Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes

Impact of Prefracture Cognitive Impairment and Postoperative Delirium on Recovery after Hip Fracture Surgery

OBJECTIVES

This study aimed to examine the impact of prefracture cognitive impairment (CI) severity and postoperative delirium on recovery after hip fracture surgery in older patients.

DESIGN

Prospective study with a 1-year follow-up.

SETTING AND PARTICIPANTS

We included 355 patients aged ≥80 years from 2 acute hospitals in Japan.

METHODS

Barthel Index (BI) ambulation scores were assessed prefracture and at 1, 3, 6, and 12 months postoperatively. The score at each time point minus the prefracture score was used as the ambulation recovery variable. The 21-item Dementia Assessment Sheet for the Community-based Care System (DASC-21) and Confusion Assessment Method were used to assess CI severity and delirium, respectively. The impacts of CI severity and delirium on recovery at 1 month and by 12 months postoperatively were examined. Linear multiple regression and linear mixed effects models were used.

RESULTS

BI ambulation scores remained the same or improved from prefracture levels in 26.8%, 34.4%, 33.0%, and 30.4% of patients at 1, 3, 6, and 12 months, respectively. Ten patients (2.8%) had fall-related hip fractures, 20 (5.6%) were rehospitalized, and 43 (12.1%) died during this period. Although DASC-21 CI severity significantly affected the recovery both at 1 month and by 12 months postoperatively [standardized β (Stdβ) = -0.39, P < .0001, and Stdβ = -0.37, P < .0001, respectively], delirium did not. Other variables affecting recovery by 12 months postoperatively included prefracture BI ambulation scores, Mini Mental State Examination scores, age, fracture type, place of residence, and time.

CONCLUSIONS AND IMPLICATIONS

Postoperative ambulation recovery, excluding the effect of death and other poor outcomes, is influenced by prefracture CI severity, and the presence of delirium itself may not be the moderating variable. These results emphasize the importance of treatment planning based on prefracture CI severity and indicate that assessments such as the DASC-21 may be useful in implementing such a plan.

The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review

INTRODUCTION

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

METHODS

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

RESULTS

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively.

CONCLUSION

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia

Importance

The decision for surgical vs nonsurgical treatment for hip fracture can be complicated among community-dwelling people living with dementia.

Objective

To compare outcomes of community-dwelling people living with dementia treated surgically and nonsurgically for hip fracture.

Design, Setting, and Participants

This retrospective cross-sectional study undertook a population-based analysis of national Medicare fee-for-service data. Participants included community-dwelling Medicare beneficiaries with dementia and an inpatient claim for hip fracture from January 1, 2017, to June 30, 2018. Analyses were conducted from November 10, 2022, to October 17, 2023.

Exposure

Surgical vs nonsurgical treatment for hip fracture.

Main Outcomes and Measures

The primary outcome was mortality within 30, 90, and 180 days. Secondary outcomes consisted of selected post-acute care services.

Results

Of 56 209 patients identified with hip fracture (73.0% women; mean [SD] age, 86.4 [7.0] years), 33 142 (59.0%) were treated surgically and 23 067 (41.0%) were treated nonsurgically. Among patients treated surgically, 73.3% had a fracture of the femoral head and neck and 40.2% had moderate to severe dementia (MSD). Among patients with MSD and femoral head and neck fracture, 180-day mortality was 31.8% (surgical treatment) vs 45.7% (nonsurgical treatment). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI, 0.49-0.62; P < .001) and the adjusted OR was 0.59 (95% CI, 0.53-0.66; P < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% (surgical treatment) vs 34.9% (nonsurgical treatment). For patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture, the unadjusted OR of 180-day mortality was 0.67 (95% CI, 0.60-0.76; P < .001) and the adjusted OR was 0.71 (95% CI, 0.63-0.79; P < .001). For patients with femoral head and neck fracture, there was no difference in admission to a nursing home within 180 days when treated surgically vs nonsurgically.

Conclusions and Relevance

In this cohort study of community-dwelling patients with dementia and fracture of the femoral head and neck, patients with MSD and mild dementia treated surgically experienced lower odds of death compared with patients treated nonsurgically. Although avoiding nursing home admission is important to persons living with dementia, being treated surgically for hip fracture did not necessarily confer a benefit in that regard. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach.

Causal relationship between dementia and delirium: Insights from a bidirectional two-sample Mendelian randomization analysis

BACKGROUND

Our previous study found dementia as a significant risk factor for delirium development in elderly patients with hip fracture. However, the causal relationship between dementia and delirium remains unclear.

