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Old people with femoral neck fracture: delirium, malnutrition and surgical methods - an intervention program
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.ORCID iD: 0000-0002-3754-5026
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Hip fracture is a global and a growing public health problem. More women than men sustain hip fractures, the incidence increases exponentially with age and mean age is above 80. About one third of hip-fracture patients suffer from dementia and are prone to develop acute confusional state (delirium). Delirium is one of the most common complications after hip-fracture surgery, and seriously impacts on morbidity and mortality. Malnutrition is also common in hip-fracture patients and is associated with postoperative complications, such as delayed healing of the wound, infections and decubitus ulcers. Arthroplasty is usually preferred procedure in displaced femoral neck fractures but is, however, controversial in patients with dementia due to the fear of dislocation of the prosthesis.

The aims of this thesis are to identify risk factors for delirium and the impact of delirium on rehabilitation outcome, to evaluate whether a postoperative multi-factorial intervention program could reduce delirium, to investigate the effect of a nutritional intervention and to evaluate complications, functional outcome and mortality regarding two surgical methods, hemiarthroplasty (HAP) and internal fixation (IF), in old patients with femoral neck fracture.

Thirty-eight out of 61 consecutive patients (62%) were delirious on admission to hospital or developed postoperative delirium. An increased risk of postoperative delirium was found among hip-fracture patients with dementia and/or depression. Delirious patients were hospitalized longer, were more dependent in their activities of daily living, had poorer psychological well-being and suffered more complications than non-delirious patients.

A postoperative multi-factorial and multidisciplinary intervention program reduced the incidence, at 55% vs 75% (p=0.003), and number of days with delirium, 5 vs 10 days (p=0.009). Postoperative complications were also reduced; decubitus ulcers 9% vs 22% (p= 0.010), urinary tract infections 31% vs 51% (p=0.005), falls 12% vs 27% (p=0.007), and the mean hospitalization period was 10 days shorter in the intervention group (p=0.030). Malnutrition was common among all these patients (53 %) and associated with postoperative complications such as decubitus ulcers and delirium. However, the nutritional intervention had no effect on nutritional parameters at four months, nevertheless men had better nutritional outcomes than women.

A higher proportion of patients with dementia operated on using HAP had regained their pre-fracture ability to walk independently at the one-year follow up compared with those operated on using IF. Six of 83 patients dislocated their HAP during hospitalization and during an episode of delirium, none had dementia. No difference in mortality between the surgical methods was seen. Dementia per se should not be a reason to disqualify patients from being treated with the most appropriate surgical method.

It is clinically important to discriminate between dementia and delirium, since delirium can be prevented and treated even in patients with dementia. Old patients undergoing surgery have special needs that are not always catered for in ordinary orthopaedic or surgical wards. The special care for these patients should include: a combined nursing and medical care based on comprehensive geriatric assessments, systematic prevention, detection and treatment of postoperative complications such as delirium, hypoxemia, urinary tract infections, pain, malnutrition and an active rehabilitation. It is obvious that improved quality of care reduces patient suffering and seemingly the costs for society.

Place, publisher, year, edition, pages
Umeå: Kirurgisk och perioperativ vetenskap , 2007. , 89 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1093
Keyword [en]
delirium, hip fracture, older people, orthopaedics, internal fixation, arthroplasty cognitive impairment, dementia, nursing, rehabilitation, femoral neck fracture, RCT, intervention, geriatric team, malnutrition, nurses
National Category
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-1049ISBN: 978-91-7264-286-7 (print)OAI: oai:DiVA.org:umu-1049DiVA: diva2:140039
Public defence
2007-04-13, Sal B, Tandläkarhögskolan, 9 tr, 901 85, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2007-03-22 Created: 2007-03-22 Last updated: 2015-04-22Bibliographically approved
List of papers
1. Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures.
Open this publication in new window or tab >>Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures.
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2005 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 19, no 2, 119-127 p.Article in journal (Refereed) Published
Keyword
Activities of Daily Living, Aged, Aged; 80 and over, Delirium/epidemiology/*etiology/prevention & control, Dementia/complications, Depression/complications, Female, Femoral Neck Fractures/*complications/*rehabilitation/surgery, Follow-Up Studies, Fracture Fixation; Internal/methods, Geriatric Assessment, Health Services Needs and Demand, Hospitals; University, Humans, Length of Stay/statistics & numerical data, Male, Mental Health, Postoperative Care/methods/standards, Quality of Health Care, Questionnaires, Risk Factors, Sweden/epidemiology, Treatment Outcome
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8292 (URN)10.1111/j.1471-6712.2005.00324.x (DOI)15877637 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
2. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study.
Open this publication in new window or tab >>Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study.
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2007 (English)In: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 19, no 3, 178-186 p.Article in journal (Refereed) Published
Abstract [en]

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

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

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

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

Keyword
Aged, Aged; 80 and over, Delirium/etiology/*therapy, Female, Femoral Neck Fractures/*surgery, Humans, Male, Postoperative Complications/etiology/*therapy, Time Factors
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8279 (URN)10.1007/BF03324687 (DOI)17607084 (PubMedID)
Available from: 2008-01-17 Created: 2008-01-17 Last updated: 2017-12-14Bibliographically approved
3. Malnutrition in hip fracture patients: an intervention study.
Open this publication in new window or tab >>Malnutrition in hip fracture patients: an intervention study.
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2007 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 16, no 11, 2027-2038 p.Article in journal (Refereed) Published
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8289 (URN)10.1111/j.1365-2702.2006.01864.x (DOI)17419798 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
4. Osteosynthesis or prosthesis for demented patients with femoral neck fracture?
Open this publication in new window or tab >>Osteosynthesis or prosthesis for demented patients with femoral neck fracture?
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(English)In: Article in journal (Refereed) Submitted
Identifiers
urn:nbn:se:umu:diva-2169 (URN)
Available from: 2007-03-22 Created: 2007-03-22 Last updated: 2015-04-22Bibliographically approved

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