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Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study

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• Peer review
• J J W Roche , clinical fellow 1 ,
• R T Wenn , audit coordinator 1 ,
• O Sahota , consultant physician 2 ,
• C G Moran ( anne.hay{at}qmc.nhs.uk ) , professor 1
• 1 Department of Trauma and Orthopaedics, University Hospital Nottingham, Nottingham, NG7 2UH
• 2 Department of Care of the Elderly, University Hospital Nottingham, Nottingham
• Correspondence to: C G Moran
• Accepted 16 September 2005

Objectives To evaluate postoperative medical complications and the association between these complications and mortality at 30 days and one year after surgery for hip fracture and to examine the association between preoperative comorbidity and the risk of postoperative complications and mortality.

Design Prospective observational cohort study.

Setting University teaching hospital.

Participants 2448 consecutive patients admitted with an acute hip fracture over a four year period. We excluded 358 patients: all those aged < 60; those with periprosthetic fractures, pathological fractures, and fractures treated without surgery; and patients who died before surgery.

Interventions Routine care for hip fractures.

Main outcome measures Postoperative complications and mortality at 30 days and one year.

Results Mortality was 9.6% at 30 days and 33% at one year. The most common postoperative complications were chest infection (9%) and heart failure (5%). In patients who developed postoperative heart failure mortality was 65% at 30 days (hazard ratio 16.1, 95% confidence interval 12.2 to 21.3). Of these patients, 92% were dead by one year (11.3, 9.1 to 14.0). In patients who developed a postoperative chest infection mortality at 30 days was 43% (8.5, 6.6 to 11.1). Significant preoperative variables for increased mortality at 30 days included the presence of three or more comorbidities (2.5, 1.6 to 3.9), respiratory disease (1.8, 1.3 to 2.5), and malignancy (1.5, 1.01 to 2.3).

Conclusions In elderly people with hip fracture, the presence of three or more comorbidities is the strongest preoperative risk factor. Chest infection and heart failure are the most common postoperative complications and lead to increased mortality. These groups offer a clear target for specialist medical assessment.

Introduction

Hip fractures related to osteoporosis constitute a major clinical and financial burden to the NHS. In 2002-3, there were 78 554 admissions to NHS hospitals in England for fractured neck of femur, 96% of these were in people aged 65. 1 Bed occupancy for hip fracture was in excess of 1.5 million days, which represents 20% of total orthopaedic bed stays and in women over 45 accounts for a higher proportion of occupancy of hospital beds than many other common disorders. 2 Excess mortality is 20% in the first year and is higher in older men. 3 4

The high mortality, particularly in the first three months, is probably due to the combination of trauma, major surgery in elderly people with concurrent medical problems, 3 and a low physiological reserve. Identifying which patients are at greatest risk of developing complications and which types of complications are life threatening has never been examined in a large prospective study.

We investigated how demographic factors and important medical conditions influence postoperative complications and mortality. Other important factors, such as delay to surgery, 5 type of treatment, and length of stay, were beyond the scope of this study.

We evaluated postoperative medical complications, the association between these complications and mortality at 30 days and one year, and the association between preoperative comorbidity, the risk of postoperative complications, and mortality in elderly patients presenting with an acute hip fracture.

Patients and methods

We prospectively evaluated all patients admitted to the university hospital in Nottingham with a hip fracture from 8 May 1999 to 7 May 2003. Follow-up ended on 7 June 2003. This is the only hospital providing a trauma service for Nottingham and its surrounding area; it has a catchment population of 675 000. Independent audit staff collected data on these patients by using a detailed proforma based on the standardised audit of hip fractures in Europe. 6 Data included demographics, type of fracture, preoperative comorbidities, operative treatment, and complications. Integration with the database of the Office for National Statistics ensured accurate mortality data for every patient. Comorbidities on admission were identified from the patient's history, medication, and medical records ( table 1 ).

Comorbidity and postoperative complications in 2448 elderly people with hip fracture

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The anaesthetist routinely assessed all patients and referred those deemed to be too unwell for immediate surgery to the resident medical registrar for treatment recommendations. All patients who had surgery were included in the study.

We diagnosed complications clinically or after investigations and recorded them prospectively until the time of hospital discharge ( table 1 ). For the purpose of this analysis we excluded patients with simultaneous bilateral fractures (n = 6), periprosthetic fractures (n = 25), and pathological fractures (n = 63), and patients < 60 years (n =165), those dying before a decision to treat was made (n = 20), and those treated without an operation (n = 79: 42 undisplaced fractures, four patients who presented more than 10 days after the injury, 22 who were severely unwell, and 11 who refused surgery).

