Scientific Research

Delirium in hip fracture patients admitted from home is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation and readmission to acute services: The IMPACT Delirium study

RS Penfold1,2, AJ Hall2,3,4, A Anand5, ND Clement2,4, AD Duckworth4,6, AMJ MacLullich1,2

1. Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK 

2. Scottish Hip Fracture Audit, Edinburgh, UK 

3. Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK 

4. Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK 

5. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK 

6. Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK 

Aim 

Delirium is associated with adverse outcomes following hip fracture, but specific associations in patients admitted directly from home are less well studied. Here we analysed relationships between delirium in patients admitted from home with: (i) mortality; (ii) total length of hospital stay; (iii) need for post-acute inpatient rehabilitation, and (iv) hospital readmission within 180 days. 

Methods 

This study utilised routine clinical data in a consecutive sample of hip fracture patients aged ≥50 years admitted to a single large trauma centre between 01/03/20-30/11/21. Delirium was prospectively assessed as part of routine care by the 4’A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, level of social deprivation, and American Society of Anesthesiologists grade.  

Results 

A total of 1821 patients (mean age 80.7 years; 71.7% female) were admitted, with 1383 (mean age 79.5; 72.1% female) directly from home. 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1734): 14.1% (189/1340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20 day longer total length of stay (p<0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (Odds Ratio (OR) 1.69, 95% Confidence Interval (CI) 1.13-2.54; p=0.013), requirement for post-acute inpatient rehabilitation (OR 2.82, CI 1.99-4.00; p<0.001), and readmission to hospital within 180 days (OR 1.77, CI 1.01-3.11; p=0.046). 

Conclusions 

Delirium affects 1 in 7 patients with a hip fracture admitted directly from home and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. 

Background:

With advancing age comes the increasing prevalence of frailty and increased risk of adverse outcomes (e.g. hospitalisation). Internationally, models of Comprehensive Geriatric Assessment (CGA) delivery in primary care/community settings vary, and effectiveness is uncertain. CGA is a complex intervention and improving the effectiveness and efficiency of it first requires exploration of how individual components may work and how the intervention can be strengthened.

Aims:

To explore how to enhance current CGA, the conditions needed to implement enhanced CGA and the outcomes that older people, families, health and care professionals identify as important. 

Methods:

A qualitative study using semi-structured interviews with older people and healthcare practitioners working in non-hospital settings with older people in the UK. Data were analysed using an abductive analysis approach. Findings were shared with our stakeholder group involving older people, family members, health and social work professionals.

Results:

Twenty-seven people participated including 14 older people and 13 healthcare professionals. We identified limitations in current CGA: the lack of information sharing between different healthcare professionals who are delivering the CGA; communication between older people and their healthcare professionals; and follow-up after conducting the CGA. There was variation in participant perceptions on the provision of digital and remote assessment. However, we found that introducing remote assessment and a designated comprehensive care coordinator might be a viable solution to address the gaps in the current delivery of CGA.

Conclusions:

The study identified potential challenges in the implementation of enhanced CGA. However, the participants suggested possible solutions that can be used to overcome these challenges, which aligned with feedback from relevant stakeholders. The next stage of this research will involve using these findings, alongside existing evidence and key stakeholder engagement, to develop and refine a model of enhanced CGA that can then be assessed for feasibility and acceptability.

Introduction

People living with dementia and MCI progressively lose abilities, through increasing cognitive impairment, co-morbidities, inactivity, acute illnesses and injuries. Rehabilitation therapy may reduce disability and falls and increase resilience.

Methods

We co-produced a therapy intervention, comprising strength, balance and dual-task exercises, functional activity training and promoting community access, providing up to 50 therapy sessions, delivered over 12 months and underpinned by a behaviour change strategy. We evaluated the intervention in a 5-site multi-centred Randomised Controlled Trial, against a brief assessment control. Participants had a diagnosis of dementia or MCI, Montreal Cognitive Assessment (MoCA) between 13 and 25. Primary outcome was the Disability Assessment in Dementia (DAD), an ADL score, after 12 months, alongside a battery of other health status measures. The COVID-19 pandemic necessitated modifications.

