Effects of a hospitalist model on elderly patients with hip fracture

BACKGROUND: Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. METHODS: During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. RESULTS: The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. CONCLUSION: In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.     

Delirium is independently associated with poor functional recovery after hip fracture

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.     

Reducing delirium after hip fracture: a randomized trial

OBJECTIVES: Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture. DESIGN: Prospective, randomized, blinded. SETTING: Inpatient academic tertiary medical center. PARTICIPANTS: 126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm. RESULTS: The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment. CONCLUSIONS: Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients.     

Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial

OBJECTIVES: To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. DESIGN: Randomized, controlled intervention trial. SETTING: Orthopedic ward in a university hospital. PARTICIPANTS: Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. INTERVENTION: Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. MEASUREMENTS: Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. RESULTS: Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. CONCLUSION: Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.     

Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients

The objectives of this study were to characterize patterns of opioid analgesia in elderly hip fracture patients, to investigate the possible differences in the treatment of cognitively impaired, delirious, or cognitively intact patients, and to study the factors that may affect the doses received by such patients. This retrospective study comprised 184 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini-mental state examination, assessment of possible delirium by the confusion assessment method, type and doses of opioid received by these patients. We found that the amount of morphine equianalgesic dose differed significantly between demented and non-demented patients (7.5 +/- 1.8 vs. 14.1 +/- 4.9, P<0.001). Patients with cognitive decline or with delirium received only 53 and 34%, respectively, of the amount of opioid that was administered to cognitively intact patients. A significant association was observed between cognitive status, or delirium, and amount of opioid analgesia (P<0.001 and P=0.003, respectively). Other parameters such as age, length of stay and type of fracture, had no effect on the use of opioid analgesia. It is concluded that the management of pain in older persons with hip fracture surgery is suboptimal with regards to insufficient administration of opioid analgesia in demented and delirious patients. The adoption of a standardized protocol for pain control may help in reducing the extent of this problem.     

Impact of prospective payment and discharge location on the outcome of hip fracture

OBJECTIVE: To determine the impact of prospective payment by diagnosis-related groups (DRGs) on length of stay in the hospital, ambulatory status, and level of post-hospital care needed for patients hospitalized with hip fracture. DESIGN: Retrospective chart review of a consecutive series of cases before and after the reference date of implementation of the prospective payment system (PPS). SETTING: Academic, tertiary-care hospital. PATIENTS/PARTICIPANTS: 181 patients 69 years of age or older admitted with International Classification of Diseases (ICD) or DRG codes for hip fracture. RESULTS: Length of stay was shorter by 1.37 days in the post-PPS era (p = 0.05). Poorer discharge ambulation was found in the post-PPS group (p = 0.089). At one year, differences in ambulation and nursing home residence were found to be related not to the implementation of PPS, but rather to the nursing home to which the patient was discharged. Patients discharged to a facility with active physical rehabilitation were less likely to remain institutionalized (p = 0.0025) than those in "ordinary" nursing homes and ambulated more independently (p = 0.05). CONCLUSIONS: The PPS did not have a significant long-term impact on hip fracture outcome. Post-hospital care may be of crucial importance to the future quality of life of hip fracture patients.     

The impact of cognitive impairment on short-term outcomes of hip fracture patients

The purpose of this study is to examine the differences in outcomes related to recovery after hip fracture among patients with and without cognitive impairment. This is a prospective cohort study of consecutively hospitalized elderly patients with acute hip fracture in a setting utilizing a multidisciplinary hip fracture service. Of the 48 patients admitted with hip fracture, 18 patients were found to have cognitive impairment postoperatively as determined by a Mini-Mental State Examination (MMSE) score 相似文献   

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM： To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS： A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service （medical or surgical）. Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS： Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography （ERCP, P = 0.01） as well with admission to medical service without adjustment for ERCP （P 〈 0.05）. Patients undergoing both magnetic resonance cholangiopancreatography （MRCP） and computed tomography （CT） scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier （30.4 ± 34.9 vs 82.7 ± 55.1 h, P 〈 0.01）, had less post-operative complications （12% vs 58%, P 〈 0.01）, and shorter length of stay （4.3 ± 3.4 vs 8.1 ± 5.2 d, P 〈 0.01）.CONCLUSION： Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed     

Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study

Objectives: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip‐surgery patients at risk for delirium. Design: Randomized, double‐blind, placebo‐controlled trial. Setting: Large medical school–affiliated general hospital in Alkmaar, the Netherlands. Participants: A total of 430 hip‐surgery patients aged 70 and older at risk for postoperative delirium. Intervention: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. Measurements: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version‐98 (DRS‐R‐98)), the duration of delirium, and the length of hospital stay. Results: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6–1.3); the mean highest DRS‐R‐98 score±standard deviation was 14.4±3.4 and 18.4±4.3, respectively (mean difference 4.0, 95% CI=2.0–5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI=4.0–8.0; P<.001); and the mean number of days in the hospital was 17.1±11.1 and 22.6±16.7, respectively (mean difference 5.5 days, 95% CI=1.4–2.3; P<.001). No haloperidol‐related side effects were noted. Conclusion: Low‐dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated.     

Comparison of Dexmedetomidine versus Propofol for Sedation in Mechanically Ventilated Patients after Cardiovascular Surgery

Many cardiovascular surgeries are fast-tracked to extubation and require short-term sedation. Dexmedetomidine and propofol have very different mechanisms of action and pharmacokinetic profiles that make them attractive sedative agents in this patient population. Recently, there has been increased use of dexmedetomidine in the intensive care unit (ICU), but few studies exist or have been published directly comparing both agents in this setting. We conducted a retrospective cohort study with patients admitted to the ICU after cardiovascular surgery from January through June 2011. Adult patients who underwent coronary artery bypass and/or cardiac valve surgery received either dexmedetomidine or propofol continuous infusion for short-term sedation after cardiovascular surgery. The primary end point was time (hours) on mechanical ventilation after surgery. Secondary end points included ICU length of stay (LOS), hospital LOS, incidence of delirium, and requirement of a second sedative agent. A total of 352 patients met study inclusion criteria, with 33 enrolled in the dexmedetomidine group and 319 in the propofol group. Time on mechanical ventilation was shorter in the dexmedetomidine group (7.4 hours vs. 12.9 hours, P = .042). No difference was seen in ICU or hospital LOS. The need for a second sedative agent to achieve optimal sedation (24% vs. 27%, P = .737) and incidence of delirium (9% vs. 7.5%, P = .747) were similar between both groups. Sedation with dexmedetomidine resulted in a significant reduction in time on mechanical ventilation. However, no difference was seen in ICU or hospital LOS, incidence of delirium, or mortality.     

Predictors of hospital readmission in a cohort of 236 elderly discharged after surgical repair of hip fracture: one-year follow-up

BACKGROUND AND AIMS: Few studies have investigated predictors for hospital readmission after hip fracture repair. METHODS: In a prospective cohort study we evaluated factors associated with early (within 3 months) and late (between 3-12 months), single and multiple hospital readmission in 236 hip-fractured older adults admitted to an orthopedic unit. Baseline patient characteristics and hospital course (functional and cognitive status, comorbidity, type of fracture, time to surgery, in-hospital stay, complications) were recorded. Hospital readmission over 12 months and ICD-9 principal diagnosis were ascertained from administrative sources. Functional status at the end of the rehabilitation program was assessed by telephone interviews. RESULTS: Seventy-one patients (30.1%) were readmitted to hospital within twelve months of discharge and 22 (9.3%) had two or more readmission. The total number of readmissions was 105, 43 (41%) occurred in the first three months. The most common readmission causes were cardiac, infectious and cerebrovascular; surgical complication accounted for 5.7%. Patients with a single readmission, like those with multiple readmissions, were sicker (CIRS-CI subscore 4.0+/-1.8 vs 3.2+/-1.6, p=0.010) and more functionally impaired at the end of rehabilitation (2 months' Katz index 2.1+/-2 vs 2.9+/-2.3, p=0.007) than controls. In a multiple logistic regression model, comorbidity and functional status at the end of rehabilitation were the only factors associated with the risk of readmission. CONCLUSIONS: Subjects at high risk of readmission can be reliably assessed, since few significant variables were associated with rehospitalization. Subgroups of patients with an elevated risk of rehospitalization after hip fracture may be the target for strategies to reduce the burden of excessive hospital use and improve overall outcomes.     

