min Ji Kwak
- Joan and Stanford Alexander Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Corresponding author: Min Ji Kwak, MD, MS, DrPH Joan and Stanford Alexander Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin St MSB 5.126, Houston, TX 77030, USA E-mail:
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Burton JK, Craig LE, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 7:CD013307. [PMID: 34280303 PMCID: PMC8407051 DOI: 10.1002/14651858.cd013307.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise E Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Pedemonte JC, Sun H, Franco-Garcia E, Zhou C, Heng M, Quraishi SA, Westover B, Akeju O. Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients. Br J Anaesth 2021; 127:102-109. [PMID: 34074525 PMCID: PMC8258970 DOI: 10.1016/j.bja.2021.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 03/06/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients. METHODS This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality. RESULTS In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect. CONCLUSIONS Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.
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Affiliation(s)
- Juan C Pedemonte
- Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Carmen Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Boston, MA, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA; Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA
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22
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Ukwuoma Ekeozor C, Jeyaruban D, Lasserson D. Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e13859. [PMID: 33236458 DOI: 10.1111/ijcp.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised. OBJECTIVES This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients. METHODS MEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO. RESULTS A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87). CONCLUSIONS Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.
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Affiliation(s)
| | - Darshana Jeyaruban
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Lasserson
- Health Sciences Division, University of Warwick, Coventry, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Monaghan C, Martin G, Kerr J, Peters ML, Versloot J. Effectiveness of Interprofessional Consultation-Based Interventions for Delirium: A Scoping Review. J Appl Gerontol 2021; 41:881-891. [PMID: 34075823 PMCID: PMC8848052 DOI: 10.1177/07334648211018032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Interprofessional geriatric consultation teams and multicomponent interventions are established models for delirium care. They are combined in interprofessional consultative delirium team interventions; however, insight into this novel approach is lacking. OBJECTIVE To describe the effectiveness and core components of consultation-based interventions for delirium. METHOD Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, and ProQuest. Data on core intervention components, outcomes, facilitators, and barriers were extracted. RESULTS 10 studies were included. Core intervention components were systematic delirium screening, ongoing consultation, implementation of non-pharmacologic and pharmacological interventions, and staff education. Of the included studies, 1/6 found a significant reduction in delirium incidence, 1/2 a reduction in delirium duration, and 2/3 found a reduction in falls. Facilitators and barriers to implementation were discussed. CONCLUSION There was consistency in team structure and core components, however intervention operationalization and effectiveness varied widely. There is some evidence that this model is effective for reducing delirium and its sequelae.
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Affiliation(s)
- Caitlin Monaghan
- Trillium Health Partners, Mississauga, Ontario, Canada.,University of Toronto, Ontario, Canada
| | | | - Jason Kerr
- Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Judith Versloot
- Trillium Health Partners, Mississauga, Ontario, Canada.,University of Toronto, Ontario, Canada
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Fraser MT, Mcilvennan CK. Reorienting Ourselves to Delirium: Caring for Older Patients Hospitalized With Heart Failure. J Card Fail 2021; 27:460-463. [PMID: 33745663 DOI: 10.1016/j.cardfail.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 10/21/2022]
Affiliation(s)
| | - Colleen K Mcilvennan
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado.
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Tehranineshat B, Hosseinpour N, Mani A, Rakhshan M. The effect of multi-component interventions on the incidence rate, severity, and duration of post open heart surgery delirium among hospitalized patients. J Cardiothorac Surg 2021; 16:32. [PMID: 33743751 PMCID: PMC7980563 DOI: 10.1186/s13019-021-01422-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background Delirium is one of the prevalent complications of post open heart surgery. The present research aimed to assess the effect of multi-component interventions on the incidence rate, severity, and duration of post open heart surgery delirium among hospitalized patients. Methods In this quasi-experimental study, 96 patients under open heart surgery were selected using convenience sampling and divided into a control and an intervention group. The interventions included the patients’ preoperative education, nurses’ education, and in-ward environmental interventions. The demographic information and Mini-Mental State Examination (MMSE) questionnaires were completed a day before surgery. The patients in both groups were also surveyed after extubation until the fourth day post operation using Delirium Observation Screening (DOS) scale considering the incidence, severity, and duration of delirium. The data were analyzed using the SPSS statistical software, version 20. Results The incidence rate of delirium was 14.6 and 6.2% in the control and intervention groups, respectively (p > 0.05). Besides, the mean severity of delirium was 0.53 in the control group and 0.40 in the intervention group (p > 0.05). Finally, the mean duration of delirium was 4.5 and 3.25 h in the two groups, respectively (p > 0.05). Conclusions Since prevention of delirium can play a considerable role in the patients’ recovery after heart surgery, it is necessary to carry out some measures to prevent such complications. Even though the interventions performed in this study did not cause significant changes in this regard, the results suggested that prevention interventions should be performed with stronger and more integrated planning for achieving better outcomes.