Results

We recruited 365 participants, 42% female. Median age was 81 years (range 65-95), MoCA 20 (13-26), DAD 82 (5-100). Baseline balance between groups was good. Participants were predominantly white and socioeconomically advantaged. Intervention group participants received a median of 31 (IQR 22-40) session and undertook and additional mean 121 minutes of exercise per week. Assessed fidelity was good. 290 (79%) were followed up. There were no significant differences in DAD score (adjusted mean difference -1.3/100, 95% CI -5.2 to +2.6; effect size (d) -0.06; -0.26 to 0.15; p=0.5), physical activity, balance, quality of life, cognition or a range of other measures. Upper 95% confidence intervals excluded even small benefits. Rate of falling reduced by 22% (Rate Ratio=0.78; 0.46 to 1.3; p=0.3), but this was not statistically significant.

Conclusions

The intensive PrAISED intervention did not improve measured outcomes. It may be impossible to reduce the rate of functional decline in dementia. Alternatively, the pandemic may have distorted outcomes or participants may have been too advantaged to benefit. There may have been unmeasured psycho-social benefits.

Introduction: Many people with dementia (PwD) are affected by anxiety and depression, leading to significant changes in patient behaviour, carer burden and negative patient outcomes. Anxiolytics and antidepressants are commonly prescribed for PwD and may contribute to potentially inappropriate prescribing. This study aims to explore patients’ and carers’ experiences and perspectives of the management of depression and anxiety in PwD. Methods: An online discussion forum, Talking Point, hosted by the Alzheimer’s Society, was searched for relevant archived threads and posts. These were identified using 64 search terms such as “depression” and “SSRI”. Data were extracted into Microsoft Word and inductive thematic analysis is ongoing to code the data and identify pertinent key themes. Results: In total, 3539 posts were identified from 931 registered forum users. Initial findings have highlighted that anxiety and depression were commonly experienced by PwD and many described the difficulties in differentiating depression from dementia during the early stages of dementia. “Initially my wife was treated for depression and anxiety but that soon changed to MCI [mild cognitive impairment], then dementia…” [TP019]. Forum users described the use of anxiolytic and antidepressant medications as a process of trial and error: “The GP gave her sertraline but that didn’t work so now on mirtazapine. Only been 10 days and really makes her sleep just with half a tablet but now crying again” [TP022]. Frank accounts of the symptoms that PwD experienced were shared, highlighting the impact depression and anxiety has on both patients and their carers. Conclusion: This online discussion forum is a source of rich and valuable data, which may not be accessible through traditional qualitative methods. This study will provide authentic insights on patients’ and carers’ lived experiences of managing anxiety and depression in PwD and will inform further qualitative work with key stakeholders.

Background: There is a growing number of older adults in India and accordingly a rising burden of non-communicable diseases (NCDs). Poor medication adherence among patients with NCDs is prevalent in India and is associated with adverse outcomes, increased mortality and consequently increased patient and healthcare system costs. Understanding the factors which influence adherence across India is vital to guide interventions towards improved adherence. This study examined the factors influencing medication adherence in older adults (50 years or older) with NCDs in India. Methods:. Data analysis was conducted from the second wave of the World Health Organisation’s ‘Study on global AGEing and adult health (SAGE)’ to identify socioeconomic, health-related, geographical and social support variables that influence medication adherence in adults with NCDs. Bivariate analysis and multivariate logistic regression modelling were conducted. Results: The average medication adherence rate was 51% across 2840 patients with one or more NCDs. The strongest factors predicting non-adherence were multimorbidity (odds ratio 0.49, 95% CI 0.41-0.58) and feelings of depression (0.48, 95% CI 0.32-0.70). Rural living (0.71, 95% CI 0.48-1.05), tobacco use (0.75, CI 0.58-0.97), never having attended school (0.75, 95% CI 0.62-0.92) and feelings of anxiety (0.83, 95% CI 0.67-1.02) were also independent associated with poor adherence. Older age (1.89, 95% CI 1.40-2.55) was associated with improved adherence while there was a weak association between increased wealth and medication use. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and low educational status.