The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study

OBJECTIVES: To investigate whether a care pathway for older hip fracture patients can reduce length of stay while maintaining the quality of clinical care. DESIGN: Prospective study of patients admitted 12 months before and after implementation of a care pathway for the management of femoral neck fracture. Audit data for corresponding time periods from nearby orthopaedic units was used to control for secular trends. SETTING: Teaching hospital. SUBJECTS: Patients aged 65 years and over with a femoral neck fracture. Exclusion criteria: multiple fractures, fractures due to malignancy, re-fracture, total hip replacement, previously entered into the study, operation performed elsewhere. Three-hundred and ninety-five (99%) and 369 (97%) case records were available for full analysis. Main outcome measures: primary outcome: length of stay on the orthopaedic unit. Secondary outcomes: ambulation at discharge, discharge destination, in-hospital complications, 30 day mortality, readmission within 30 days of discharge, post-operative days the patient first sat out of bed and walked. RESULTS: Mean length of stay increased by 6.5 days (95% confidence interval 3.5-9.5 days, P < 0.0005) in the second period with a significant improvement in ambulation on discharge (odds ratio 1.6, 95% confidence interval 1.0-2.6, P = 0.033) and a trend towards reduction in admission to long term care (odds ratio 0.6, 95% confidence interval 0.3-1.0, P = 0.058). CONCLUSIONS: This care pathway was associated with longer hospital stay and improved clinical outcomes. Care pathways for hip fracture patients can be a useful tool for raising care standards but may require additional resources.     

One-year mortality after hip fracture in older individuals: the effects of delirium and dementia

BackgroundDelirium is common in older hip fracture patients, yet its association with mortality after hip fracture remains uncertain. This study aimed to determine whether delirium was associated with all-cause one-year mortality after hip fracture in older patients and whether the effect of delirium was independent of dementia status.MethodA retrospective analysis of linked hospitalisation and mortality data for patients aged ≥65 years with a hip fracture during 1 January 2010 to 30 June 2014 in New South Wales, Australia. The association between delirium and mortality after a hip fracture was assessed using Cox proportional hazard regression.ResultsThere were 4,065 (14.6%) of 27,888 hip fracture hospitalisations identified with delirium during hospitalisation. Individuals with delirium had a higher age-adjusted rate of all-cause one-year mortality after hip fracture compared to individuals without delirium (35.3% versus 23.9%). After adjusting for covariates, the risk of all-cause mortality was increased at one-year post-admission for older individuals compared to those aged 65-69 years, for individuals with multiple comorbidities, dementia (Hazard Ratio (HR): 1.14; 95%CI:1.08-1.20), delirium (HR: 1.19; 95%CI:1.12-1.26), and who had an Intensive Care Unit admission (HR: 1.44; 95%CI:1.31-1.59). Comorbid delirium did not add additional mortality risk for individuals with a hip fracture who have dementia.ConclusionsDelirium identified in hospital was associated with all-cause one-year mortality after hip fracture in older Australians without dementia. As delirium is potentially preventable, better systematic assessment and documentation of a hip fracture patient’s cognitive state is warranted to select the most effective strategies to prevent and manage delirium.     

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. DESIGN: Controlled trial based on assignment by convenience. SETTING: Trauma ward in a university hospital. PARTICIPANTS: One hundred seventy‐one people with hip fracture aged 65 and older. INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between‐group differences could be documented for mortality, new nursing home admission, or readmission rate. CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more‐intensive approach with more‐direct control over patient management, more‐specific recommendations, and more‐intense education would be effective.     

Does functional recovery in elderly hip fracture patients differ between patients admitted from long-term care and the community?

BACKGROUND: It is largely unknown whether functional recovery following hip fracture differs between long-term care (LTC) and community-dwelling residents. Our primary purpose was to compare recovery between these patients 6 months following hip fracture, controlling for known prognostic factors. Secondarily, we examined the contribution of residential status, in addition to patient characteristics, to functional recovery. METHODS: We studied a population-based inception cohort of 451 hip fracture patients >/= 65 years old admitted to one Canadian health region hospital between July 1999 and September 2000. Participants completed the Modified Barthel Functional Index (MBI) in hospital and again via telephone interviews 6 months postoperatively. Data were also collected on surgery and rehabilitation timing, length of hospital stay (LOS). and discharge destination. Relative change from prefracture function adjusting for known prognostic factors, and the proportion of participants returning to prefracture function were compared between the LTC and community-dwelling residents. RESULTS: LTC residents (n = 115) were older, with lower function prefracture, more comorbidities, and increased dementia than community-dwelling residents (n = 336). Six months postfracture, 17 (22%) LTC and 180 (71%) community-dwelling residents had regained prefracture function (p <.001). LTC residents had 33% lower (-40.6, -27.2) and community-dwelling residents 11.6% lower (-14.8, -8.4) 6-month MBI scores relative to prefracture scores after risk adjustment. Residential status was significantly associated with risk-adjusted functional recovery (p <.001). Median LOS was 4 days less for LTC than for community-dwelling residents (p <.001). Twelve (10%) LTC and 266 (79%) community-dwelling residents were discharged to inpatient rehabilitation (p <.001). CONCLUSION: Following hip fracture, most LTC residents do not regain prefracture function irrespective of known prognostic factors. Further investigation is needed as to the extent to which personal and environmental characteristics contribute to outcome after hip fracture.     

Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair

OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity in a cohort of patients aged 65 and older; to examine the association between severity of delirium and patient outcomes; and to examine the association between psychomotor variants of delirium and each of those outcomes. DESIGN: Prospective assessment of sample. SETTING: Hospital. PARTICIPANTS: One hundred twenty-two older patients (mean age +/- standard deviation = 79 +/- 8) who had undergone acute hip fracture surgery. MEASUREMENTS: We used standardized instruments to assess prefracture activities of daily living (ADLs), ambulatory status, cognition, and living situation. Postoperatively, each patient was interviewed daily. Delirium was diagnosed using the Confusion Assessment Method (CAM), and delirium severity was measured using the MDAS. The MDAS was also used to categorize the psychomotor types of delirium into "purely hypoactive" or "any hyperactivity." Telephone or face-to-face interviews were conducted at 1 and 6 months to assess survival, ADL function, ambulatory status, and living situation. RESULTS: Of 122 patients, 40% developed CAM-defined delirium. Delirious patients had higher average MDAS scores than nondelirious patients (11.7 vs 2.4, P <.0001). We used the median of the average MDAS score to classify patients into mild or severe delirium. Severe delirium was generally associated with worse outcomes than was mild delirium, and the associations reached statistical significance for nursing home placement or death at 6 months (52% vs 17%, P =.009). Additionally, patients who did not meet full CAM criteria for delirium experienced worse outcomes if they had some symptoms of delirium than if they had no or few symptoms (nursing home placement or death at 6 months: 27% vs 0%, P =.001). Surprisingly, these patients with subsyndromal delirium who did not fulfill CAM criteria for delirium but demonstrated significant delirium symptoms, had outcomes similar to or worse than those with mild CAM-defined delirium. Pure hypoactive delirium accounted for 71% (34/48) of cases and was less severe than was delirium with any hyperactivity (average MDAS score 10.6 vs 14.8, P =.007). In our cohort, patients with pure hypoactive delirium had better outcomes than did those with any hyperactivity (nursing home placement or death at 1 month: 32% vs 79%, P =.003); this difference persisted after adjusting for severity. CONCLUSION: In this study of delirium in older hip fracture patients, the MDAS, a continuous severity measure, was a useful adjunct to the CAM, a dichotomous diagnostic measure. In patients with CAM-defined delirium, severe delirium was generally associated with worse outcomes than was mild delirium. In patients who did not fulfill CAM criteria, subsyndromal delirium was associated with worse outcomes than having few or no symptoms of delirium. Patients with subsyndromal delirium had outcomes similar to patients with mild delirium, suggesting that a dichotomous approach to diagnosis and management may be inappropriate. Pure hypoactive delirium was more common than delirium with any hyperactive features, tended to be milder, and was associated with better outcomes even after adjusting for severity. Future studies should confirm our preliminary associations and examine whether treatment to reduce the severity of delirium symptoms can improve outcomes after hip fracture repair.     

Does cognitive performance affect physical therapy regimen after hip fracture surgery?