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Affiliation(s)
- Banafsheh Tehranineshat
- Community Based Psychiatric Care Research Center, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand St., Nemazee Sq, Shiraz, 7193613119, Iran
| | - Nima Hosseinpour
- Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Mani
- Psychiatry Department, Research Center for Psychiatry & Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran , Shiraz, Iran
| | - Mahnaz Rakhshan
- Community Based Psychiatric Care Research Center, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand St., Nemazee Sq, Shiraz, 7193613119, Iran.
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Lin C, Rosen S, Breda K, Tashman N, T Black J, Lee J, Chiang A, Rosen B. Implementing a Geriatric Fracture Program in a Mixed Practice Environment Reduces Total Cost and Length of Stay. Geriatr Orthop Surg Rehabil 2021; 12:2151459320987701. [PMID: 33747608 PMCID: PMC7905728 DOI: 10.1177/2151459320987701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/27/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction: Geriatric-orthopaedic co-management models can improve patient outcomes. However, prior reports have been at large academic centers with “closed” systems and an inpatient geriatric service. Here we describe a Geriatric Fracture Program (GFP) in a mixed practice “pluralistic” environment that includes employed academic faculty, private practice physicians, and multiple private hospitalist groups. We hypothesized GFP enrollment would reduce length of stay (LOS), time to surgery (TTS), and total hospital costs compared to non-GFP patients. Materials and Methods: A multidisciplinary team was created around a geriatric Nurse Practitioner (NP) and consulting geriatrician. Standardized geriatric focused training programs and electronic tools were developed based on best practice guidelines. Fracture patients >65 years old were prospectively enrolled from July 2018 – June 2019. A trained biostatistician performed all statistical analyses. A p < 0.05 was considered significant. Results: 564 operative and nonoperative fractures in patients over 65 were prospectively followed with 153 (27%) enrolled in the GFP and 411 (73%) admitted to other hospitalists or their primary care provider (non-GFP). Patients enrolled in the GFP had a significantly shorter median LOS of 4 days, compared to 5 days in non-GFP patients (P < 0.001). There was a strong trend towards a shorter median TTS in the GFP group (21.5 hours v 25 hours, p = 0.066). Mean total costs were significantly lower in the GFP group ($25,323 v $29085, p = 0.022) Discussion: Our data shows that a geriatric-orthopaedic co-management model can be successfully implemented without an inpatient geriatric service, utilizing the pre-existing resources in a complex environment. The program can be expanded to include additional groups to improve care for entire geriatric fracture population with significant anticipated cost savings. Conclusions: With close multidisciplinary team work, a successful geriatric-orthopaedic comanagement model for geriatric fractures can be implemented in even a mixed practice environment without an inpatient geriatrics service.
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Affiliation(s)
- Carol Lin
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sonja Rosen
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | - Jae Lee
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aaron Chiang
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Weber C, Fierz K, Katapodi M, Hasemann W. An advanced practice nurse-led delirium consultation service reduces delirium severity and length of stay in orthopedic patients: A nonrandomized posttest only evaluation study. Perspect Psychiatr Care 2020; 56:804-810. [PMID: 32128829 DOI: 10.1111/ppc.12495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 01/02/2020] [Accepted: 02/22/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Delirium is an acute neuropsychiatric disorder and is a common and serious complication during hospitalization for older people. This study evaluated the value of an advanced practice nurse (APN)-led delirium consultation service on patient outcomes DESIGN AND METHODS: This was a retrospective chart review of 137 patients over 65 years, hospitalized between 2012 and 2015 in a tertiary care setting in Switzerland, who underwent orthopedic surgery and experienced delirium. FINDINGS Of the 137 eligible patients, 53 received the delirium consultation service and 84 received the standard care. The group receiving "early" delirium consultation experienced significantly reduced delirium severity over the course of time and the shortest length of stay. PRACTICE IMPLICATIONS The APN-led delirium consultation service had a positive effect on patient outcomes.
