Objective: The purpose of this study was to determine the incidence of delirium in very old patients, it’s predisposing and precipitating factors and implications of delirium on the rehabilitation outcomes and mortality.
Design: Prospective cohort study.
Materials and Methods: Kaplan-Harzfeld Medical Center, Gedera, Israel, from August 2001 to January 2002. Participants: 137 consecutive patients with hip fractures, over the age of 75, who were admitted to the orthopedic section of the emergency department.
Results: Patients were evaluated at three points: at admission, one week after the surgery for hip fracture, and one month after the surgery. The evaluation included a wide range of demographic, clinical and laboratory parameters, and the assessments of the cognitive and functional status which were performed by the Mini-Mental-State Examination (MMSE) test and by the Functional Independence Measures (FIM) test. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) was used for the definition of the previous cognitive status. Delirium was diagnosed by the Confusion Assessment Method (CAM), and in order to support and validate the diagnosis of delirium the Delirium Rating Scale (DRS) was used. To identify predictors of delirium we constructed a multiple logistic regression model having as dependent variable delirium. Rehabilitation outcomes were defined as length of hospitalization, mortality (one, three and six-month), and the changes in MMSE and FIM scores.
Results: The cumulative incidence of delirium was 11.4%. No significant difference was found between delirious and non-delirious patients in terms of all demographic, socio-economic, and preoperative parameters. Cognitive impairment before the fracture and four or more regular medications prescribed to the patients was the only predictive factors for the development of delirium in multivariate model (odds ratio 9.4, 95% confidence interval=1.1-8.12, and odds ratio 4.45, 95% confidence interval=1.1-18.3, respectively). Delirium was not a significant predictor of any rehabilitation outcome.
Conclusion: The results of our study documented that the incidence of significant delirium after hip fracture in the elderly patients much lower that it was reported in some previous studies. Premorbid cognitive impairment was the most significant predisposing condition for the development of delirium. Thorough evaluation of previous cognitive status could improve the probability of the diagnosis of delirium and pinpoint a limited group of patients for delirium-preventive approach. The fact that delirium did not influence the rehabilitation outcomes emphasizes the importance of rehabilitation measures in this subgroup of hip fractured patients.
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