METHODS

To assess the causal relationship between delirium and dementia, we conducted a bidirectional Mendelian randomization (MR) analysis. Inversevariance weighted (IVW), weighted median, MR Egger, weighted mode, and simple mode were employed to conduct the MR analysis. Heterogeneity was assessed using the Cochran Q statistic in MR-Egger and IVW methods. Horizontal pleiotropy was examined via the MR pleiotropy residual sum and outliers (MR-PRESSO) and MR-Egger intercept tests.

RESULTS

The forward MR analysis revealed a significant association between unclassified dementia (1.604 (1.326-1.941), p = 1.12 × 10-6), Alzheimer's disease (1.259 (1.128-1.405), p = 4.10 × 10-5), and dementia with Lewy bodies (1.121 (1.026-1.225), p = 0.011) with an increased risk of delirium. In the reverse MR analysis, delirium was also suggested to increase the risk of unclassified dementia (1.133 (1.066-1.204), p = 6.31 × 10-5) and vascular dementia (1.246 (1.075-1.444), p = 0.003). These significant results were further validated in the multivariable MR analysis. No evidence of heterogeneity or horizontal pleiotropy was observed (p > 0.05).

LIMITATIONS

(1) Limited to European populations. (2) Sample population overlap between delirium and dementia. (3) Not all dementia subtypes were causally associated with delirium.

CONCLUSIONS

This study provides genetic evidence supporting a causal relationship between dementia and delirium, indicating that dementia may influence the risk of delirium while delirium may also increase the risk of dementia.

Risk prediction models for postoperative delirium in elderly patients with fragility hip fracture: A systematic review and critical appraisal

BACKGROUND

Elderly patients with fragility hip fracture continue to experience a high rate of postoperative delirium (POD), which has a significant negative impact on prognosis and imposes a huge economic burden. A number of risk prediction models have been developed to detect POD early. However, the risk of bias and clinical applicability of the models remain unclear. The aim of this study was to systematically evaluate risk prediction models for POD.

METHODS

CNKI, WanFang DATA, Vip Database, SinoMed, PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies published by July 2023. The literature was screened independently by two investigators. The Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) and the Prediction Model Risk of Bias Assessment Tool (PROBAST) were respectively used for data extraction, risk of bias, and applicability assessment.

RESULTS

A total of 16 studies on the construction of POD risk prediction models were included. The area under the ROC curve of the models ranges from 0.670 to 0.957. The most common predictors of POD included age, history of dementia, history of delirium, ASA classification, preoperative waiting time, and preoperative albumin level. All models had a high risk of bias, mainly due to inadequate sample size, inappropriate handling of missing data, a lack of model performance evaluation, and overfitting of the models.

CONCLUSIONS

Overall, risk prediction models for POD in fragility hip fracture patients are still in the development stage. The majority of POD prediction models have substantial bias risks, attributable primarily to poor reporting of analysis and evaluation of model performance. In future research, it is recommended to conduct validation of the models or develop localized prediction models with demonstrated high performance, with the aim of benefiting POD screening.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023449153.

The safety and effectiveness of enhanced recovery after surgery (ERAS) in older patients undergoing orthopedic surgery: a systematic review and meta-analysis

INTRODUCTION

To systematically review and analyze the safety and effectiveness of ERAS in older patients undergoing orthopedic surgeries.

MATERIALS AND METHODS

We searched PubMed, EMBASE, CINAHL, MEDLINE (Ovid), Web of Science, the Cochrane Library, and other databases to identify all randomized controlled studies and cohorts. We used the Cochrane Risk of Bias Assessment Tool and the Newcastle‒Ottawa Scale to assess the study quality. A meta-analysis was performed using the inverse variance weighting method.

RESULTS

This study included 15 studies involving a total of 2591 older patients undergoing orthopedic surgeries with 1480 in the ERAS group. The ERAS group had a lower incidence of postoperative complications than the control group (RR 0.52; 95% CI 0.42-0.65). Length of stay was 3.37 days lower in the ERAS group than in the control group (P < 0.01). And the ERAS protocol reduced the patient's postoperative VAS score (P < 0.01). Meanwhile, there was a lack of evidence of significant differences between the ERAS group and the control group in total bleeding and 30-day readmission rate.

CONCLUSIONS

The implementation of the ERAS program in older patients undergoing orthopedic surgeries is safe and effective. However, there is still a lack of standardization of protocols across institutions and centers for orthopedic surgery for older patients. Identifying ERAS components that are beneficial to older patients and developing ERAS protocols that are appropriate for older adults may further improve outcomes.