Background: Foot pain in older adults may reduce physical activity, resulting in impaired mobility and an increased risk of falls. Orthotics, both with and without a metatarsal pad, may provide foot pain relief and improved stability. Objective: Compare the use of Aetrex orthotics with and without a metatarsal pad in decreasing pain and fear of falling in older adults. Methods: 206 participants over 60 years old were randomised into the intervention group, who received Aetrex L2305 Orthotics with a metatarsal pad, or the control group, who received Aetrex L2300 Orthotics with no metatarsal pad. At baseline and 6-week follow-up, musculoskeletal pain was reported via Numerical Rating Scales (NRS), foot pain and functionality via the Foot Health Status Questionnaire (FHSQ), and fear of falling via the Short Falls Efficacy Scale International. Results: Both groups reported significant improvements in pain in the back, hips, knees, ankles, and feet using the NRS (P < 0.001). Using the FHSQ, foot pain significantly improved in both the intervention (x̄= 18.47 ±20.58, P < 0.001) and control group (x̄= 17.21 ±18.74, P < 0.001). Function also improved significantly in both groups (x̄= 18.35 ±20.67, P < 0.001 and x̄ = 15.07 ±20.15, P < 0.001, respectively), as did fear of falling (x̄= 1.55 ±3.79, P < 0.001 and x̄= 1.23 ±3.53, P < 0.001, respectively). No statistically significant difference was observed between groups for any outcome (P > 0.05). Conclusion: Aetrex orthotics, with and without metatarsal pads, decrease pain and fear of falling in older adults.

Background: Motoric cognitive risk syndrome (MCR), characterized by slow gait speed (GS) and subjective cognitive complaints, is a simple way to screen older adults at high risk of dementia. In primary care service, however, assessing GS may still be a challenge due to the short consultation time and space constraints common in general practice. Therefore, there is a need to explore alternative MCR subtypes with motor domains that can be measured conveniently. This study aimed to explore a new subtype of MCR, using low handgrip strength (HGS) as the motoric phenotype, and examined its association with the incidence of cognitive impairments among the Chinese community-dwelling older adults.

Methods: We used four-wave data (2011-2018) of participants (≥60 years) in the China Health and Retirement Longitudinal Study. We investigated two MCR subtypes. First, MCRg was defined in the literature as the coexistence of slow GS and cognitive complaints without dementia or morbidity disability. Then, we defined a new subtype, MCRh, by replacing slow GS with low HGS. Cox proportional hazards models were used to examine the association between baseline MCR subtypes (MCRg and MCRh) and incident cognitive impairment, controlling for sociodemographic characteristics, lifestyle behaviors and health conditions.

Results: Of 3325 participants (Mean age: 66.7±5.7, males: 54.9%), 5.2% had MCRg and 5.4% MCRh. Based on Cox models, both MCR subtypes were associated with the increased risk of cognitive impairment, with adjusted hazard ratios (95% CI) of 1.821 (1.402 to 2.368) for MCRg and 2.008 (1.567 to 2.574) for MCRh.

Conclusion: Low HGS, which can be quickly measured and requires no additional space, may be considered as a promising motoric phenotype of MCR subtypes. This study preliminarily supports the potential utilization of the HGS-based MCR subtype for early risk identification of cognitive impairment in primary care settings.

Introduction

About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery.

Method

We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed.

Results

We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21.

Conclusion

Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).

