New research from the University of Toronto has found that 48% of hip fracture patients, age 65 and older, had delirium, or acute confusion, before, during and after surgery (perioperative), resulting in significantly longer hospital stays and higher costs for care. The study, recently presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), found that perioperative delirium was associated with 7.4 additional hospital days.
According to the March 24, 2015 news release, “The patients with delirium had a mean age of 85, and were more likely to have a higher American Society of Anesthesiologists (ASA) score (“one” represents a “completely healthy fit patient, ” and “five, ” a patient not expected to live beyond 24 hours without surgery). After controlling for these differences, perioperative delirium was associated with $8, 282 ($8, 649 in U.S. dollars) in additional hospital costs (1.5 times the cost of patients who did not experience delirium). A significantly greater proportion of patients who experienced perioperative delirium required long-term and/or skilled care facility admission following their hospital stay (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 orthopedic surgeon and lead study author Michael G. Zywiel, M.D. “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.”
Dr. Zywiel told OTW, “We were particularly surprised to learn that almost 50% of these patients experienced delirium while in hospital. This was higher than we expected, and reinforces how easy it is to miss delirium if patients aren’t being routinely screened for it using validated methods.”
Regarding solutions, Dr. Zywiel commented to OTW, “The first step is to recognize the problem. We believe that this requires incorporating delirium screening as a routine part of ward care. The second step involves close coordination among all providers involved in the episode of care to proactively address all known modifiable factors that predispose to and precipitate delirium, because we know that treating delirium is far less effective than preventing it in the first place. At minimum this includes coordination between ER, geriatrics, hospitalist medicine, orthopedics, anesthesia, nursing, and rehabilitation teams. The list of evidence-based interventions is long, but includes: early regional pain control, minimizing systemic narcotics, minimizing delay to surgery, blood management techniques to reduce risk of transfusion, minimizing depth of sedation intra-op, avoiding intra-operative hypotension, limited use of Foley catheters, addressing polypharmacy and avoiding medications known to increase risk of delirium, ensuring availability of patient orientation aids (eyeglasses, hearing aids; clock, information board, window within view; regular visitation by family), early and frequent post-operative mobilization.”
