Time from admission to operation is a risk factor for preoperative delirium, whereas low BMI is an important risk factor for postoperative delirium in hip fracture patients. Cognitive impairment and indoor injury are independent risk factors for preoperative and postoperative delirium.

Background: Delirium is believed to constitute a risk factor for dementia, but previous research has failed to satisfactorily take account of the patients’ preexisting level of cognitive functioning. Methods: A prospective 6-month follow-up of 106 elderly hip fracture patients free from prefracture dementia. Delirium was assessed by the Confusion Assessment Method. Caregivers described the patients’ prefracture cognition by the Informant Questionnaire on Cognitive Decline in the Elderly, Short Form (IQCODE-SF). Cognition was measured after 6 months, using 5 validated cognitive tests. An expert panel assessed each case as to whether the diagnostic criteria for dementia according to the DSM-IV were fulfilled at baseline and after 6 months. Results: 29/106 patients (27%) developed delirium in the acute phase. In the delirious group, 11/29 (38%) fulfilled the criteria of dementia after 6 months, compared to 5/77 (7%) in the group without delirium (p < 0.001; χ² test). Delirium was the strongest predictor of dementia after 6 months (adjusted odds ratio: 10.5; 95% CI: 1.6–70.3). IQCODE-SF score was a nonsignificant risk factor for incident dementia. Conclusion: In hip fracture patients free from prefracture dementia, delirium constitutes the main predictor of dementia 6 months later, adjusted for prefracture cognitive decline measured by the IQCODE-SF.

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BackgroundDelirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia.MethodsProspective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively.ResultsPreoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively.ConclusionRisk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture.

Background: The relationship between delirium and mortality remains obscure. The aims of this study were to investigate the effect of delirium and the interaction between delirium and chronic cognitive impairment on mortality in elderly hip fracture patients. Methods: This is a prospective observational study, including 331 hip fracture patients. Information on comorbidity, medications and clinical findings was collected at the time of fracture. Information on cause and time of death was obtained from the Norwegian Cause of Death Register. Patients were screened for delirium by the Confusion Assessment Method. Results: Delirium was not associated with mortality when adjusting for the severity of chronic cognitive impairment, measured by the Infor- mant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Estimated by Kaplan-Meier plots, delirium in patients with dementia was significantly associated with an increased risk of death from stroke (p = 0.004) and dementia (p ≤ 0.001). Conclusions: No association between delirium and mortality was demonstrated when adjusting for the IQCODE score, but delirium in patients with prefracture dementia was associated with an increased risk of death from stroke and dementia. The effect of delirium on the cause of death might be explained by an aggravation of an ongoing neuro-inflammation.

BackgroundThe mortality after hip fracture has remained high and stable the past 50 years despite improved surgical treatment. The aim of this study was to identify medications and medical factors associated with mortality after hip fracture.MethodsThis is a prospective observational study with median observation time of 21 months. Three hundred and sixty-four patients, mean age 83.4 years and 75.8% women, were enrolled. Information on comorbidity, medications, surgery, and clinical findings were collected at the time of fracture. Information on cause and time of death was obtained from the Norwegian Cause of Death Register.ResultsSix risk factors and one protective factor were identified by Cox proportional hazards model adjusted for propensity score: the use of diuretics (adjusted hazard ratio [HR] = 4.03, 95% confidence interval [CI] = 2.13–7.64), history of coronary heart disease (CHD) (HR = 2.61, CI = 1.37–4.98), male sex (HR = 2.32, CI = 1.27–4.24), Barthel Index ≤ 18/20 (HR = 2.48, CI = 1.23–5.01), heart rate > 100 on admission (HR = 2.47, CI = 1.18–5.14), body mass index ≤ 20 (HR = 1.94, CI = 1.13–3.34), and the use of statins (HR = 0.23, CI = 0.08–0.68). Patients using diuretics had increased risk of death from all causes, including death from CHD, chronic obstructive pulmonary disease, and falls or other accidents.ConclusionsThe use of diuretics is the strongest predictor of mortality, followed by CHD at the time of fracture, whereas the use of statins is associated with improved survival. Future research is needed to evaluate whether improved diagnosis and management of CHD and congestive heart failure among hip fracture patients would improve survival.

Background A validated questionnaire to assess medication management of hip fracture patients within and outside the hospital setting was lacking. The study aims were to describe the hip fracture patient pathway, and develop a valid and feasible questionnaire to assess clinicians’ experience with medication management of hip fracture patients in different care settings throughout the patient pathway. Methods This qualitative, descriptive methodological study used strategic and snowball sampling. The questionnaire was developed, and face and content validity explored through interviews with stakeholders. Phase I described the hip fracture patient pathway, and identified questionnaire dimensions in semi-structured interviews with management and clinicians (n = 37). The patient pathway was also discussed in six meetings (n = 70). Phase II refined a first draft of the questionnaire through cognitive interviews with future respondents (n = 23). The draft was modified after each interview. Post hoc, cognitive interview data were analysed using matrix analysis to condense problems and solutions into themes and subthemes. Phase III, converted the final version to a digital format, and tested its feasibility with a subset of the cognitive interview participants (n = 21) who completed the questionnaire and provided feedback. Results Phase I: Hip fracture patients were cared for in at least three different care settings, and went through at least four handovers between and within primary and secondary care. Three questionnaire dimensions were identified: 1) Medication reconciliation and review, 2) Communication of key information, and 3) Profession and setting. Phase II: The MedHipPro-Q was representative of how the different professions experienced medication management in all settings, and hence showed face and content validity. Post hoc analysis: Problem themes (with sub-themes) were Representativeness (-of patient pathway and -of respondent reality) and Presentation (Language and Appearance). Solution themes (with sub-themes) were: Content (added or deleted) and Presentation (modified appearance or corrected language). Phase III: Participants did not identify technical, linguistic or content flaws in the questionnaire, and the digital version was considered feasible for use. Conclusion The novel MedHipPro-Q showed good face and content validity, and was feasible for use throughout the hip fracture patient pathway. The rigorous development process supports its construct validity and reliability.