Hawley Samuel, Inman Dominic, Gregson Celia L, Whitehouse Michael, Johansen Antony, Judge Andrew
Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Care Quality Improvement Department, Royal College of Physicians, London, UK.
J Am Med Dir Assoc. 2023 May;24(5):694-701.e7. doi: 10.1016/j.jamda.2023.02.008. Epub 2023 Mar 15.
To identify risk factors of postoperative delirium among hip fracture patients with normal preoperative cognition, and examine associations with returning home or recovery of mobility.
Prospective cohort study.
We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018-2019), but excluded those with abnormal cognition [abbreviated mental test score (AMTS) < 8] on presentation.
We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1-3 being an intermediate score not excluding delirium.
Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home [odds ratio (OR), 0.46; 95% CI, 0.38-0.55] or regain outdoor mobility (OR, 0.63; 95% CI, 0.53-0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81-0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1-3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance.
Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
确定术前认知功能正常的髋部骨折患者术后谵妄的危险因素，并研究其与回家或恢复活动能力之间的关联。
前瞻性队列研究。
我们使用国家髋部骨折数据库（NHFD）来识别2018 - 2019年在英格兰出现髋部骨折的患者，但排除了就诊时认知功能异常[简易精神状态检查表（AMTS）评分<8]的患者。
我们检查了使用4A测试（4AT）进行的常规谵妄筛查结果，该测试通过一个包含4个项目的心理测试来评估警觉性、注意力、急性变化和定向力。估计了4AT评分与120天时回家或恢复户外活动能力之间的关联，并确定了4AT评分异常的危险因素：（1）4AT≥4提示谵妄，（2）4AT = 1 - 3为不排除谵妄的中间评分。
总体而言，63502名患者（63%）术前AMTS≥8，其中4454名（7%）患者术后4AT评分≥4提示谵妄。这些患者在120天时回家的可能性较小[比值比（OR），0.46；95%置信区间（CI），0.38 - 0.55]或恢复户外活动能力的可能性较小（OR，0.63；95% CI，0.53 - 0.75）。包括术前AMTS的任何缺陷和营养不良在内的多种因素与4AT≥4的较高风险相关，而术前使用神经阻滞与较低风险相关（OR，0.88；95% CI，0.81 - 0.95）。在12042名（19%）4AT = 1 - 3的患者中也观察到较差的结果；与该评分相关的其他危险因素包括社会经济剥夺以及不符合国家卫生与保健优化研究所指南的手术类型。
髋部骨折手术后的谵妄显著降低了回家或恢复户外活动能力的可能性。我们的研究结果强调了预防术后谵妄措施的重要性，并有助于识别谵妄预防可能改善预后的高危患者。