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Affiliation(s)
- Christa Weber
- Department of Orthopedic and Traumatology, University Hospital of Bern, Bern, Switzerland
| | - Katharina Fierz
- ZHAW Zurich University of Applied Sciences, School of Health Professions, Institute of Nursing, Winterthur, Switzerland
| | - Maria Katapodi
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Wolfgang Hasemann
- Practice Development Unit, Department of Nursing and Allied Health Professions, University Hospital Basel, Basel, Switzerland.,University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
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Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis. J Clin Anesth 2020; 67:110004. [PMID: 32768990 DOI: 10.1016/j.jclinane.2020.110004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/19/2020] [Accepted: 07/17/2020] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE An estimated 80% of older people undergoing surgery develop postoperative delirium (POD) making them a high-risk group. Research in this area is growing fast but there is no established consensus on strategies for POD prevention or management. A systematic review and meta-analysis were conducted to synthesise data on clinical interventions used to reduce POD among older people undergoing elective and emergency surgery. METHODS A range of database searches generated 336 papers. A total of 25 studies met the inclusion criteria and were assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The studies were undertaken across the world. RESULTS This review identified a range of intervention approaches: comparisons between anaesthetic and sedatives agents, medication-specific interventions and multidisciplinary models of care. Results found more consistencies across multidisciplinary interventions than the pharmacological interventions. In pooled analyses, haloperidol (OR 0.74; 95% CI (confidence interval) 0.44, 1.26) was not statistically significantly associated with reduced POD incidence any more than a placebo. CONCLUSION There is a need to implement multidisciplinary interventions, as well as collaboration between clinicians on pre- and postoperative care practices regarding pharmacological interventions to more effectively reduce and manage POD in older people.
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Garlich JM, Pujari A, Moak Z, Debbi E, Yalamanchili R, Stephenson S, Stephan S, Polakof L, Little M, Moon C, Anand K, Lin CA. Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients. J Am Geriatr Soc 2020; 68:2043-2050. [PMID: 32442348 DOI: 10.1111/jgs.16547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN This is a prospective observational study. SETTING A level 1 trauma center in California. PARTICIPANTS From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). CONCLUSION FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE The level of evidence was II.
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Affiliation(s)
- John M Garlich
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amit Pujari
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Zachary Moak
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eytan Debbi
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raj Yalamanchili
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sam Stephenson
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Landon Polakof
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Milton Little
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Charles Moon
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kapil Anand
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carol A Lin
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, Fluck D, Osmani A, Sharmin R, Sharma P, Fry CH, Han TS. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing 2020; 49:411-417. [PMID: 31813951 DOI: 10.1093/ageing/afz161] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.
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Affiliation(s)
- Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Peter Enwere
- Dementia Service, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | | | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Melanie Irvin-Sellers
- Department of Respiratory Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Ahmad Osmani
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Rifat Sharmin
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
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Tittel S, Burkhardt J, Roll C, Kinner B. Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome. Orthop Traumatol Surg Res 2020; 106:141-147. [PMID: 31870558 DOI: 10.1016/j.otsr.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 05/04/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management. METHODS Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated. RESULTS In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate. CONCLUSION We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients. LEVEL OF EVIDENCE III, prospective non-randomised cohort study.
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Affiliation(s)
- Sandra Tittel
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Janosch Burkhardt
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Christina Roll
- Zentrum für Ambulante Rehabilitation, Regensburg, Germany
| | - Bernd Kinner
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
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Zhou Y, Rui Y, Lu P, Qiu X, Zou J, Li X, Ren L, Liu S, Yang Y, Ma M, Wang C, Chen H. [Research progress of multidisciplinary team co-management models for geriatric hip fracture treatment]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:132-138. [PMID: 31939248 PMCID: PMC8171832 DOI: 10.7507/1002-1892.201904133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/27/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To summarize the research progress of multidisciplinary team (MDT) co-management models in the clinical treatment of geriatric hip fractures. METHODS The literature about types and characteristics of MDT for geriatric hip fracture treatment were extensively reviewed, and the advantages of its clinical application were analysed and summarised. Finally, the MDT model and characteristics of geriatric hip fracture in the Zhongda Hospital affiliated to Southeast University were introduced in detail. RESULTS Clinical models of MDT are diverse and have their own characteristics, and MDT can shorten the length of stay and waiting time before operation, reduce the incidence of internal complications, save labor costs, and reduce patient mortality. CONCLUSION The application of MDT in the treatment of geriatric hip fracture has achieved remarkable results, which provides an optimal scheme for the treatment of geriatric hip fracture.
