NIHR Signal Comprehensive assessment may reduce risk of delirium after hip fracture

Published on 29 August 2017

Comprehensive geriatric assessment reduced the risk of delirium by 20% in patients having hip fracture surgery. Forty-three percent developed delirium on average compared with 53% who didn’t receive these assessments.

The assessment of the older persons’ medical condition was typically undertaken by a team of healthcare professionals who assessed functional ability, living circumstances and risk factors in order to develop a tailored plan for prevention and treatment of delirium after surgery.

This review identified four trials in people having surgery for hip fracture. Two assessed teams where geriatricians visited patients on orthopaedic wards. The other trials reported ward assessments where patients were already being looked after on an elderly care ward.

The ‘team’ assessments reduced the risk of delirium more than ‘ward’ assessments, though caution should be taken due to the small number of trials.

No trials came from the UK, but were from countries with similar populations and health systems. The results support current UK guidelines that recommend that all older people with hip fracture are assessed for delirium and receive multidisciplinary care from orthopaedic and geriatrician teams.

Why was this study needed?

Hip fracture is the most common form of serious injury in older adults and up to a third die within one year. Patients with hip fracture take up 1.5 million hospital bed days, with NHS and societal costs of £1 billion a year. This is equivalent to 1% of the entire NHS budget.

Delirium is a state of acute mental confusion. It’s the most common complication of hip fracture occurring in about 61% of this population and is associated with an increased risk of death.

Comprehensive geriatric assessment (CGA) is a process that assesses older people’s medical problems, mental health, functional ability and social circumstances with the aim of developing a tailored management plan.

A previous review of 20 studies has shown that CGA increases the chance of survival and of returning to independent life in a general population of older people admitted to hospital as an emergency.

The researchers wanted to find out how effective CGA is in preventing delirium after surgery for a hip fracture.

What did this study do?

This systematic review identified four randomised controlled trials including 973 patients who had hip fracture surgery with or without comprehensive geriatric assessment (CGA).

Two trials examined team-based CGA where geriatricians reviewed patients on orthopaedic wards, one with daily visits daily and the other on an “as needed” basis (reactive consultation). Two trials evaluated ward-based assessments on a geriatric ward. Studies varied in patient inclusion criteria, with most excluding fracture due to cancer.

All trials assessed delirium rates, and this was the main (primary) outcome for three of the four. In three studies doctors assessing delirium knew whether assessments had been performed which could have biased results in favour of a benefit in this group.

Trials were conducted in the US, Sweden, Norway and Spain, countries with similar health systems to the UK.

What did it find?

  • Any type of assessment reduced the risk of delirium by 20% (relative risk [RR] 0.81, 95% confidence interval [CI] 0.69 to 0.94, four studies). Forty-three percent of patients who had an assessment developed delirium compared with 53% of those who didn’t.
  • When analysed by assessment type, only those delivered by a visiting team reduced the risk of delirium. Delirium rates were 34% for ‘team’ assessments vs 43% without (RR 0.77, 95% CI 0.61 to 0.98). Fewer people who received ward assessments developed delirium (51%) than those without (60%) but this difference fell short of statistical significance (RR 0.83, 95% CI 0.64 to 1.08). However, there was considerable difference in the results of these two studies, so caution is needed when interpreting this result.
  • No consistent effects of the assessments were observed for hospital length of stay (which varied from five to 38 days across studies), severity or duration of delirium, or in-hospital mortality.

What does current guidance say on this issue?

NICE guidelines (2011) recommend that to minimise the risk of delirium and maximise patient independence, healthcare professionals should actively look for cognitive impairment when patients first present with hip fracture. NICE recommend that all patients receive multidisciplinary management from admission, with an orthogeriatric or orthopaedic ward-based Hip Fracture Programme that identifies goals to help recover mobility and independence.

The British Geriatrics Society also recommends joint orthopaedic and geriatrician care for older people with fractures. The society doesn’t recommend reactive consultation by geriatricians, where patients are reviewed on an ‘ad hoc’ basis.

What are the implications?

This review supports messages from UK guidelines. These stress the comprehensive multidisciplinary approach that orthopaedic and elderly care teams provide for people with hip fracture.

There are some caveats, including the small number of trials, which varied in patient inclusions and methods (including the use of a reactive or ad-hoc consultation not recommended in the UK).

However, given previous findings that comprehensive geriatric assessment also improves survival and independence in a general population of older people, this suggests it has an important role in the care of hospitalised older patients.

Identifying risk factors for delirium in older patients with a hip fracture may require increased awareness, training and a project approach as exemplified by the service improvement initiative from Hertfordshire and Bedfordshire Critical Care Network.