Statistical methods

Our measured outcomes were postoperative complications and mortality at 30 days and one year. We used univariate Cox regression analysis to evaluate the crude effect of comorbidities and complications on mortality. Multivariate Cox regression analysis allowed adjustment for age, sex, and the confounding variables shown in table 1 . Multivariate logistic regression determined the association between postoperative complications and comorbidities on admission. We have presented the hazard ratios and odds ratios generated at the final step of analysis. We used multivariate Cox and logistic regression analyses to ensure results for variables such as age and sex were generated even if they were not significant. The significance level for all statistical tests was set at 5% (P < 0.05). Data were coded and stored in Microsoft Excel 2000 and analysed with the SPSS statistical program (version 12.0.1).

Demographics

Over the four year period 2806 patients were admitted with a hip fracture. We excluded 358, leaving 2448 patients within the study. The mean age was 82 years (range 60-103 years), and 80% (1955) were women ( table 2 ).

Age and sex distribution (% in age group)

The median score of the mini-mental test was 7 out of 10 (range 0-10); 1485 patients (61%) had good cognitive function (score 7-10), and 580 (24%) had severe cognitive impairment (score 0-3). Patients were admitted from their own homes (61%), warden-aided accommodation (10%), residential homes (15%), nursing homes (13%), and elsewhere (2%). Of the fractures, 57% were intracapsular and 43% were extracapsular. The median length of stay was 12 days on a trauma ward (interquartile range 8-17 days) and 18 days (11-30 days) when we included time on rehabilitation wards.

Comorbidities

Forty one per cent (1011) had no comorbidity; 35% had one, 17% had two, and 7% had three or more comorbidities. Table 1 lists the comorbidities recorded and their incidence. The most common were cardiovascular disease (24%), chronic obstructive airways disease (14%), and cerebrovascular disease (13%).

Postoperative complications

Twenty percent of patients (498/2448) had a postoperative complication. The complication rate was 14% (147/1011) for patients with no comorbidity on admission. Table 1 shows the incidence of postoperative complications. The most common complications were chest infection (9%, 215/2448; diagnosed clinically in the presence of fever, clinical findings with or without radiographic changes consistent with bronchopneumonia); heart failure (5%, 119/2448; diagnosed clinically with or without radiographic changes consistent with acute left ventricular failure); and urinary tract infection (4%, 98/2448; diagnosed positive results on urine culture). There were 35 cerebrovascular events (diagnosed with computerised tomography) and 25 myocardial infarctions (diagnosed by changes on electrocardiogram together with a rise in troponin I concentration).

Mortality was 9.6% at 30 days (n = 231) and 33% at one year (n = 747). Mortality at 30 days was 8.2% (n = 158) in women and 15% (n = 73) in men, a significant difference (log rank test 20.91, P < 0.01).

Table 3 shows unadjusted hazard ratios for individual complications and comorbidities. Table 4 shows the results of the multivariate Cox regression analysis. In patients with postoperative heart failure the mortality was 65% at 30 days (n = 77/119) (hazard ratio 8.0, 95% confidence interval 5.5 to 11.6). At one year the mortality was 92% (n = 109/119) (5.0, 3.9 to 6.5). In patients who developed a postoperative chest infection the mortality was 43% (n = 92/215) (3.0, 2.1 to 4.2) at 30 days and 71% (n = 153/215) (2.4, 1.9 to 3.0) at one year.

Univariate Cox regression analysis of all variables for mortality at 30 days and one year: final step. Figures are hazard ratios (95% confidence intervals)

Multivariate Cox regression analysis of all variables for 30 day and one year mortality. Figures are hazard ratios (95% confidence intervals)

Forty two patients (1.7%) developed deep vein thrombosis (diagnosed by Doppler ultrasonography or venogram, or both) or pulmonary embolus (diagnosed by ventilation/perfusion (V/Q) scan or CT angiography) despite receiving prophylactic low molecular weight heparin. In these patients the hazard ratio was 4.5 (2.7 to 7.6) for death at 30 days.

Preoperative risk factors for mortality

After adjustment for age and sex, patients with three or more comorbidities had a hazard ratio for death at 30 days of 2.5 (1.6 to 3.9). The figure shows the unadjusted mortality curve over the first 30 postoperative days. Table 5 shows the results of the multivariate Cox regression analysis. Significant factors for increased mortality at 30 days include number of comorbidities present on admission—patients with three or more comorbidities being at increased risk compared with those with none (hazard ratio 2.5, 1.6 to 3.9), male sex (1.2, 1.5 to 2.6), respiratory disease (1.8, 1.3 to 2.5), and renal disease (2.0, 1.2 to 3.5). Increasing age was also a significant factor.