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Affiliation(s)
- Yangyang Zhou
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yunfeng Rui
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009,
| | - Panpan Lu
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiaodong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Jihong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xingjuan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Liqun Ren
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Songqiao Liu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yi Yang
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Ming Ma
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Rehabilitation Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Chen Wang
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hui Chen
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
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Non-pharmacological approaches in the prevention of delirium. Eur Geriatr Med 2020; 11:71-81. [DOI: 10.1007/s41999-019-00260-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/30/2019] [Indexed: 12/19/2022]
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Lim BG, Lee IO. Anesthetic management of geriatric patients. Korean J Anesthesiol 2019; 73:8-29. [PMID: 31636241 PMCID: PMC7000283 DOI: 10.4097/kja.19391] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 12/15/2022] Open
Abstract
The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.
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Affiliation(s)
- Byung-Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il-Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Knobe M, Böttcher B, Coburn M, Friess T, Bollheimer LC, Heppner HJ, Werner CJ, Bach JP, Wollgarten M, Poßelt S, Bliemel C, Bücking B. [Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]. Unfallchirurg 2019; 122:134-146. [PMID: 29675629 DOI: 10.1007/s00113-018-0502-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. OBJECTIVE The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). METHODS A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). RESULTS In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035). CONCLUSION There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.
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Affiliation(s)
- M Knobe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - B Böttcher
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - M Coburn
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - T Friess
- Klinik für Unfall- und Handchirurgie, Zentrum für Alterstraumatologie im St. Clemens-Hospital Oberhausen, Oberhausen, Deutschland
| | - L C Bollheimer
- Lehrstuhl für Altersmedizin, RWTH Aachen mit Klinik für Innere Medizin und Geriatrie am Franziskushospital Aachen, Aachen, Deutschland
| | - H J Heppner
- Geriatrische Klinik und Tagesklinik, Lehrstuhl für Geriatrie, Universität Witten/Herdecke, Witten, Deutschland
| | - C J Werner
- Klinik für Neurologie, Sektion Interdisziplinäre Geriatrie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - J-P Bach
- Klinik für Neurologie, Sektion Interdisziplinäre Geriatrie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - M Wollgarten
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - S Poßelt
- Kaufmännisches Controlling, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - C Bliemel
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Marburg, Deutschland
| | - B Bücking
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Marburg, Deutschland
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. MAIN BODY The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). SHORT CONCLUSION In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy.
- Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
- Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy
- University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
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Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
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Sheehan KJ, Guerrero EM, Tainter D, Dial B, Milton-Cole R, Blair JA, Alexander J, Swamy P, Kuramoto L, Guy P, Bettger JP, Sobolev B. Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review. Osteoporos Int 2019; 30:1339-1351. [PMID: 31037362 DOI: 10.1007/s00198-019-04976-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/14/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence. METHODS We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph. RESULTS We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies. CONCLUSIONS Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.
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Affiliation(s)
- K J Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK.
| | - E M Guerrero
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - D Tainter
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Dial
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - R Milton-Cole
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - J A Blair
- Department of Orthopaedics and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA
| | - J Alexander
- Department of Rehabilitation Sciences, Kingston & St George's University of London, London, UK
| | - P Swamy
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - L Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - J P Bettger
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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McKenzie J, Joy A. Family intervention improves outcomes for patients with delirium: Systematic review and meta‐analysis. Australas J Ageing 2019; 39:21-30. [DOI: 10.1111/ajag.12688] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 05/10/2019] [Accepted: 05/22/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Jessica McKenzie
- Occupational Therapy Occupational Therapist Eastern Health Melbourne Victoria Australia
| | - Anna Joy
- Advanced Occupational Therapy Senior Occupational Therapist Eastern Health Melbourne Victoria Australia
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Chou MY, Wang YC, Peng LN, Liang CK, Chu CS, Liao MC, Lin YT, Hsu CJ, Chen LK. Intraoperative blood transfusion predicts postoperative delirium among older patients undergoing elective orthopedic surgery: A prospective cohort study. Int J Geriatr Psychiatry 2019; 34:881-888. [PMID: 30761615 DOI: 10.1002/gps.5086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 02/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery. METHODS This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis. RESULTS Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates. CONCLUSIONS Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.
