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Reducing Delirium After Hip Fracture: A Randomized Trial

Authors

  • Edward R. Marcantonio MD, SM,

    1. Division of General Medicine and the
    2. Department of Medicine and Research and Training Institute, Hebrew Rehabilitation Center for Aged,
    3. Division on Aging, Harvard Medical School; and the
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  • Jonathan M. Flacker MD,

    1. Department of Medicine and Research and Training Institute, Hebrew Rehabilitation Center for Aged,
    2. Division on Aging, Harvard Medical School; and the
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  • R. John Wright MD,

    1. Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts;
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  • Neil M. Resnick MD

    1. Division of General Medicine and the
    2. Department of Medicine and Research and Training Institute, Hebrew Rehabilitation Center for Aged,
    3. Division on Aging, Harvard Medical School; and the
    4. Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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  • Portions of this paper were presented at the American Geriatrics Society National Meeting, 1999.

Address correspondence to Edward R. Marcantonio, MD, Department of Medicine, Hebrew Rehabilitation Center for Aged, 1200 Centre Street, Boston, MA 02131.

Abstract

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.

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