Perioperative Delirium Common in Hip Fracture Patients

Forty-eight percent of hip fracture patients, aged 65 years and older, experienced delirium before, during and after surgery, resulting in significantly longer hospital stays and higher costs for care (Paper 308), Michael G. Zywiel, MD, reported at the 2015 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

“As reimbursement schemes evolve toward greater reliance on bundled episode of care payment, perioperative delirium may have a marked impact on the financial viability of hip fracture care,” the researchers wrote in their abstract.

The investigators, from the University of Toronto, in Canada, sought to determine the economic implications of perioperative delirium in older orthopedic patients with a prospective review of hip fracture records between January 2011 and December 2012. A total of 242 hip fracture patients with a mean age of 82 (range 65-103) were studied. Demographic, clinical, surgical and adverse events data were analyzed.

Perioperative delirium was assessed using the Confusion Assessment Method (CAM). The study found that 116 patients (48%) experienced delirium during hospital admission. The patients with delirium were significantly older (mean age 85; P<0.001) and were more likely to have a higher American Society of Anesthesiologists (ASA) physical status score (with I representing a “completely healthy fit patient” and V a patient not expected to live beyond 24 hours without surgery).

After controlling for these differences, perioperative delirium was associated with 7.4 additional hospitalization days (length of stay ratio, 1.80; 95% confidence interval [CI], 3.8-11.1 days;P<0.001) and $8,649 in additional hospital costs (P<0.001), which was 1.5 times the cost of patients who did not experience delirium. There were no differences in mean time between triage or admission and surgery, length of surgery or anesthesia type between groups. A significantly greater proportion of patients who had perioperative delirium required long-term and/or skilled care facility admission following their hospital stay than patients without delirium (8% versus 0%).

“Older patients are at high risk of developing delirium during hospitalization for a hip fracture, which is associated with worse outcomes,” said Dr. Zywiel, an orthopedic surgeon. “Our work demonstrates that delirium also markedly increases the cost of elderly patient care while in the hospital. Given the high number of patients hospitalized every year with a hip fracture, there is a real need to develop and fund improved interventions to prevent in-hospital delirium in these patients.”

The research suggested that reducing the rate of delirium would increase the quality of patient care while decreasing the cost of that care, “presenting hospitals, surgeons and other stakeholders with promising opportunities to improve the value of hip fracture care,” Dr. Zywiel said.

Approximately 300,000 Americans are hospitalized with hip fractures each year. The risk is particularly high in postmenopausal women who face an increased risk for osteoporosis. Delirium is common among older hip fracture patients, and multiple studies have found that patients with postoperative delirium are more likely to have complications, including infections, and are less likely to return to their pre-injury level of function. Patients with delirium also are more frequently placed in nursing homes following surgery, and have an increased death rate.

The AAOS’ new clinical practice guideline, “Management of Hip Fractures in the Elderly,” makes a series of recommendations to reduce delirium in older hip fracture patients. They include:

• Preoperative regional analgesia to reduce pain.
• Hip fracture surgery within 48 hours of hospital admission.
• Intensive physical therapy after hospital discharge to improve functional outcomes.
• An osteoporosis evaluation, as well as vitamin D and calcium supplements, for patients after a hip fracture.
• The reduction of delirium in older patients has been recognized as an important goal for improving patient clinical outcomes in the hospital.