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Affiliation(s)
- Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Chia Nan University of Pharmacy and Science
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Li-Ning Peng
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Mei-Chen Liao
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Jen Hsu
- Department of Orthopedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Chia Nan University of Pharmacy and Science
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43
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Talevski J, Sanders KM, Duque G, Connaughton C, Beauchamp A, Green D, Millar L, Brennan-Olsen SL. Effect of Clinical Care Pathways on Quality of Life and Physical Function After Fragility Fracture: A Meta-analysis. J Am Med Dir Assoc 2019; 20:926.e1-926.e11. [PMID: 30975586 DOI: 10.1016/j.jamda.2019.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate the effect of clinical care pathways (CCPs) on health-related quality of life (HRQoL) and physical function following fragility fracture and identify the specific characteristics of CCPs that are associated with improved outcomes. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Randomized controlled studies and nonrandomized studies that involved participants aged ≥50 years who sustained a fragility fracture, evaluated the effects of a CCP compared to usual care, and reported outcomes of HRQoL or physical function. METHODS We systematically searched Ovid Medline, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials from the earliest records to July 25, 2018. Two reviewers independently extracted study data and assessed methodologic quality. RESULTS Overall, 22 studies (17 randomized controlled trials, 5 nonrandomized studies) were included, comprising 5842 participants. Twenty-one studies included hip fracture patients, and 1 included wrist fracture patients. Majority of studies (82%) were assessed as high quality. Meta-analyses showed moderate improvements in the CCP group for HRQoL [standardized mean difference (SMD) = 0.24, 95% confidence interval (CI) 0.12, 0.35] and physical function (SMD 0.21, 95% CI 0.10, 0.33) compared with usual care post hip fracture. Inpatient CCPs that extended to the outpatient setting showed greater improvements in HRQoL and physical function compared to CCPs that were only inpatient or outpatient. CCPs that included a care coordinator, geriatric assessment, rehabilitation, prevention of inpatient complications, nutritional advice, or discharge planning also showed greater improvements in outcomes. CONCLUSIONS AND IMPLICATIONS Treatment with CCPs following fragility fracture showed greater improvements in HRQoL and physical function compared with usual care. Further research is warranted to assess the combination of CCP components that provide the most beneficial results, evaluate the effect of CCPs in patients with nonhip fractures, and determine which patient groups are more likely to benefit from CCPs.
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Affiliation(s)
- Jason Talevski
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia.
| | - Kerrie M Sanders
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Gustavo Duque
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Catherine Connaughton
- Institute for Health and Ageing, Australian Catholic University, Melbourne, Victoria, Australia
| | - Alison Beauchamp
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia; School of Rural Health, Monash University, Moe, Victoria, Australia
| | - Darci Green
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Lynne Millar
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Sharon L Brennan-Olsen
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
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Kinjo S, Lim E, Magsaysay MV, Sands LP, Leung JM. Volatile anaesthetics and postoperative delirium in older surgical patients-A secondary analysis of prospective cohort studies. Acta Anaesthesiol Scand 2019; 63:18-26. [PMID: 30051465 DOI: 10.1111/aas.13227] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Volatile Anaesthetics (VAs) may be associated with postoperative delirium (POD). However, to date, the effects of VAs on POD are not completely understood. The objective of this study was to investigate the incidence of POD in different VA groups. METHODS A secondary analysis was conducted using a database created from prospective cohort studies in patients who underwent elective major noncardiac surgery. Patients who received general anaesthesia with desflurane, isoflurane, or sevoflurane were included in the study. POD occurring on either of the first two postoperative days was measured using the Confusion Assessment Method. RESULTS Five hundred and thirty-two patients were included in this study, with a mean age of 73.5 ± 6.0 years (range, 65-96 years). The overall incidence of POD on either postoperative day 1 or 2 was 41%. A higher incidence of POD was noted in the desflurane group compared with the isoflurane group (Odds Ratio = 3.35, 95% CI = 1.54-7.28). The incidence of POD between the sevoflurane and isoflurane or desflurane group was not statistically significant. CONCLUSION Each VA may have different effects on postoperative cognition. Further studies using a prospective randomized approach will be necessary to discern whether anaesthetic type or management affects the occurrence of postoperative delirium.
