Abstract
Objectives
To identify risk factors of postoperative delirium among hip fracture patients with normal preoperative cognition, and examine associations with returning home or recovery of mobility.
Design
Prospective cohort study.
Setting and Participants
We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018–2019), but excluded those with abnormal cognition [abbreviated mental test score (AMTS) < 8] on presentation.
Methods
We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1–3 being an intermediate score not excluding delirium.
Results
Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home [odds ratio (OR), 0.46; 95% CI, 0.38–0.55] or regain outdoor mobility (OR, 0.63; 95% CI, 0.53–0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81–0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1–3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance.
Conclusion and Implications
Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
To identify risk factors of postoperative delirium among hip fracture patients with normal preoperative cognition, and examine associations with returning home or recovery of mobility.
Design
Prospective cohort study.
Setting and Participants
We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018–2019), but excluded those with abnormal cognition [abbreviated mental test score (AMTS) < 8] on presentation.
Methods
We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1–3 being an intermediate score not excluding delirium.
Results
Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home [odds ratio (OR), 0.46; 95% CI, 0.38–0.55] or regain outdoor mobility (OR, 0.63; 95% CI, 0.53–0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81–0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1–3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance.
Conclusion and Implications
Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
| Original language | English |
|---|---|
| Pages (from-to) | 694-701.e7 |
| Number of pages | 15 |
| Journal | Journal of the American Medical Directors Association |
| Volume | 24 |
| Issue number | 5 |
| Early online date | 15 Mar 2023 |
| DOIs | |
| Publication status | Published - 1 May 2023 |
Bibliographical note
Funding Information:This work was performed to provide individual hospitals participating in the NHFD with information on the association between delirium after hip fracture and 120-day outcomes, and on risk factors for delirium. This was part of a Royal College of Physicians audit program commissioned by the HealthCare Quality Improvement Partnership (HQIP). This study was also supported by Research England Policy Support Funding ( University of Bristol ), in addition to the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol (Grant Reference number: IS-BRC-1215-20011 ). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Funding Information:
This work was performed to provide individual hospitals participating in the NHFD with information on the association between delirium after hip fracture and 120-day outcomes, and on risk factors for delirium. This was part of a Royal College of Physicians audit program commissioned by the HealthCare Quality Improvement Partnership (HQIP). This study was also supported by Research England Policy Support Funding (University of Bristol), in addition to the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol (Grant Reference number: IS-BRC-1215-20011). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Publisher Copyright:
© 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine