Acute Confusional State in Elderly Patients with Hip Fracture. Identification of risk factors and intervention using a prehospital and perioperative management program
Abstract: Abstract The overall aim of this thesis was to increase knowledge about underlying causes and perioperative risk factors of Acute Confusional State (ACS) in elderly patients with hip fracture and to investigate the effect of a multi-factorial intervention program in order to decrease the number of patients who develop ACS. The aim in paper I was to describe elderly patients with hip fracture on the basis of the American Society of Anesthesiologists’ ASA classification system and to identify preoperative risk factors in relation to the postoperative outcome measured up to 4-months after surgery. The aim in paper II was to identify perioperative risk factors in relation to postoperative outcome up to 4-months after surgery. In paper III the aim was to critically examine the Organic Brain Syndrome (OBS) Scale using the criteria and guidelines formulated by the Scientific Advisory Committee of the Medical Outcomes Trusts (SAC) for the evaluation of assessment instruments; and to investigate its relevance and suitability for use in various clinical settings. In paper IV the aim was to investigate whether an implementation of a multi-factorial intervention program including prehospital, pre-, intra- and postoperative treatment and care can reduce the incidence of acute ACS among elderly patients with hip fracture, lucid at admission to hospital. Design: In paper I and II a descriptive, cohort design was used, using data prospectively registered, and data retrospectively collected from medical records and nursing charts. The design used in study III was a two-stage strategy for identifying and reviewing scientific papers. In study IV a quasi-experimental, nonequivalent comparison group design was used. Results: In paper I risk factors for a poorer 4-month’s survival after hip fracture found were ‘ASA-status 3 and 4’, ‘more extensive fractures’, ‘age ≥85’, ‘male sex’, and ‘dependency in living.’ Mortality within 4-months was significantly associated with ‘ASA status 3 and 4’, ‘age ≥85 years’, ‘male sex’, ‘dementia diagnosis’, ‘Short Mental Status Questionnaire (SPMSQ) score <8 correct answers’, ‘prescribed drugs ≥4’, ‘hemoglobin <100 g/L’, ‘creatinine >100 micromol/L’, ‘dependency in living’, ‘unable to walk alone’, and ‘fracture other than undisplaced intracapsular’. In paper II significant perioperative risk factors for a poorer recovery and survival after hip fracture were ‘oxygen saturation (SpO2) <90 %’, ‘fasting time ≥12 hours’, and ‘blood transfusion ≥1 unit ’. ‘SpO2 <90 %’, and ‘blood transfusion ≥1’ unit were factors significantly associated with postoperative confusion, in-hospital complications and/or death within 4-months after hip fracture. A ‘postoperative hemoglobin <100 g/L’ was also significantly associated with postoperative confusion and in-hospital complications. In paper III the result showed that the OBS Scale in many aspects satisfies the requirements formulated by the SAC, but there is a need for additional evaluation, especially with regard to different forms of reliability, and the translation and adaptation to other languages. In paper IV the incidence of ACS was reduced by 64 % in the intervention group (29 of 131) compared to the control group (45 of 132) (p=0.031). Patients developing ACS had significantly higher levels of serious complications and 30-day mortality compared to patients without ACS. Conclusion: Elderly patients acutely admitted to hospital due to a hip fracture often suffer from increased morbidity. The incidence of complications is high in this patient group. It is of great importance that patients at risk of developing postoperative complications such as ACS are identified and treated promptly in order to prevent complications. Patient’s baseline characteristics, such as high age, number of prescribed drugs, or functional status are not possible to affect. On the other hand, factors such as oxygen saturation in blood, anemia, fluid balance, pain, or the length of fasting time are possible to intervene already at an early stage.
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