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Affiliation(s)
- Sakura Kinjo
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
| | - Eunjung Lim
- Biostatistics Core Facility; Department of Complementary & Integrative Medicine; John A Burns School of Medicine; University of Hawaii; Honolulu Hawaii
| | - Maria Victoria Magsaysay
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
| | - Laura P. Sands
- Human Development Center for Gerontology; Virginia Polytechnic Institute and State University; Blacksburg Indiana
| | - Jacqueline M. Leung
- Department of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco California
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Devriendt E, Heeren P, Fieuws S, Wellens NIH, Deschodt M, Flamaing J, Sabbe M, Milisen K. Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol of a prospective single centre quasi-experimental study. BMC Geriatr 2018; 18:244. [PMID: 30326860 PMCID: PMC6191899 DOI: 10.1186/s12877-018-0933-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/01/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed. METHODS The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality. DISCUSSION URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive. TRIAL REGISTRATION The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).
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Affiliation(s)
- Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000 Brussels, Belgium
| | - Steffen Fieuws
- I-Biostat Interuniversity Institute for Biostatistics and statistical Bioinformatics KU Leuven, Kapucijnenvoer 35/3, 3000 Leuven, Belgium
| | - Nathalie I. H. Wellens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Public Health and Social Affairs Department, Government Canton Vaud, Avenue des Casernes 2, 1014 Lausanne, Switzerland
| | - Mieke Deschodt
- Department of Chronic Diseases, Metabolism and Ageing, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Public Health, Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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Effectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review. Int Psychogeriatr 2018; 30:481-492. [PMID: 29295719 DOI: 10.1017/s1041610217002782] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED 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.
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Abstract
Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, One Brigham Circle, 3rd Floor, Boston, MA 02120, USA.
| | - Sharon K Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University School of Medicine, Mason F. Lord Building, 5200 Eastern Avenue, 7th Floor, Room 721, Baltimore, MD 21224, USA
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Zerah L, Cohen-Bittan J, Raux M, Meziere A, Tourette C, Neri C, Verny M, Riou B, Khiami F, Boddaert J. Association between Cognitive Status before Surgery and Outcomes in Elderly Patients with Hip Fracture in a Dedicated Orthogeriatric Care Pathway. J Alzheimers Dis 2018; 56:145-156. [PMID: 27911302 DOI: 10.3233/jad-160655] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dementia is associated with a worse prognosis of hip fracture, but the impact of a dedicated geriatric care pathway on the prognosis of these patients has not been evaluated. OBJECTIVE According to the cognitive status before surgery, our main objective was to compare mortality rate at 6 months; secondary outcomes were to compare in-hospital complications, the risk of new institutionalization, and the ability to walk at 6 months. METHODS Between 2009 and 2015, all patients (>70 years) admitted after hip fracture surgery into a dedicated unit of peri-operative geriatric care were included: patients with dementia (DP), without dementia (NDP), and with cognitive status not determined (CSND). Data are expressed as hazard ratio (HR) for multivariate cox analysis or odds ratio (OR) for multivariate logistic regression analysis and their 95% confidence interval (CI). RESULTS We included 650 patients (86±6 years): 168 DP, 400 NDP, and 82 CSND. After adjustment for age, sex, comorbidities, polypharmacy, pre-fracture autonomy, time-to-surgery, and delirium, there were no significant differences for 6-month mortality (DP versus NDP: HR = 0.7[0.4-1.2], DP versus CSND: HR = 0.6[0.3-1.4], CSND versus NDP: HR = 0.8[0.4-1.7]); but DP and CSND were more likely to be newly institutionalized after 6 months compared to NDP (OR DP = 2.6[1.4-4.9], p = 0.003, OR CSND = 2.9[1.4-6.1], p = 0.004). 92% of population was walking after 6 months (63% with assistance): no difference was found between the three groups. CONCLUSION In a dedicated geriatric care pathway, DP and CSND undergoing hip surgery have the same 6-month mortality and walking ability as NDP.