INTRODUCTION: Frailty assessment in stroke is not commonly integrated into clinical practice, despite current clinical recommendations. Pre-stroke frailty is associated with longer-term mortality, length of admission, and disability. Similarly, anticholinergic burden (ACB) is not routinely reviewed, even though it is associated with cognitive and physical impairment, increased hospital admissions, and higher mortality in older people. Healthcare Improvement Scotland-Frailty (HIS-Frailty) is a novel tool for the evaluation of frailty in older people. Our aim was to compare and correlate the identification and severity of frailty with HIS-Frailty to the Rockwood Clinical Frailty Scale (CFS) in stroke. We also used the ACB Score to determine if there was a difference in ACB between hospital admission and discharge in these patients.

METHODS: We conducted a prospective, observational, single-center study in a stroke unit. Patients with a cerebrovascular diagnosis were included. We compared frailty assessment through linear correlation and ACB through mean difference in scores. Results were considered statistically significant if p-value < 0.05 and highly statistically significant if p-value < 0.005. SPSS® 26.0 was used to perform data analysis.

RESULTS: We included 145 patients. 110 (76%) were older than 60 years and 75 (52%) were male. Most admissions were due to ischemic stroke (67%), closely followed by TIA (14%). Forty-eight (32%) were classified as frail. There was a strong positive correlation between HIS-Frailty and the CFS (r = 0.95; p <0.00001; R2 = 0.91). Seventy-nine (55%) patients had significant ACB. There was no significant difference between ACB at admission and discharge (MD = 0.010, CI 95% -0.52 to 0.54; p = 0.97).

CONCLUSION: HIS-Frailty may prove to be a consistent and easy tool for the systematic identification of frailty in stroke patients, in accordance with best clinical practice guidelines. We should standardise measures to reduce ACB after stroke.

Introduction

There is relatively little known about physical health of older people who are unpaid carers. The English Longitudinal Study of Ageing (ELSA) Wave 9 (2019) was used to examine the relationship between unpaid caring and health. This study contains information on frailty, caring, comorbidities and Instrumental Activities of Daily Living (IADL) from 8,736 participants 50 years and over.

Methods

We included participants who received a nurse visit in Wave 9 (n=3,047), 21 were excluded due to missing data. Frailty was calculated using the ELSA-Frailty Index (FI). Carers were those in receipt of Carers Allowance or self-reported unpaid caring.

Results

351 carers and 2675 non-carers were included. Carers were younger (64.5 (10.2) vs 66.7 (10.5), p<.001) and more likely to be married (78.1% vs 62.8%, p<0.001). carers had a lower median fi score (0.07 (0.04-0.14) 0.15 (0.12-0.21), p="0.000)" however, 45 />536(8%) of moderately and severely frail participants were carers. Of 966 non-frail (FI <.12) participants: 9 />246(2.6%) carers experienced difficulties with IADLs, compared to 5/720(0.69%) non-carers; 79/246(31%) of carers had impaired mobility, compared to 39/720(5%) of non-carer; and 51/246(20%) had 2+ comorbidities, compared to 17/720(2.4%) non-carers. Of 1524 mildly frail (FI>0.12-0.24) participants: 16/60(26.7%) carers experienced difficulties with IADLs, compared to 116/1464(0.69%) non-carers; 58/60(97%) of carers had impaired mobility, compared to 807/1464(55%) non-carers; and 42/60(70%) had 2+ comorbidities, compared to 607/1464(41.4%) non-carers. On frailty-adjusted multivariable analysis there was a strong association between carer status and comorbidities with Odds Ratio (OR)3.01 (95%CI 2.21-4.10); impaired mobility, OR 11.08 (95%CI7.52-16.32); and impaired IADLs, OR 5.44(95%CI3.48-8.48)

Conclusions

Carers are less likely to be frail but more likely to struggle with at least one IADL, experience comorbidity or mobility impairment than equivalently frail peers. This suggests that, in the over 50s, either caring contributes to impairment or the burden of care falls on the more impaired.