Survival analysis based on number of preoperative comorbidities

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Multivariate Cox regression analysis of effect of all preoperative variables on 30 day mortality. Figures are hazard ratios (95% confidence intervals)

Preoperative risk factors for postoperative complications

Chest infection —Respiratory disease (odds ratio 2.7, 1.9 to 3.8), male sex (2.0, 1.5 to 2.8), enteral steroids (2.5, 1.2 to 5.2), and greater age were all important risk factors for developing a chest infection after surgery for hip fracture ( table 6 ). Interestingly, in our patients smoking was not a significant risk factor (P = 0.098, table 6 ). Compared with those with no comorbidity, patients with an increasing number of comorbidities had greater risk of postoperative chest infection (odds ratios were 1.7 (1.2 to 2.5) for one comorbidity, 2.2 (1.5 to 3.3) for two, and 5.3 (3.3 to 8.5) for three or more).

Multivariate logistic regression analysis of effect of all preoperative variables on incidence of postoperative chest infection and cardiac failure. Figures are odds ratios (95% confidence intervals)

Cardiac failure —Age90 years compared with younger (4.1, 1.5 to 10.9), male sex (1.8, 1.2 to 2.8), and a history of cardiovascular disease (2.3, 1.6 to 3.4) were all significant risks for developing postoperative heart failure ( table 6 ). Patients with two or three or more comorbidities on admission had an increased risk of developing postoperative heart failure compared with those with no comorbidity (2.0, 1.2 to 3.5, and 4.6, 2.5 to 8.3, respectively). Even in a study with 2448 patients, the numbers with a postoperative myocardial infarction, clinical pulmonary embolus, or deep vein thrombosis were insufficient to identify any specific risk factors. Those patients with previous stroke were at increased risk of a second stroke in the postoperative period (4.7, 2.3 to 9.5).

Heart failure and chest infection are thought to be major postoperative complications in elderly patients undergoing surgery for hip fracture, 7 8 and our large prospective study confirms this. The demographics of our study population were similar to previously reported UK studies. 4 9 The 30 day mortality is comparable with that of the Oxford NHS health region from 1984-98 and is also typical of other units within the UK, 9 10 Europe, and the US. 3 7 11 Our most striking result was the high mortality for patients who developed acute heart failure or a chest infection after surgery for hip fracture. In the 30 days after surgery, 13% (334) of our patients developed one of these complications yet they accounted for 73% (169) of the deaths.

Patients with more comorbidities on admission had a greater risk of postoperative complications and increased mortality. This is consistent with results of previous smaller retrospective studies. 8 12 Cardiovascular disease and chronic lung disease predispose patients to the most common and serious postoperative complications. These patients may be a target group for specialist preoperative medical assessment.

Management of high risk patients

To reduce mortality, attention must focus on optimising health status preoperatively, preventing postoperative complications, and, when these complications develop, providing optimal specialist medical care. No study has specifically examined high risk patients who may have most to gain from more specialised medical care. The difference in outcome between patients who have access to joint orthopaedic and geriatric care and those who do not has been investigated. 13 14 These studies mainly evaluated interventions related to rehabilitation rather than acute medical assessment and, unsurprisingly, have not shown a significant difference in early mortality. Despite this, as far back as 1989 the Royal College of Physicians recommended medical assessment of patients with hip fracture to reduce their operative risk, 15 and this has been reinforced in several subsequent publications. 16 17 Specialist medical assessment and management of elderly patients with hip fracture before and after surgery, however, remains uncommon in the UK. The resident medical registrar assessed a number of our patients after anaesthetic assessment, and they subsequently underwent surgery. The number assessed was small and most of the patients who died postoperatively had no formal specialist medical assessment before or after surgery.

Further studies would identify optimal management for these patients, but experience suggests that they may benefit from specialist senior medical input both before and after surgery. A retrospective study of over 8000 elderly patients with hip fracture found that perioperative transfusion had no influence on mortality in patients with haemoglobin concentrations > 80 g/l, 18 but smaller studies have shown that transfusion at higher haemoglobin concentrations for patients with known cardiac disease may be beneficial. 19 20 Persistent hypoxia may be present in all patients with hip fracture from the time of admission until up to five days postoperatively, 21 and episodes of myocardial ischaemia occur in postoperative patients with known ischaemic heart disease. 22 Therefore measures such as higher triggers for transfusion and monitoring oxygen saturation and arterial blood gases before and after surgery may help reduce complications.

Invasive physiological monitoring with oesophageal Doppler ultrasonography or pulmonary artery catheters in the perioperative period may be of benefit. 23 In other surgical specialities, outcome is improved in high risk patients undergoing major surgery in whom fluid and inotrope therapy is monitored with pulmonary artery catheters. 24 This has not been extrapolated to orthopaedic surgery. These invasive techniques, however, may be helpful in optimising cardiac output and reducing postoperative cardiac failure in the vulnerable patients we have identified.

