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Delirium in old patients with femoral neck fracture: risk factors, outcome, prevention and treatment
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Delirium is probably the most common presenting symptom of disease in old age. Delirium, as defined in DSM-IV, is a neuropsychiatric syndrome characterized by disturbance in attention and consciousness, which develops over a short period of time and where the symptoms tend to fluctuate during the course of the day. The overall aim was to increase knowledge about the risk factors and outcome of delirium in old patients with femoral neck fracture and to develop and evaluate a multi-factorial intervention program for prevention and treatment of delirium in these patients.

In a prospective study of 101 consecutive patients with a femoral neck fracture, 29.7% were delirious before surgery and another 18.8% developed delirium postoperatively. Of those who were delirious preoperatively all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and seemed to have more postoperative complications, such as infections. Patients with preoperative delirium had a poorer walking ability on discharge compared to patients with postoperative delirium only.

In a five-year prospective follow up study 30 out of 78 (38.5%) non-demented patients with a femoral neck fracture developed dementia. Twenty out of 29 (69%) who were delirious postoperatively developed dementia compared to 10 out of 49 (20%) who were not delirious during hospitalization (p<0.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years compared to 17/49 (34.7%) of those who remained lucid postoperatively (p=0.001).

A non-randomized multi-factorial intervention study with the aim of preventing and treating delirium among patients with femoral neck fracture (n=49) showed that the incidence of delirium was significantly lower than reported in previously published studies. The incidence of other postoperative complications was also lower and a larger proportion of the patients regained independent walking ability and could return to their previous living conditions on discharge.

A similar multi-factorial intervention program evaluated as a randomized controlled trial including 199 femoral neck fracture patients showed that fewer intervention patients than controls suffered postoperative delirium (56/102, 55% vs. 73/97, 75%, p=0.003). For intervention patients the postoperative delirium was also of shorter duration (5.0±7.1 days vs. 10.2±13.3 days, p=0.009). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from significantly fewer in-hospital complications, such as decubital 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).

In conclusion, pre- and postoperative delirium is common and seems to be associated with various risk factors, which require different strategies for prevention and treatment. Delirium is also associated with the development of dementia and a higher mortality rate. Multifactorial intervention programs can successfully be implemented and result in the reduction of delirium, fewer complications and shorter hospitalization.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2004. , 77 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 909
Keyword [en]
delirium, femoral neck fractures, dementia, risk factors, RCT, intervention, multifactorial, outcome, mortality
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-379ISBN: 91-7305-704-5 (print)OAI: oai:DiVA.org:umu-379DiVA: diva2:143321
Public defence
2004-12-17, Aulan, Vårdvetarhuset, Umeå, 09:00
Opponent
Available from: 2004-11-25 Created: 2004-11-25 Last updated: 2014-02-20Bibliographically approved
List of papers
1. Delirium before and after operation for femoral neck fracture
Open this publication in new window or tab >>Delirium before and after operation for femoral neck fracture
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2001 (English)In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 49, no 10, 1335-1340 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The aim of this study was to investigate the differences between preoperative and postoperative delirium regarding predisposing, precipitating factors and outcome in older patients admitted to hospital with femoral neck fractures.

DESIGN: A prospective clinical assessment of patients treated for femoral neck fractures.

SETTING: Department of orthopedic surgery at Umeå University Hospital, Sweden.

PARTICIPANTS: One hundred one patients, age 65 and older admitted to the hospital for treatment of femoral neck fractures.

MEASUREMENTS: The Organic Brain Syndrome (OBS) Scale.

RESULTS: Thirty patients (29.7%) were delirious before surgery and another 19 (18.8%) developed delirium postoperatively. Of those who were delirious preoperatively, all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, had been treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium, and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and had more postoperative complications such as infections. Male patients were more often delirious both preoperatively and postoperatively. Patients with preoperative delirium were more often discharged to institutional care and had poorer walking ability both on discharge and after 6 months than did patients with postoperative delirium only.

CONCLUSIONS: Because preoperative and postoperative delirium are associated with different risk factors it is necessary to devise different strategies for their prevention.

Keyword
delirium, femoral neck fractures, risk factors
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-4292 (URN)10.1046/j.1532-5415.2001.49261.x (DOI)11890492 (PubMedID)
Available from: 2004-11-25 Created: 2004-11-25 Last updated: 2017-12-14Bibliographically approved
2. Dementia after delirium in patients with femoral neck fractures.
Open this publication in new window or tab >>Dementia after delirium in patients with femoral neck fractures.
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2003 (English)In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 51, no 7, 1002-1006 p.Article in journal (Refereed) Published
Abstract [en]

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

DESIGN: A 5-year prospective follow-up study.

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

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

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

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

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

Keyword
delirium, dementia, femoral neck fractures, mortality
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-4293 (URN)10.1046/j.1365-2389.2003.51315.x (DOI)12834522 (PubMedID)
Available from: 2004-11-25 Created: 2004-11-25 Last updated: 2017-12-14Bibliographically approved
3. Reorganization of nursing and medical care to reduce the incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures
Open this publication in new window or tab >>Reorganization of nursing and medical care to reduce the incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures
1999 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 13, no 3, 193-200 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate the effectiveness of a nursing and medical intervention programme for the prevention and treatment of delirium in elderly patients treated for femoral neck fractures. Forty-nine patients consecutively admitted to an orthogeriatric rehabilitation unit in a county hospital in northern Sweden were compared with historical cohorts of corresponding patients in the same and other hospitals. There was a total reorganization of nursing and medical care of patients with femoral neck fractures. The intervention programme consisted of staff education, co-operation between orthopaedic surgeons and geriatricians, individual care and planning of rehabilitation, improved ward environment, active nutrition, improved continuity of care and prevention and treatment of complications associated with delirium. The main result of the study was that the incidence of delirium was significantly lower than in all previously published studies. The incidence of other postoperative complications was also lower, and a larger proportion of the patients regained independent walking ability and could return to their previous living conditions on discharge. It can be concluded that the intervention programme reduced the incidence and duration of delirium and improved functional outcome for elderly patients treated for femoral neck fractures.

Keyword
nursing intervention, delirium, rehabilitation, hip fracture
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-4294 (URN)10.1111/j.1471-6712.1999.tb00539.x (DOI)12033125 (PubMedID)
Available from: 2004-11-25 Created: 2004-11-25 Last updated: 2017-12-14Bibliographically approved
4. 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

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