Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium

Abstract Background Postoperative delirium (POD) is a common complication of older people undergoing hip fracture surgery, which negatively affects clinical- and healthcare-related outcomes. Unfortunately, POD pathophysiology is still largely unknown, despite previous studies showing that neuroinflammation, neuroendocrine dysfunction, increased reactive oxidative stress (ROS), and endothelial dysfunctions may be involved. There is also evidence that many of the pathophysiological mechanisms which are involved in delirium are involved in sarcopenia too. This article describes the protocol of a pilot study to evaluate the feasibility of a larger one that will explore the pathophysiological mechanisms correlating POD with sarcopenia. We will analyse whether various biomarkers reflecting neuroinflammation, ROS, neuroendocrine disorders, and microvasculature lesions will be simultaneously expressed in in the blood, cerebrospinal fluid (CSF), and muscles of patients developing POD. Methods Two centres will be involved in this study, each recruiting a convenient sample of ten older patients with hip fracture. All of them will undergo a baseline Comprehensive Geriatric Assessment, which will be used to construct a Rockwood-based Frailty Index (FI). Blood samples will be collected for each patient on the day of surgery and 1 day before. Additionally, CSF and muscle fragments will be taken and given to a biologist for subsequent analyses. The presence of POD will be assessed in each patient every morning until hospital discharge using the 4AT. Delirium subtypes and severity will be assessed using the Delirium Motor Subtype Scale-4 and the Delirium-O-Meter, respectively. We will also evaluate the patient’s functional status at discharge, using the Cumulated Ambulation Score. Discussion This study will be the first to correlate biomarkers of blood, CSF, and muscle in older patients with hip fracture.

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Sedation Depth During Spinal Anesthesia and the Development of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Repair

Mayo Clinic Proceedings ◽

10.4065/mcp.2009.0469 ◽

2010 ◽

Vol 85 (1) ◽

pp. 18-26 ◽

Cited By ~ 250

Author(s):

Frederick E. Sieber ◽

Khwaji J. Zakriya ◽

Allan Gottschalk ◽

Mary-Rita Blute ◽

Hochang B. Lee ◽

...

Keyword(s):

Hip Fracture ◽

Elderly Patients ◽

Spinal Anesthesia ◽

Postoperative Delirium ◽

Fracture Repair

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Recovery Room Delirium Predicts Postoperative Delirium After Hip-Fracture Repair

Anesthesia & Analgesia ◽

10.1213/01.ane.0000167383.44984.e5 ◽

2005 ◽

Vol 101 (4) ◽

pp. 1215-1220 ◽

Cited By ~ 78

Author(s):

Punita T. Sharma ◽

Frederick E. Sieber ◽

Khwaja J. Zakriya ◽

Ronald W. Pauldine ◽

Kevin B. Gerold ◽

...

Keyword(s):

Hip Fracture ◽

Recovery Room ◽

Postoperative Delirium ◽

Fracture Repair

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Predisposing Factors for Postoperative Delirium After Hip Fracture Repair in Individuals with and without Dementia

Journal of the American Geriatrics Society ◽

10.1111/j.1532-5415.2011.03725.x ◽

2011 ◽

Vol 59 (12) ◽

pp. 2306-2313 ◽

Cited By ~ 94

Author(s):

Hochang B. Lee ◽

Simon C. Mears ◽

Paul B. Rosenberg ◽

Jeannie-Marie S. Leoutsakos ◽

Allan Gottschalk ◽

...

Keyword(s):

Hip Fracture ◽

Postoperative Delirium ◽

Predisposing Factors ◽

Fracture Repair

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Comparison of regional with general anaesthesia on postoperative delirium (RAGA-delirium) in the older patients undergoing hip fracture surgery: study protocol for a multicentre randomised controlled trial

BMJ Open ◽

10.1136/bmjopen-2017-016937 ◽

2017 ◽

Vol 7 (10) ◽

pp. e016937 ◽

Cited By ~ 11

Author(s):

Ting Li ◽

Joyce Yeung ◽

Jun Li ◽

Yan Zhang ◽

Teresa Melody ◽

...

Keyword(s):

Clinical Trial ◽

Hip Fracture ◽

General Anaesthesia ◽

Older Patients ◽

Postoperative Delirium ◽

Controlled Trial ◽

Controlled Clinical Trial ◽

Hip Fracture Surgery ◽

Randomised Controlled ◽

Fracture Surgery

IntroductionPostoperative delirium (POD) is a common serious postoperative complication especially in older people and is associated with increased mortality, morbidity and healthcare costs. There is no clear consensus which anaesthesia is associated with less incidence of POD for older patients. We aim to assess whether regional anaesthesia results in lower incidence of POD comparing with general anaesthesia (GA) among older patients undergoing hip fracture surgery.Methods and analysisRAGA-delirium is a pragmatic, multicentre, prospective, parallel grouped, randomised controlled clinical trial comparing RA or GA for hip fracture surgery. A total of 1000 patients who are 65 years or over and who are having planned hip fracture surgery in nine clinical trial centres of China will be randomised in a 1:1 ratio to receive either anaesthesia for the surgery. The primary endpoint will be the incidence of POD at day 7. The secondary endpoints will be the subtype, severity and duration of delirium, postoperative acute pain score, incidence of other postoperative non-delirium complications, quality of life and cost-effective outcomes. Randomisation will be performed at the patient level using computer-generated assignment. Outcome assessors will be blinded from intervention assignment. Assessments will be conducted before surgery, intraoperatively, postoperatively, during the hospital stay, at 30-day, 6-month and 1-year postoperative intervals.Potential impact of studyThis study will provide clinical evidence with a more robust methodology to help anaesthetists in selecting appropriate anaesthesia for older patients with high risk for POD. At the era of increasing emphasis on delirium prevention, this trial has the potential to inform the future national guideline to reduce POD.Ethics and disseminationEthical approved by the local institutional review board. Trial results will be presented at national and international academic conferences, and published in peer-reviewed journals.Trial registration numberClinicalTrials.gov (NCT02213380); pre-results.