Strengths and weaknesses

It was not possible to have diagnostic criteria driven by protocol, and treatment for each comorbidity and more accurate premorbid data would have been useful—for example, echocardiography to assess the degree of heart failure or lung function tests to define the severity of lung disease. The study was observational and did not look at different systems of care for these patients. However, we did have complete data on a large consecutive series of patients with 100% follow-up for mortality statistics. This study reflects everyday clinical practice in the UK. National audits based on hospital episode statistics, such as those produced by Imperial College and Dr Foster ( http://www.drfoster.co.uk/ ), provide only crude mortality data. In contrast, we also provided information on comorbidities, complications, and mortality.

What is already known on this topic?

Mortality is high after surgery for hip fracture in elderly patients

Postoperative complications are associated with a poor outcome

What this study adds

Patients with multiple comorbidities, especially respiratory disease and malignancy, before surgery for hip fracture are at higher risk of mortality

Postoperative complications, such as chest infection and heart failure, are also associated with increased mortality

Conclusions

We have shown a 9% mortality at 30 days after hip fracture in elderly patients. A fifth of patients had a postoperative complication, the most common being chest infection and heart failure. Within 30 days of surgery 65% of patients with heart failure and 43% with postoperative chest infection died. Most patients (92%) with heart failure died within a year of surgery. Age, male sex, and the presence of three or more comorbidities on admission all predicted a high risk of complications. Further studies are urgently required to evaluate different systems of medical care to establish whether these can reduce the incidence and severity of these complications and improve the standard of care for elderly patients with hip fracture.

Acknowledgments

We thank N Badhe, N D Downing, D M Hahn, M Hatton, B J Holdsworth, C J Howell, J B Hunter, P J James, A R J Manktelow, J A Oni, P J Radford, B E Scammell, E P Szypryt, and A M Taylor for allowing their patients to be included in this study. We also thank Christopher T White for his assistance with statistical analysis and Sarah Armstrong (University of Nottingham) for her supervision of the statistical analysis.

Contributors JJWR carried out the literature search and wrote the manuscript. RTW collected the data, carried out statistical analyses, and reviewed the manuscript. OS was involved with writing the paper, interpreting data, and critical revision. CGM was responsible for conception and management of the study and audit design, edited the manuscript, and is guarantor.

Funding None.

Competing interests None declared.

Ethical approval Not required.

• Department of Health
• Royal College of Physicians
• Kenzora JE ,
• McCarthy RE ,
• Lowell JD ,
• Parker MJ ,
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• Fractured neck of femur
• Scottish Intercollegiate Guidelines Network
• British Orthopaedic Association
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The relationship between postoperative complications and outcomes after hip fracture surgery

• Annals of the Academy of Medicine Singapore 34(2):163-8
• 34(2):163-8

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Complications of hip fracture.

Serious complications can result from a hip fracture. A patient may have to remain in traction for a specified period of time after surgery. Blood clots can occur in the veins, usually in the legs. If a clot breaks off, it can travel to a blood vessel in the lung. This blockage, called a pulmonary embolism, can be fatal.

Other complications can include:

• Muscle atrophy (wasting of muscle tissue)
• Post-operative infection
• Non-union or improper union of the bone
• Mental deterioration following surgery in older patients
• Bedsores from lying in the same position with minimal movement

With some fractures, blood cannot circulate properly to the femoral head, resulting in a loss of blood supply to this area. This is called femoral vascular necrosis or avascular necrosis. This complication may occur depending on the type of fracture and the anatomy of a person's blood supply to the head of the femur bone. This is more common with femoral neck fractures.

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Case study of hip fracture in an older person

Affiliation.

• 1 Wichita State University, USA. [email protected]
• PMID: 14606134
• DOI: 10.1111/j.1745-7599.2003.tb00331.x

Purpose: To discuss proximal femoral (hip) fractures as the leading cause of hospitalization for injuries among older persons, using a case example that illustrates not only the orthopedic injury but also how an older person's chronic problems complicate the acute event.

Data sources: Extensive review of scientific literature on the conditions discussed, supplemented by the case study.

Conclusions: Hip fractures in older adults can present multiple challenges to care when complicated by preexisting or coexisting conditions. This case of an older man with a hip fracture emphasizes the resuscitation priorities for the patient found after a "long lie" and the impact of chronic alcoholism and malnutrition, which lead to serious complications.

Implications for practice: Careful physical and psychosocial assessment is important for determining the presenting problem and comorbid conditions. Priorities for postoperative management of hip fracture and its complications guide the nurse practitioner through the successful return of the patient to the community.

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Doctor, when should i start walking revisiting postoperative rehabilitation and weight-bearing protocols in operatively treated acetabular fractures: a systematic review and meta-analysis.

