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Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.ORCID iD: 0000-0002-3754-5026
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
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2007 (English)In: Aging Clinical and Experimental Research, ISSN 1594-0667, 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.

Place, publisher, year, edition, pages
2007. Vol. 19, no 3, 178-186 p.
Keyword [en]
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: urn:nbn:se:umu:diva-8279DOI: 10.1007/BF03324687PubMedID: 17607084OAI: oai:DiVA.org:umu-8279DiVA: diva2:147950
Available from: 2008-01-17 Created: 2008-01-17 Last updated: 2015-04-22Bibliographically approved
In thesis
1. Old people with femoral neck fracture: delirium, malnutrition and surgical methods - an intervention program
Open this publication in new window or tab >>Old people with femoral neck fracture: delirium, malnutrition and surgical methods - an intervention program
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
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:nbn:se:umu:diva-1049 (URN)978-91-7264-286-7 (ISBN)
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
2. Delirium in old patients with femoral neck fracture: risk factors, outcome, prevention and treatment
Open this publication in new window or tab >>Delirium in old patients with femoral neck fracture: risk factors, outcome, prevention and treatment
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
delirium, femoral neck fractures, dementia, risk factors, RCT, intervention, multifactorial, outcome, mortality
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-379 (URN)91-7305-704-5 (ISBN)
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

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Lundström, MariaOlofsson, BirgittaStenvall, MichaelKarlsson, StigNyberg, LarsEnglund, UndisSvensson, OlleGustafson, Yngve

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