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Affiliation(s)
- Lorene Zerah
- Department of Geriatrics, Unit of Peri-Operative Geriatric Care, Groupe Hospitalier (GH) Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France
| | - Judith Cohen-Bittan
- Department of Geriatrics, Unit of Peri-Operative Geriatric Care, Groupe Hospitalier (GH) Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Mathieu Raux
- Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Departments of Anesthesiology and Critical Care, GH Pitié-Salpêtrière, APHP, Paris, France
| | - Anthony Meziere
- Department of Rehabilitation, GH Charles Foix, APHP, Ivry sur Seine, France
| | - Cendrine Tourette
- Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Centre National de la Recherche Scientifique (CNRS), UMR 8256, Paris, France
| | - Christian Neri
- Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Centre National de la Recherche Scientifique (CNRS), UMR 8256, Paris, France
| | - Marc Verny
- Department of Geriatrics, Unit of Peri-Operative Geriatric Care, Groupe Hospitalier (GH) Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Centre National de la Recherche Scientifique (CNRS), UMR 8256, Paris, France
| | - Bruno Riou
- Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Departments of Emergency Medicine and Surgery, GH Pitié-Salpêtrière, APHP, Paris, France
| | - Frederic Khiami
- Departments of Orthopedic Surgery and Trauma, GH Pitié-Salpêtrière, APHP, Paris, France
| | - Jacques Boddaert
- Department of Geriatrics, Unit of Peri-Operative Geriatric Care, Groupe Hospitalier (GH) Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Sorbonne University, University Pierre and Marie Curie (UPMC) Paris 06, University Hospital Department Fight Aging and Stress (DHU FAST), Paris, France.,Centre National de la Recherche Scientifique (CNRS), UMR 8256, Paris, France
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Kamińska M, Golec J, Czechowska D. Selected life quality variables of women treated surgically due to intertrochanteric femur fractures in the aspect of nursing and rehabilitation standards. REHABILITACJA MEDYCZNA 2018. [DOI: 10.5604/01.3001.0010.8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: The aim of presented study was to evaluate selected quality of life indicators for women treated surgically due to intertrochanteric femur fractures in terms of implementation of physiotherapeutic and nursing standards.
Clinical Hospital in Krakow (5WSK) within the period from January 2015 to December 2016. At that time, 145 women with intertrochanteric femur fracture were admitted to the hospital. The age of the patients ranged between 58 and 92 years, with an average of 83.6 years. The following questionnaires and score scales were used to assess the quality of life: Short Pfeiffer Mental Status Questionnaire (SPMSQ), Instrumental Activities of Daily Living (IADL) scale, SF-36 Quality of Life Questionnaire, Barthel scale, HOOS scale, Geriatric Depression Scale (GDS) by Yesavage, the author’s questionnaire on rehabilitation care problems related to urinary tract infections, bed sores, pneumonia, gastrointestinal disorders, gastrointestinal infections and thromboembolic complications as well as survival rate.
Results and conclusions: 1. The quality of life of women operated because of intertrochanteric femoral fractures using an intramedullary Gamma nail had deteriorated in both short and long-term observation. 2. Maintenance and individualization of nursing standards and rehabilitation in women treated surgically due to intertrochanteric femoral fractures had a positive effect on the overall process of their treatment. 3.The level of physical activity declared by women operated due to intertrochanteric femur fracture prior to the occurrence of these fractures, has a signifi cant effect on their functional results in short and long-term observation. The higher the level of physical activity of these patients before the fracture, the more favourable was the functional outcome. 4. The level of mood and self-acceptance of the disease in women treated surgically for this fracture had signifi cant impact on the process of their nursing as well as rehabilitation, and on functional status in short and long-term follow-up. The higher the level of mood and self-acceptance of the disease in these women, the better the process of their nursing, rehabilitation and the functional outcome.
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Affiliation(s)
- Małgorzata Kamińska
- Klinika Chirurgii Urazowej i Ortopedii 5 Wojskowego Szpitala Klinicznego z Polikliniką SP ZOZ w Krakowie / 5th Military Clinical Hospital with Polyclinic in Krakow, Department of Trauma and Orthopaedic Surgery, Krakow, Poland
| | - Joanna Golec
- Zakład Rehabilitacji w Traumatologii, Wydział Rehabilitacji Ruchowej, AWF w Krakowie / Department of Rehabilitation in Traumatology, Faculty of Motor Rehabilitation, University School of Physical Education, Krakow, Poland
| | - Dorota Czechowska
- Zakład Rehabilitacji w Ortopedii, Wydział Rehabilitacji Ruchowej, AWF w Krakowie / Department of Rehabilitation in Orthopaedics, Faculty of Motor Rehabilitation, University School of Physical Education, Krakow, Poland
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Neuner B, Hadzidiakos D, Bettelli G. Pre- and postoperative management of risk factors for postoperative delirium: who is in charge and what is its essence? Aging Clin Exp Res 2018; 30:245-248. [DOI: 10.1007/s40520-017-0890-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/30/2017] [Indexed: 12/20/2022]
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