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Giordano, V.; Pires, R.E.; Faria, L.P.G.d.; Temtemples, I.; Macagno, T.; Freitas, A.; Joeris, A.; Giannoudis, P.V. Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis. J. Clin. Med. 2024 , 13 , 3570. https://doi.org/10.3390/jcm13123570

Giordano V, Pires RE, Faria LPGd, Temtemples I, Macagno T, Freitas A, Joeris A, Giannoudis PV. Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine . 2024; 13(12):3570. https://doi.org/10.3390/jcm13123570

Giordano, Vincenzo, Robinson Esteves Pires, Luiz Paulo Giorgetta de Faria, Igor Temtemples, Tomas Macagno, Anderson Freitas, Alexander Joeris, and Peter V. Giannoudis. 2024. "Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis" Journal of Clinical Medicine 13, no. 12: 3570. https://doi.org/10.3390/jcm13123570

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Total hip arthroplasty in displaced fracture neck femur in active elderly patients, ehab mohamed shehata, el-sayed el-etewy soudy, mohamed mansour el zohairy, mohamed ibrahim eldesoky.

Background : Femoral neck fracture is an established public health concern globally owing to longer life expectancy especially that  femoral neck fractures and hip fractures in general are more common in older population. The aim of the present study was to evaluate  the clinical and radiological outcome results of total hip arthroplasty after displaced neck femur fractures.

Methods : This interventional  clinical trial included 18 elderly patients with displaced neck femur fractures who attended the Orthopedic department, Faculty of  Medicine, Zagazig University Hospitals. Modified Harris Hip Score (MHHS) was evaluated pre and post operatively. The follow up period  was 2 years.

Results : The mean age of the studied group was 62.6±1.8 years. The average post-operative MHHS was 78.7±18.6. There was a statistically significant improvement in the MHHS score. There was significant difference regarding modified Harris hip pain scores pre  and postoperatively for patients with neck femur fractures. There was high significant difference regarding modified Harris functional hip  score for activities pre and postoperatively. Most of patients didn’t have any postoperative complications, one case had a dislocation  (5.6%), one case had a Periprosthetic fracture (5.6%) and one case had a superficial infection (5.6%).

Conclusions : THR is an effective  technique for management of displaced neck femur fractures in active elderly people. 

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Journal Identifiers

• DOI: 10.1016/j.injury.2024.111696
• Corpus ID: 270679171

Persistent Racial Disparities in Postoperative Management after Tibia Fracture Fixation: A Matched Analysis of US Medicaid Beneficiaries

• Malcolm DeBaun , Mari F. Vanderkarr , +6 authors Christian A. Pean
• Published in Injury 1 June 2024

24 References

The effect of social deprivation on fracture-healing and patient-reported outcomes following intramedullary nailing of tibial shaft fractures, complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis, racial disparities in the use of surgical procedures in the us., fracture-related outcome study for operatively treated tibia shaft fractures (f.r.o.s.t.): registry rationale and design, racial disparity in time to surgery and complications for hip fracture patients, complications of open reduction and internal fixation of distal humerus fractures, race and gender influence management of humerus shaft fractures., racial disparities in outcomes of operatively treated lower extremity fractures, tibial shaft fracture: a large-scale study defining the injured population and associated injuries., racial and socioeconomic disparities in hip fracture care., related papers.

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Is there a difference between preoperative and postoperative delirium in elderly hip fracture patients?: A retrospective case control study

Chaemoon lim.

a Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Korea

Young Ho Roh

Yong-geun park, jaeryun lee, kwang woo nam.

b Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu-si, Gyeonggi-do, Korea.

Delirium is associated with greater morbidity, higher mortality, and longer periods of hospital day after hip fracture. There are number of studies on postoperative delirium after a hip fracture. However, few studies have made a distinction between preoperative and postoperative delirium. The purpose of this study is to compare risk factors and clinical outcome between preoperative and postoperative delirium in elderly patients with a hip fracture surgery. A total of 382 consecutive patients aged > 65 years who underwent operation for hip fracture were enrolled. Among them, the patients diagnosed with delirium were divided into 2 groups (a preoperative delirium group and a postoperative delirium group) according to the onset time of delirium. To evaluate risk factors for preoperative and postoperative delirium, we analyzed demographic data, preoperative laboratory data, and perioperative data. To compare clinical outcomes between preoperative and postoperative delirium, we analyzed postoperative complications, KOVAL score, regression, readmission, and 2-year survival rate. Delirium was diagnosed in 150 (39.3%) patients during hospitalization. Preoperative and postoperative delirium occurred in 67 (44.6%) and 83 (55.4%) patients, respectively. Independent risk factors of preoperative delirium included age (odds ratio: 1.47, 95% confidential interval [CI]: 1.13–2.23, P  = .004), stroke (odds ratio [OR]: 2.70, 95% CI: 1.11–6.01, P  = .015), American Society of Anesthesiologist (OR: 1.68, 95% CI: 1.137–2.24, P  = .033), and time from admission to operation (OR: 1.08, 95% CI: 1.01–1.16, P  = .031). There was no significant difference in preoperative KOVAL score between the 2 groups. However, postoperative KOVAL score (5.1 ± 2.0 vs 4.4 ± 2.1, P  = .027) and regression rate (68.7% vs 44.6%, P  = .029) were significantly higher in the preoperative delirium group than in the postoperative delirium group. Moreover, the 2-year survival rate was significantly lower in the preoperative delirium group than in the postoperative delirium group (62.7% vs 78.3%, P  = .046). Characteristics, risk factors, and prognosis are different for patients with preoperative delirium and postoperative delirium. Preoperative delirium patients showed different risk factors with poorer prognosis and higher mortality. Therefore, hip fracture patients with risk factors for preoperative delirium should be monitored more carefully due to their greater risk of mortality.