Citation and Funding

Shields L, Henderson V, Caslake R. Comprehensive Geriatric Assessment for Prevention of Delirium After Hip Fracture: A Systematic Review of Randomized Controlled Trials. J Am Geriatr Soc. 2017;65(7):1559-165.

No funding information was provided for this study.

Bibliography

British Geriatrics Society. Comprehensive assessment of the frail older patient. London: British Geriatrics Society; 2010.

British Geriatrics Society. Orthogeriatric models of care. London: British Geriatrics Society; 2007.

Cameron ID, Kurrle S. Geriatric consultation services-are wards more effective than teams? BMC Medicine. 2013;11:49.

Ellis G, Whitehead MA, O’Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011;(7):CD006211.

Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. Br Med Bull. 2005;71(1):45-59.

Gladman JRF. Delivering comprehensive geriatric assessment in new settings: advice for frontline clinicians. J R Coll Physicians Edinb. 2016;46(3):174-79.

Leal J, Gray AM, Prieto-Alhambra D, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int. 2016;27(2):549-58.

NICE Delirium: prevention, diagnosis and management. CG103. London: National Institute for Health and Clinical Excellence; 2010.

NICE Hip fracture: management. CG124. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Transition between in-patient hospital settings and community care or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2016.

NICE. Dementia: supporting people with dementia and their carers in health and social care. CG42. London: National Institute for Health and Care Excellence; 2006.

RCP. National hip fracture database (NHFD) annual report 2016. London: The Royal College of Physicians; 2016.

RCP. National hip fracture database (NHFD) Commissioning hip fracture services 2016. London: The Royal College of Physicians; 2016.

Why was this study needed?

Hip fracture is the most common form of serious injury in older adults and up to a third die within one year. Patients with hip fracture take up 1.5 million hospital bed days, with NHS and societal costs of £1 billion a year. This is equivalent to 1% of the entire NHS budget.

Delirium is a state of acute mental confusion. It’s the most common complication of hip fracture occurring in about 61% of this population and is associated with an increased risk of death.

Comprehensive geriatric assessment (CGA) is a process that assesses older people’s medical problems, mental health, functional ability and social circumstances with the aim of developing a tailored management plan.

A previous review of 20 studies has shown that CGA increases the chance of survival and of returning to independent life in a general population of older people admitted to hospital as an emergency.

The researchers wanted to find out how effective CGA is in preventing delirium after surgery for a hip fracture.

What did this study do?

This systematic review identified four randomised controlled trials including 973 patients who had hip fracture surgery with or without comprehensive geriatric assessment (CGA).

Two trials examined team-based CGA where geriatricians reviewed patients on orthopaedic wards, one with daily visits daily and the other on an “as needed” basis (reactive consultation). Two trials evaluated ward-based assessments on a geriatric ward. Studies varied in patient inclusion criteria, with most excluding fracture due to cancer.

All trials assessed delirium rates, and this was the main (primary) outcome for three of the four. In three studies doctors assessing delirium knew whether assessments had been performed which could have biased results in favour of a benefit in this group.

Trials were conducted in the US, Sweden, Norway and Spain, countries with similar health systems to the UK.

What did it find?

  • Any type of assessment reduced the risk of delirium by 20% (relative risk [RR] 0.81, 95% confidence interval [CI] 0.69 to 0.94, four studies). Forty-three percent of patients who had an assessment developed delirium compared with 53% of those who didn’t.
  • When analysed by assessment type, only those delivered by a visiting team reduced the risk of delirium. Delirium rates were 34% for ‘team’ assessments vs 43% without (RR 0.77, 95% CI 0.61 to 0.98). Fewer people who received ward assessments developed delirium (51%) than those without (60%) but this difference fell short of statistical significance (RR 0.83, 95% CI 0.64 to 1.08). However, there was considerable difference in the results of these two studies, so caution is needed when interpreting this result.
  • No consistent effects of the assessments were observed for hospital length of stay (which varied from five to 38 days across studies), severity or duration of delirium, or in-hospital mortality.

What does current guidance say on this issue?

NICE guidelines (2011) recommend that to minimise the risk of delirium and maximise patient independence, healthcare professionals should actively look for cognitive impairment when patients first present with hip fracture. NICE recommend that all patients receive multidisciplinary management from admission, with an orthogeriatric or orthopaedic ward-based Hip Fracture Programme that identifies goals to help recover mobility and independence.

The British Geriatrics Society also recommends joint orthopaedic and geriatrician care for older people with fractures. The society doesn’t recommend reactive consultation by geriatricians, where patients are reviewed on an ‘ad hoc’ basis.

What are the implications?

This review supports messages from UK guidelines. These stress the comprehensive multidisciplinary approach that orthopaedic and elderly care teams provide for people with hip fracture.

There are some caveats, including the small number of trials, which varied in patient inclusions and methods (including the use of a reactive or ad-hoc consultation not recommended in the UK).

