Association between delirium, adverse clinical events and functional outcomes in older patients admitted to rehabilitation settings after a hip fracture: A multicenter retrospective cohort study

Abstract

Aim The aim of the present study is to investigate how delirium and adverse clinical events (ACE) contribute independently and in combination to functional outcomes in older patients admitted to rehabilitation settings after a hip fracture. Methods This is a multicenter retrospective cohort study of patients aged ≥65 years admitted after hip fracture surgical repair to three Italian rehabilitation units. Delirium on admission was evaluated with the Confusion Assessment Method. ACE during the rehabilitation stay were recorded, including infections (i.e. urinary tract infections, other infections), non‐infectious ACE (i.e. cardiovascular events, respiratory failure, pulmonary embolism) and falls. A multivariable linear regression was used to evaluate the effect of ACE and delirium on functional outcome, adjusting for covariates determined a priori. Results A total of 519 patients were included in the study. The mean ± SD age was 82.9 ± 9.4 years. ACE occurred in 277 patients (53.4%), delirium alone was present in 19 patients (3.6%). Both conditions were present in 58 patients (11.2%). Compared with patients without delirium or ACE, those with ACE or delirium were more likely to have a worse functional outcome (−6.7 Barthel Index points [−11.6; −1.7]; P = 0.008; −13.2 [−25.6; −0.8]; P = 0.038) at discharge, and patients with both conditions had an even lower Barthel Index score (−18.6 Barthel Index points [−26.9; −10.3]; P < 0.001). Conclusions ACE and delirium are very common in older patients admitted to rehabilitation settings after hip fracture, and frequently coexist. As both ACE and delirium could impact on functional outcome, alone and in combination, a clinical geriatric approach is necessary for this population to minimize risks. Geriatr Gerontol Int 2019; 19: 404–408.

A two-year multicenter point prevalence study of older patients with hip fractures admitted to rehabilitation units in Italy

“…The presence of dysphagia and especially the acute dysphagia related for instance to the presence of delirium can lead to malnutrition with adverse outcomes on the rehabilitation process. In our investigation we found a 19% prevalence of malnutrition, which is likely underestimated compared to previous reports which indicate a prevalence ranging from 19 to to 46% assessing the nutritional status with the Mini Nutritional Assessment [28][29][30]. In our study protein supplements were prescribed only in 22.7% of the patients.…”

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

“…Return to independence in activities of daily living (ADLs) was less likely for those >85 years old (20% vs. 44%), with dementia (8% vs. 39%) and with a Charlson comorbidity index greater than 2 (23% vs 44%) [52] Functional outcomes after a hip fragility fracture seem to depend more on patient characteristics than treatment-related factors [127] In a retrospective cohort study of 519 patients with hip fracture admitted to rehabilitation settings, it has been reported that both delirium and clinical adverse events (infections, respiratory failure, pulmonary embolism, falls) affected functional outcome. A clinical orthogeriatric approach is necessary in order to minimize the impact of these adverse events on the rehabilitation program [128].…”

Improving the quality of delirium practices in a large Australian tertiary hospital: an evidence implementation initiative

“…The emphasis is on primary prevention using multicomponent, non-pharmacological interventions targeted to high-risk patients. 11,12 Various screening instruments, such as the Confusion Assessment Method (CAM), 4As Test (4AT), Delirium Triage Screen (DTS), Delirium Rating Scale (DRS) and Nursing Delirium Screening Checklist (NuDESC), have been developed to identify high-risk patients as well as diagnose and rate the severity of delirium. 13 Once delirium is detected, a comprehensive assessment is required and management strategies implemented.…”

“…Typically, the management of delirium involves a multicomponent approach that includes reorientation, adequate hydration and nutrition, sleep promotion, early mobilisation, reduction of psychoactive drugs and optimising use of vision and hearing devices. 12 It also requires an interdisciplinary approach that includes doctors, nurses and rehabilitation therapists along with well-informed and engaged families or caregivers. Families or caregivers, when provided with adequate information about the nature of delirium, symptoms and their integral role in the prevention Discussion: The quality improvement activity highlighted that education remains one of the most important and critical first steps in facilitating change in clinical practice.…”