1. Introduction

Hip fractures are common with an increasing incidence in elderly patients. [ 1 ] The number of hip fracture patients is expected to be 4.5 million by 2050 according to a previous report. [ 2 ] Although surgical treatment has become the first treatment for hip fracture, it has been reported that the one-year mortality rate is 15–25% and that more than 30% of patients lose their mobility function. [ 3 ] Therefore, a better understanding for factors affecting mortality and functional recovery after hip fracture is important.

Delirium is an acute brain dysfunction caused by maladaptation of the brain to hip fracture or surgical stress. [ 4 ] Delirium is a common complication of hip fracture among elderly patients. The incidence of delirium after hip fracture ranges from 20% to 50%. [ 5 , 6 ] Delirium is associated with great rates of morbidity and mortality in elderly patients who sustain a hip fracture. [ 7 ] It may delay postoperative functional recovery, prolong the length of hospitalization, and increase the burden of medical care. [ 8 ] Therefore, identification and management of risk factors for delirium after a hip fracture are important for preventing morbidity and mortality and recovering mobility function.

Several studies on risk factors associated with delirium after a hip fracture in elderly patients have reported that advanced age, sex, preexisting cognitive dysfunction, medial comorbidity, general anesthesia, and blood loss are possible risk factors. [ 9 – 12 ] However, few studies have reported the time course of delirium and distinguished between preoperative delirium and postoperative delirium in elderly patients with a hip fracture. Moreover, differences of risk factors and clinical outcome according to the time when delirium occurs after a hip fracture have not been well evaluated yet. Different approach might be important for preoperative and postoperative delirium to reduce mortality and improve functional recovery.

Therefore, the purpose of this study was to compare risk factors and clinical outcomes between preoperative and postoperative delirium in elderly patients with a hip fracture surgery.

After this study was approved by our Institutional Review Board, all methods were carried out in accordance with the guideline and regulation based on the Declaration of Helsinki. The requirement for informed consent was waived by the Institutional Review Board because of the retrospective nature of this study.

2.1. Study population

In this case control study, a total of 433 patients admitted with a hip fracture between January 2014 to January 2020 were assessed. Inclusion criteria were: (i) hip fracture (femoral neck, intertrochanteric, subtrochanteric fracture) requiring surgery, (ii) >65 years at the time of surgery, and (iii) available medical and radiologic records. Exclusion criteria were: (i) < 2 years of follow-up period (n = 27); and (ii) metabolic bone disease or secondary hip fracture due to tumor (n = 4). Thus, 382 patients were analyzed for this study. Delirium was indicated on the basis of Diagnostic and Statistical Manual of Mental disorder, fifth edition, which included: (i) disturbance in attention and awareness, (ii) disturbance developed acutely and the severity tended to fluctuate, (iii) at least one additional disturbance in cognition, (iv) disturbance could not be better explained by a preexisting dementia, (v) disturbances not occurring in the context of a severely reduced level of arousal or coma, (vi) evidence of an underlying organic cause or cause. Delirium was categorized into preoperative delirium and postoperative delirium according to the onset time of delirium.

2.2. Risk factors

We evaluated the demographic data and perioperative data to analyze risk factors for delirium and compared risk factors between preoperative delirium and postoperative delirium. Demographic data including age, sex, body mass index, dementia, parkinsonism, stroke, depression, hypertension, diabetic mellitus, chronic kidney disease, osteoporosis, and fracture type (femur neck, intertrochanteric, subtrochanteric) were investigated. Perioperative data such as American Society of Anesthesiologist grade, type of anesthesia, type of operation, time from admission to operation, operation time, postoperative intensive care unit care, and preoperative laboratory data were investigated. The type of operation included close reduction and internal fixation with internal medullary nail, close reduction and internal fixation with screw, bipolar hemiarthroplasty, and total hip arthroplasty. Preoperative laboratory data including white blood cell, erythrocyte sedimentation rate, C-reactive protein, hemoglobin, blood urine nitrogen, creatinine, and albumin were collected.