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Machine Learning Algorithm Using Electronic Chart-Derived Data to Predict Delirium After Elderly Hip Fracture Surgeries: A Retrospective Case-Control Study

Frontiers in Surgery ◽

10.3389/fsurg.2021.634629 ◽

2021 ◽

Vol 8 ◽

Author(s):

Hong Zhao ◽

Jiaming You ◽

Yuexing Peng ◽

Yi Feng

Keyword(s):

Machine Learning ◽

Risk Factors ◽

Hip Fracture ◽

Elderly Patients ◽

Postoperative Delirium ◽

Frailty Index ◽

Fracture Repair ◽

Learning Models ◽

Electronic Chart ◽

Machine Learning Models

Background: Elderly patients undergoing hip fracture repair surgery are at increased risk of delirium due to aging, comorbidities, and frailty. But current methods for identifying the high risk of delirium among hospitalized patients have moderate accuracy and require extra questionnaires. Artificial intelligence makes it possible to establish machine learning models that predict incident delirium risk based on electronic health data.Methods: We conducted a retrospective case-control study on elderly patients (≥65 years of age) who received orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2018, and May 31, 2019. Anesthesia records and medical charts were reviewed to collect demographic, surgical, anesthetic features, and frailty index to explore potential risk factors for postoperative delirium. Delirium was assessed by trained nurses using the Confusion Assessment Method (CAM) every 12 h during the hospital stay. Four machine learning risk models were constructed to predict the incidence of postoperative delirium: random forest, eXtreme Gradient Boosting (XGBoosting), support vector machine (SVM), and multilayer perception (MLP). K-fold cross-validation was deployed to accomplish internal validation and performance evaluation.Results: About 245 patients were included and postoperative delirium affected 12.2% (30/245) of the patients. Multiple logistic regression revealed that dementia/history of stroke [OR 3.063, 95% CI (1.231, 7.624)], blood transfusion [OR 2.631, 95% CI (1.055, 6.559)], and preparation time [OR 1.476, 95% CI (1.170, 1.862)] were associated with postoperative delirium, achieving an area under receiver operating curve (AUC) of 0.779, 95% CI (0.703, 0.856).The accuracy of machine learning models for predicting the occurrence of postoperative delirium ranged from 83.67 to 87.75%. Machine learning methods detected 16 risk factors contributing to the development of delirium. Preparation time, frailty index uses of vasopressors during the surgery, dementia/history of stroke, duration of surgery, and anesthesia were the six most important risk factors of delirium.Conclusion: Electronic chart-derived machine learning models could generate hospital-specific delirium prediction models and calculate the contribution of risk factors to the occurrence of delirium. Further research is needed to evaluate the significance and applicability of electronic chart-derived machine learning models for the detection risk of delirium in elderly patients undergoing hip fracture repair surgeries.

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A 2-min cognitive screener for predicting 1-year functional recovery and survival in older adults after hip fracture repair

The Journals of Gerontology Series A ◽

10.1093/gerona/glab156 ◽

2021 ◽

Author(s):

Sileno de Queiroz Fortes-Filho ◽

Márlon Juliano Romero Aliberti ◽

Juliana de Araújo Melo ◽

Daniel Apolinario ◽

Maria do Carmo Sitta ◽

...

Keyword(s):

Cognitive Impairment ◽

Hip Fracture ◽

Functional Recovery ◽

Cognitive Assessment ◽

Older Patients ◽

Fracture Repair ◽

Screening Tools ◽

Hip Surgery ◽

Word Recall ◽

Risk Of Death

Abstract Background Implementing cognitive assessment in older people admitted to hospital with hip fracture – lying in bed, experiencing pain – is challenging. We investigated the value of a quick and easy-to-administer 10-point cognitive screener (10-CS) in predicting 1-year functional recovery and survival after hip surgery. Methods Prospective cohort study comprising 304 older patients (mean age=80.3±9.1 years; women=72%) with hip fracture consecutively admitted to a specialized academic medical center that supports secondary hospitals in Sao Paulo Metropolitan Area, Brazil. The 10-CS, a 2-minute bedside tool including temporal orientation, verbal fluency, and three-word recall, classified patients as having normal cognition, possible cognitive impairment, or probable cognitive impairment on admission. Outcomes were time-to-recovery activities of daily living (ADLs; Katz index) and mobility (New Mobility Score), and survival during 1-year after hip surgery. Hazard models, considering death as a competing risk, were used to associate the 10-CS categories with outcomes after adjusting for sociodemographic and clinical measures. Results On admission, 144 (47%) patients had probable cognitive impairment. Compared to those cognitively normal, patients with probable cognitive impairment presented less postsurgical recovery of ADLs (77% vs. 40%; adjusted sub-hazard ratio [HR]=0.44; 95%CI=0.32-0.62) and mobility (50% vs. 30%; adjusted sub-HR=0.52; 95%CI=0.34-0.79), and higher risk of death (15% vs. 40%; adjusted HR=2.08; 95%CI=1.03-4.20) over 1-year follow-up. Conclusions The 10-CS is a strong predictor of functional recovery and survival after hip fracture repair. Cognitive assessment using quick and easy-to-administer screening tools like 10-CS can help clinicians make better decisions and offer tailored care for older patients admitted with hip fracture.

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