From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Ms. Haynes, Mr. Alder, Dr. Toombs, Dr. Rubin, and Dr. Grauer), and the Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Mr. Amakiri).
J Am Acad Orthop Surg Glob Res Rev. 2021 May 14;5(5):e20.00221. doi: 10.5435/JAAOSGlobal-D-20-00221.
Postoperative delirium is common for patients with hip fracture. Predictors of postoperative delirium and its association with preexisting dementia and adverse postoperative outcomes in a geriatric hip fracture population were assessed.
Patients with hip fracture aged 60 years and older were identified in the 2016 and 2017 National Surgical Quality Improvement Program Procedure Targeted Databases. Independent risk factors of postoperative delirium were identified. Associations with mortality, readmission, and revision surgery were evaluated using moderation and mediation analysis.
Of 18,754 patients with hip fracture, 30.2% had preoperative dementia, 18.8% had postoperative delirium, and 8.3% had both preoperative dementia and postoperative delirium. Independent predictors of postoperative delirium were as follows: older age, male sex, higher American Society of Anesthesiologists score, dependent functional status, nongeneral anesthesia, preoperative diabetes, bleeding disorder, and preoperative dementia. Preoperative dementia and postoperative delirium each had an independent correlation with 30-day mortality (odds ratios = 2.06 and 1.92, respectively, with P < 0.001 for both). However, when both were present, those with preoperative dementia and postoperative delirium had an even higher odds of mortality based on moderation analysis (odds ratio = 2.25, P < 0.001). Readmissions and reoperations were significantly correlated with postoperative delirium, but not with preoperative dementia. The combination of preoperative dementia and postoperative delirium, however, did have compounding effects. Furthermore, a significant proportion of the total effect of preoperative dementia on mortality and readmission was accounted for by the development of postoperative delirium based on mediation analysis (medeff: 7%, P < 0.001 and medeff: 35%, P < 0.001).
Postoperative delirium is a potentially preventable postoperative adverse outcome that was seen in 18.8% of 18,754 patients with hip fracture. Those with preoperative dementia seem to be a particularly at-risk subpopulation. Quality improvement initiatives to minimize postoperative delirium in this hip fracture population should be considered and optimized.
髋部骨折患者术后谵妄较为常见。本研究评估了老年髋部骨折患者中术后谵妄的预测因素及其与术前痴呆和术后不良结局的关系。
在 2016 年和 2017 年国家手术质量改进计划程序靶向数据库中确定了年龄在 60 岁及以上的髋部骨折患者。确定了术后谵妄的独立危险因素。使用调节和中介分析评估与死亡率、再入院和翻修手术的相关性。
在 18754 例髋部骨折患者中，30.2%有术前痴呆，18.8%有术后谵妄，8.3%同时有术前痴呆和术后谵妄。术后谵妄的独立预测因素如下：年龄较大、男性、美国麻醉医师协会评分较高、功能依赖状态、非全身麻醉、术前糖尿病、出血性疾病和术前痴呆。术前痴呆和术后谵妄均与 30 天死亡率独立相关（比值比分别为 2.06 和 1.92，均 P<0.001）。然而，当两者同时存在时，根据调节分析，那些同时患有术前痴呆和术后谵妄的患者死亡率更高（比值比=2.25，P<0.001）。再入院和再手术与术后谵妄显著相关，但与术前痴呆无关。然而，术前痴呆和术后谵妄的组合确实具有叠加效应。此外，根据中介分析，术前痴呆对死亡率和再入院的总影响中，有很大一部分是由术后谵妄引起的（中介效应量：7%，P<0.001；中介效应量：35%，P<0.001）。
术后谵妄是髋部骨折患者一种潜在可预防的术后不良事件，在 18754 例髋部骨折患者中占 18.8%。那些有术前痴呆的患者似乎是一个特别危险的亚群。应考虑并优化针对该髋部骨折人群减少术后谵妄的质量改进措施。