2.3. Clinical outcomes

We evaluated postoperative complications and clinical outcomes of delirium patients and compared these results between preoperative delirium patients and postoperative delirium patients. Postoperative complication such as operation site infection, pneumonia, pulmonary embolism, and deep vein thrombosis were investigated. Clinical outcome was assessed based on the duration of hospital stay, preoperative and postoperative KOVAL scores, readmission, and 2-year survival rate. The length of hospital stay was calculated from the admission day until discharge, including surgical treatment and rehabilitation procedure time. Ambulatory ability was assessed with KOVAL score (score of 1: independent community ambulator, 2: community ambulator with cane, 3: community ambulator with walker/crutches, 4: independent household ambulator, 5: household ambulator with cane, 6: household ambulator with walker/crutches, and VII: nonfunctional ambulator). Postoperative KOVAL scores were evaluated at the last follow-up. Regression was defined when the postoperative KOVAL score was lower than the postoperative KOVAL score. Any readmission after discharge was analyzed. Two-year survival rate was evaluated with direct or telephone interview and medical record at postoperative 2 years.

2.4. Statistical analysis

Continuous data are presented as means and standard deviation. Categorical data are shown as frequency or proportions. Student t test was used for continuous data. Chi-square test was employed for categorical data. Logistic regression analysis was performed to adjust for potentially confounding variables (age, gender, body mass index). Odds ratio (OR) and 95% confidence interval (CI) are reported. Two-year survival rate was analyzed using Kaplan–Meier survival curves. All analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY) and P  < .05 was considered significant.

3.1. Baseline characteristics

Delirium was developed in 150 (39.3%) patients after a hip fracture. Among these delirium patients, 67 (44.7%) were diagnosed with preoperative delirium and 83 (55.3%) were diagnosed with postoperative delirium (Fig. ​ (Fig.1). 1 ). Their demographic characteristics are summarized in Table ​ Table1. 1 . The mean age of preoperative delirium patients was significantly higher than that of postoperative delirium patients (85.1 ± 6.9 years vs 80.8 ± 11.9 years, P  = .041). More preoperative patients had underlying stoke before hip fracture ( P  = .017). Perioperative characteristics are summarized in Table ​ Table2. 2 . The number of days from admission to operation was larger for preoperative delirium patients than for postoperative delirium patients ( P  = .013).

Demographic characteristics of preoperative delirium patients and postoperative delirium patients.

BMI = body mass index, CKD = chronic kidney disease, DM = diabetic mellitus, HTN = hypertension, SD = standard deviation.

Perioperative characteristics of preoperative delirium patients and postoperative delirium patients.

ASA = American Society of Anesthesiologist, BUN = blood urine nitrogen, Cr = creatinine, CRIF = close reduction and internal fixation, CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, Hb = hemoglobin, ICU = intensive care unit, IM = internal medullary, SD = standard deviation, WBC = white blood cell.

Flowchart of patient inclusion.

3.2. Predictors of preoperative delirium

To identify independent predictors of preoperative delirium, a multivariate logistic regression analysis was performed (Table ​ (Table3). 3 ). Age (OR: 1.049, 95% CI: 1.010–1.090, P  = .014), stroke (OR: 2.906, 95% CI: 1.263–6.685, P  = .012), and days from admission to operation (OR: 1.047, 95% CI: 1.007–1.089, P  = .020) were significant predictors of preoperative delirium.

Predictors of preoperative delirium patients.

CI = confidence interval, OR = odds ratio.

3.3. Clinical outcomes

Postoperative KOVAL score of preoperative delirium patients was significantly higher than that of postoperative delirium patients (5.1 ± 2.0 vs. 4.4 ± 2.1, P  = .027). Regression of walking ability was more frequent in preoperative delirium patients than in postoperative delirium patients (68.7% vs 44.6%, P  = .029). Preoperative delirium patients showed significantly lower survival rate than postoperative delirium patients (62.7% vs 78.3%, P  = .046) (Table ​ (Table4 4 and Fig. ​ Fig.2 2 ).

Postoperative results of preoperative delirium patients and postoperative delirium patients.

DVT = deep vein thrombosis, Op = operation.

Kaplan–Meier survival curves for 2 years survival rates after surgery.

4. Discussion

This retrospective study compared risk factors and clinical outcomes between preoperative and postoperative delirium elderly patients with a hip fracture surgery. This study demonstrated several important findings: (1) preoperative delirium patients and postoperative delirium patients showed different characteristics and predictors; (2) preoperative delirium patients were associated with advanced age, stroke, and longer days from admission to operation than postoperative delirium patients; (3) preoperative delirium patients were associated with a reduced walking ability after a hip fracture surgery; (4) preoperative delirium patients showed lower 2-year survival rate after a hip fracture surgery compared to postoperative delirium patients. This study was important in that it evaluated the time course of delirium and distinguished between preoperative delirium and postoperative delirium in elderly patients with a hip fracture.