BACKGROUND AND AIMS: To evaluate whether and which clinical factors affect the regimen of physical therapy (PT) treatment in elderly patients after hip fracture (HF). METHODS: HF patients consecutively admitted to a rehabilitation unit (from January 2002 to May 2004) without adverse clinical events on admission or during hospital stay were considered (n=80). All patients underwent multidimensional assessment including demographic, clinical, cognitive, affective and functional status. Outcome measure was the number of rehabilitative procedures (NRP), computed as the ratio between sum of rehabilitative procedures and length of hospital stay. RESULTS: Patients received 3.8+/-1.3 NRP on average, although with large variability. Age and impairment of cognitive and pre-fracture functional status were significantly higher in those receiving fewer NRP. In a multiple regression model, only the Mini Mental State Examination (MMSE) significantly predicted NRP: compared with patients with MMSE < or =17, those with MMSE = 18-23, 24-26 and > or =27 received 0.3 (95% CI - 0.5-1.1, p=0.46), 1.5 (95% CI 0.6-2.4, p=0.001), and 1.6 (95% CI 0.7-2.5, p=0.001) more NRP. CONCLUSIONS: Cognitive performance affects NRP in elderly HF patients. Specific rehabilitative approaches, according to baseline cognitive performance, should be considered.     

Development of a postoperative delirium risk scoring tool using data from the Australian and New Zealand Hip Fracture Registry: an analysis of 6672 patients 2017-2018

Background and purposeThis study aimed to determine the incidence, predictors of postoperative delirium and develop a post-surgery delirium risk scoring tool.Patients and MethodsA total of 6672 hip fracture patients with documented assessment for delirium were analyzed from the Australia and New Zealand Hip Fracture Registry between June 2017 and December 2018.Thirty-six variables for the prediction of delirium using univariate and multivariate logistic regression were assessed. The models were assessed for diagnostic accuracy using C-statistic and calibration using Hosmer-Lemeshow goodness-of-fit test. A Delirium Risk Score was developed based on the regression coefficients.ResultsDelirium developed in 2599/6672 (39.0%) hip fracture patients. Seven independent predictors of delirium were identified; age above 80 years (OR=1.6 CI 1.4-1.9; p=0.001), male (OR=1.3 CI 1.1-1.5; p=0.007), absent pre-operative cognitive assessment (OR=1.5 CI 1.3-1.9; p=0.001), impaired pre-operative cognitive state (OR=1.7 CI 1.3 -2.1; p=0.001), surgery delay (OR=1.7 CI 1.2-2.5; p=0.002) and mobilisation day 1 post-surgery (OR=1.9 CI 1.4-2.6; p=0.001). The C-statistics for the training and validation datasets were 0.74 and 0.75, respectively. Calibration was good (χ2=35.72 (9); p<0.001). The Delirium Risk Score for patients ranged from 0 to 42 in the validation data and when used alone as a risk predictor, had similar levels of diagnostic accuracy (C-statistic=0.742) indicating its potential for use as a stand-alone risk scoring tool.ConclusionWe have designed and validated a delirium risk score for predicting delirium following surgery for a hip fracture using seven predicting factors. This could assist clinicians in identifying high risk patients requiring higher levels of observation and post-surgical care.     

A short comprehensive assessment to predict outcome of elderly patients after hip fracture

BACKGROUND AND AIMS: Hip fractures result in significant functional impairment and a high rate of institutionalization. The aim of our study was to evaluate in patients with a recent hip fracture the contribution of a short (15-min) comprehensive assessment to predict the length of stay and the risk of discharge to a nursing home. METHODS: Prospective clinical study conducted in a rehabilitation ward of the Geriatric Hospital. Functional assessment included basic activities of daily living (BADL), cognitive status (MMSE) and a 4-item geriatric depression scale (Mini-GDS). Information on demographic data, living situation, diagnosis and illness burden was also collected. RESULTS: The mean age of the 86 patients (67W/19M) was 84.2 +/- 6.8 years. In a multiple regression analysis, the length of stay in a geriatric hospital was significantly associated with both marital status (living alone) (p = 0.035) and the intervention of a caregiver on a regular basis (p = 0.036), but not with Charlson's comorbidity score. In a logistic regression model, adjusted for age, gender, marital status, intervention of a caregiver on a regular basis, BADL, Mini-GDS and Charlson's comorbidity score, the only independent predictor of nursing home admission was a MMSE < 24, which increased by 10.7-fold (2.2-50.9) the risk of being admitted to a nursing home (p = 0.003). CONCLUSIONS: A short comprehensive assessment completed a few days after a hip fracture is useful in predicting length of stay and risk of nursing home admission.     

A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients

OBJECTIVES: To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients. DESIGN: Prospective intervention study. SETTING: Department of General Internal Medicine, Sundsvall Hospital, Sweden. PARTICIPANTS: Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward. INTERVENTION: The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care. MEASUREMENTS: The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03). CONCLUSION: This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.