However, given previous findings that comprehensive geriatric assessment also improves survival and independence in a general population of older people, this suggests it has an important role in the care of hospitalised older patients.

Identifying risk factors for delirium in older patients with a hip fracture may require increased awareness, training and a project approach as exemplified by the service improvement initiative from Hertfordshire and Bedfordshire Critical Care Network.

Citation and Funding

Shields L, Henderson V, Caslake R. Comprehensive Geriatric Assessment for Prevention of Delirium After Hip Fracture: A Systematic Review of Randomized Controlled Trials. J Am Geriatr Soc. 2017;65(7):1559-165.

No funding information was provided for this study.

Bibliography

British Geriatrics Society. Comprehensive assessment of the frail older patient. London: British Geriatrics Society; 2010.

British Geriatrics Society. Orthogeriatric models of care. London: British Geriatrics Society; 2007.

Cameron ID, Kurrle S. Geriatric consultation services-are wards more effective than teams? BMC Medicine. 2013;11:49.

Ellis G, Whitehead MA, O’Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011;(7):CD006211.

Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. Br Med Bull. 2005;71(1):45-59.

Gladman JRF. Delivering comprehensive geriatric assessment in new settings: advice for frontline clinicians. J R Coll Physicians Edinb. 2016;46(3):174-79.

Leal J, Gray AM, Prieto-Alhambra D, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int. 2016;27(2):549-58.

NICE Delirium: prevention, diagnosis and management. CG103. London: National Institute for Health and Clinical Excellence; 2010.

NICE Hip fracture: management. CG124. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Transition between in-patient hospital settings and community care or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2016.

NICE. Dementia: supporting people with dementia and their carers in health and social care. CG42. London: National Institute for Health and Care Excellence; 2006.

RCP. National hip fracture database (NHFD) annual report 2016. London: The Royal College of Physicians; 2016.

RCP. National hip fracture database (NHFD) Commissioning hip fracture services 2016. London: The Royal College of Physicians; 2016.

Comprehensive Geriatric Assessment for Prevention of Delirium After Hip Fracture: A Systematic Review of Randomized Controlled Trials

Published on 14 April 2017

Shields, L.,Henderson, V.,Caslake, R.

J Am Geriatr Soc , 2017

OBJECTIVES: To assess the efficacy of comprehensive geriatric assessment (CGA) in prevention of delirium after hip fracture. DESIGN: Systematic review and metaanalysis. SETTING: Ward based models on geriatrics wards and visiting team based models on orthopaedics wards were included. PARTICIPANTS: Four trials (three European, one U.S.; 973 participants) were identified. Two assessed ward-based, and two assessed team-based interventions. MEASUREMENTS: MEDLINE, EMBASE, CINAHL and PsycINFO databases; Clinicaltrials.gov; and the Central Register of Controlled Trials were searched. Reference lists from full-text articles were reviewed. Incidence of delirium was the primary outcome. Length of stay, delirium severity, institutionalization, long-term cognition and mortality were predefined secondary outcomes. Duration of delirium was included as a post hoc outcome. RESULTS: There was a significant reduction in delirium overall (relative risk (RR) = 0.81, 95% confidence interval (CI) = 0.69-0.94) in the intervention group. Post hoc subgroup analysis found this effect to be preserved in the team-based intervention group (RR = 0.77, 95% CI = 0.61-0.98) but not the ward-based group. No significant effect was observed on any secondary outcome. CONCLUSION: There was a reduction in the incidence of delirium after hip fracture with CGA. This is in keeping with results of non-randomized controlled trials and trials in other populations. Team-based interventions appeared superior in contrast to the Ellis CGA paper, but it is likely that heterogeneity in interventions and population studied affected this.

The Hip Fracture Programme involves an assessment by an orthogeriatrician (a geriatrician specialising in the treatment of older people with musculoskeletal problems). It aims to ensure patients are in the best condition for surgery and identifies rehabilitation goals, in collaboration with social services, general practice, mental health and falls prevention services.

Expert commentary

There is a high prevalence of delirium among patients with hip fractures. It is associated with worse health outcomes. Comprehensive Geriatric Assessment, a multidisciplinary assessment and evaluation of an older person’s physical condition, mental health, functioning and social circumstances, has been shown to improve outcomes, such as increased independence and mobility.

Its multi-domain strategy is best placed to manage delirium which is usually multi-causal, varied in its presentation and needs a multi-component treatment plan. Further research is needed to identify how and where assessments can be optimally delivered to patients with hip fractures.

Terence Ong, Research Fellow and Honorary Consultant, Nottingham University Hospitals NHS Trust

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  •   Health management, Later life, Mental health and illness, Musculo-skeletal disorders, Acute and general medicine