In this study, we found that preoperative delirium patients were associated with an advanced age compared to postoperative delirium patients. It is already known that advanced age is one of the most important risk factors for postoperative delirium. Kong et al have reported that elderly patients (≥75 years of age) with a hip fracture are 3.112 times more likely to develop delirium after a hip surgery. [ 13 ] In general, elderly patients have poor functional ability and degeneration of internal organs accompanied by many chronic medical diseases. Moreover, they are prone to merge due to poor oral intake and metabolic disorder, leading to malnutrition. [ 14 ] Mak et al have reported that preoperative malnutrition in elderly patients with hip fracture is one of the main risk factors for delirium. [ 15 ] In case of advanced aged patients with a hip fracture, careful review of patient’s medical problem and optimal management for pain, malnutrition, and medication are important. [ 16 ]

We also found that preexisting stroke was associated with preoperative delirium patients. Previous studies have reported that cognitive impairment such as dementia is an independent risk factor of delirium. [ 17 ] Moreover, several studies have demonstrated that preexisting stroke is associated with delirium after a hip fracture in elderly patients. [ 18 , 19 ] High hypothalamic–pituitary–adrenal axis activity and cerebral cholinergic system might be 2 important mechanisms for delirium after a hip fracture. It has been reported that a decrease of acetylcholine has an important role in the development of delirium. [ 20 ] Preoperative opiated (anticholinergic medication), hypoglycemia, and hypoxia can result in a decrease of acetylcholine. [ 21 ] An intervention program for protecting cerebral oxidative and cholinergic metabolism can result in reduced frequency, duration, and severity of delirium after a hip fracture in stroke patients. [ 19 ] Such intervention program is needed for stroke patients with a hip fracture.

An important finding of this study was the association between delay of surgery and preoperative delirium. There are many factors that can cause a delay of surgery, such as preoperative comorbidity, delay of evaluation of operative risk, and time required for stabilization for medial comorbidity. [ 22 ] Previous studies have reported a greater mortality if the operative treatment is delayed by more than 48 hours. [ 23 ] Moreover, a delay of surgery has been associated with longer length of hospital stay, infectious complications, and pressure ulcers. [ 24 ] The odds of preoperative delirium is increased by 5% per hour of delay of surgery. [ 25 ] Thus, surgeons should make effort to reduce delay of surgery.

In this study, preoperative delirium patients showed poor functional recovery of walking ability and higher mortality rate after a hip surgery. It is well known that delirium in elderly patients with hip fracture is associated with delay of postoperative functional recovery, increase of hospital stay, and postoperative mortality. [ 26 , 27 ] However, comparison of clinical outcome between preoperative delirium and postoperative delirium has been rarely reported. The poorer functional recovery and the higher mortality rate in preoperative delirium patients might be due to vulnerability of elderly patients and delay of rehabilitation. Advanced age of preoperative delirium patients compared to postoperative delirium patients might be the cause of a higher mortality in 2 years after operation. Early mobilization and rehabilitation in elderly hip fracture patients are associated with better functional outcomes. [ 28 ] Therefore, delay of surgery in preoperative delirium patients might be the cause of their poorer functional recovery compared to postoperative delirium patients. Although our limited data cannot fully explain different prognostic implication between preoperative delirium patients and postoperative delirium patients, a more cautious approach would be needed for preoperative delirium patients.

This study has several limitations. First, this study performed a retrospective analysis with a small sample size. There might be some biases to detect potential risk factors. Second, some potential risk factors such as, preoperative nutritional status, blood loss during operation, and transfusion were not analyzed in this study duo to the lack of information. In addition, data on causes of death were unavailable in this study. Therefore, future studies are needed to identify potential risk factors and develop intervention to prevent preoperative delirium.

In conclusion, characteristics, risk factors, and prognosis are different between preoperative delirium and postoperative delirium. Preoperative delirium patients showed different risk factors with poorer prognosis and higher mortality. Therefore, hip fracture patients with risk factors for preoperative delirium should be monitored more carefully due to their greater risk of mortality.

Acknowledgments

The authors wish to acknowledge Corentec Co., Ltd., an implant specialist company, for their help with the creation of the contents included in this paper.

Author contributions

Conceptualization: Chaemoon Lim, Kwang Woo Nam.

Data curation: Young Ho Roh, Jaeryun Lee.

Formal analysis: Chaemoon Lim, Yong-Geun Park.

Methodology: Chaemoon Lim, Kwang Woo Nam.

Software: Yong-Geun Park, Jaeryun Lee.

Supervision: Kwang Woo Nam.

Validation: Yong-Geun Park.

Writing – original draft: Chaemoon Lim.

Writing – review & editing: Young Ho Roh, Yong-Geun Park, Jaeryun Lee, Kwang Woo Nam.

Abbreviations:

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

How to cite this article: Lim C, Roh YH, Park Y-G, Lee J, Nam KW. Is there a difference between preoperative and postoperative delirium in elderly hip fracture patients? A retrospective case control study. Medicine 2024;103:4(e36584).