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Orthogeriatrics Current Awareness Bulletin

Quarterly

Summer 2016

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Contents Your Local Librarian................................................................................................................................. 2

New from Cochrane Library .................................................................................................................... 3

No New Evidence from Cochrane .................................................... Error! Bookmark not defined.

New from NICE ........................................................................................................................................ 3

New Activity in UptoDate ....................................................................................................................... 4

Current Awareness Database Articles related to Orthogeriatrics .......................................................... 5

Fragility fractures ................................................................................................................................ 5

Postoperative delirium ..................................................................................................................... 15

Other ................................................................................................................................................. 20

Journal Tables of Contents .................................................................................................................... 23

Bone and Joint Journal (UK) .............................................................................................................. 23

Your Local Librarian Whatever your information needs, the library is here to help. As your outreach librarian I offer

literature searching services as well as training and guidance in searching the evidence and critical

appraisal – just email me at library @uhbristol.nhs.uk

OUTREACH: Your Outreach Librarian can help facilitate evidence-based practise for all in the

Orthogeriatrics team, as well as assisting with academic study and research. We can help with

literature searching, obtaining journal articles and books, and setting up individual current

awareness alerts. We also offer one-to-one or small group training in literature searching,

accessing electronic journals, and critical appraisal. Get in touch: library@uhbristol.nhs.uk

LITERATURE SEARCHING: We provide a literature searching service for any library member. For

those embarking on their own research it is advisable to book some time with one of the librarians

for a 1 to 1 session where we can guide you through the process of creating a well-focused literature

research and introduce you to the health databases access via NHS Evidence. Please email requests

to lbrary@uhbristol.nhs.uk

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New from Cochrane Library

No New Evidence

New from NICE

Health-related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis

Source: PubMed - 04 June 2016

ABSTRACT: Health-related quality of life in osteoporotic patients with vertebral fracture is of

increasing interest, but relevant studies have yielded debatable results. This systematic

review and meta-analysis of 16 observational studies demonstrate a clear association

between physical health status and presence of vertebral fracture after accounting for age.

This meta-analysis was conducted to identify if there are any differences between physical

and/or mental health-related quality of life (HRQoL) in older people with osteoporosis based

on conventional T-score definitions and the presence or absence of vertebral fracture.

Reinforced fixation of distal fibula fractures in elderly patients; A meta-analysis of biomechanical studies

Source: PubMed - 11 May 2016

BACKGROUND: There is an increasing incidence of fragility fractures of the ankle in the

elderly population. The open reduction and internal fixation of these fractures is

challenging, due to reduced bone stock quality as a result of osteoporosis. Biomechanical

studies have shown contradicting results using reinforced constructions in the fixation of

fibular fractures. We therefore performed a meta-analysis of biomechanical studies on

reinforced fixation of distal fibular fractures.

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New Activity in UptoDate

New updates in point-of-care evidence summarising tools UpToDate

Hospital management of older adults

Author: Melissa Mattison, MD, SFHM

Literature review current through: Jun 2016.|This topic last updated: Jun 15, 2015.

INTRODUCTION — Patients 65 years and older represented 40 percent of hospitalized adults and nearly half of all healthcare dollars spent on hospitalization in 2008, but comprised less than 13 percent of the population in the United States [1]. Individuals 85 years and older make up only 1.8 percent of the total population but account for 8 percent of all hospital discharges [2]. Hospitalizations and healthcare spending for older adults are expected to rise as the population continues to age.

INTRODUCTION INCREASED VULNERABILITY PATIENT ASSESSMENT Medication reconciliation Advance directives Social support Vaccinations

PREVENTING SPECIFIC ADVERSE OUTCOMES Functional decline Falls Delirium Sleeplessness/sleep deprivation Tethers Infections Malnutrition Pressure ulcers Venous thromboembolism Adverse drug events

HOSPITAL-WIDE INTERVENTIONS Multidisciplinary team Checklists and order sets Protocols for medication-appropriateness Early mobilization programs Safety equipment

SITES OF CARE Intensive care in critical illness Geriatric units Alternatives to hospital care

https://www.uptodate.com/contents/hospital-management-of-older-

adults?source=search_result&search=ortho+geriatric&selectedTitle=3%7E150#H25046739

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Current Awareness Database Articles

related to Orthogeriatrics

Below is a selection of articles related to orthogeriatrics recently added to the healthcare

databases, grouped in the following categories:

If you would like any of the following articles in full text, or if you would like a more focused

search on your own topic, then get in touch: library@uhbristol.nhs.uk

Fragility fractures

Title: A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement. Citation: Aging clinical and experimental research, Aug 2016, vol. 28, no. 4, p. 797-803 Author(s): Blain, H, Masud, T, Dargent-Molina, P, Martin, F C, Rosendahl, E, Abstract: Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

Title: Epidemiology of fractures in the United Kingdom 1988-2012: Variation with age, sex, geography, ethnicity and socioeconomic status Citation: Bone, June 2016, vol./is. 87/(19-26) Author(s): Curtis E.M., van der Velde R., Moon R.J., van den Bergh J.P.W., Geusens P., Abstract: Summary: Rates of fracture worldwide are changing. Using the Clinical Practice Research Datalink (CPRD), age, and gender, geographical, ethnic and socioeconomic trends in fracture rates across the United Kingdom were studied over a 24-year period 1988-2012. Previously observed patterns in fracture incidence by age and fracture site were evident. New data on the influence of geographic location, ethnic group and socioeconomic status were obtained. Introduction: With secular changes in age- and sex-specific fracture incidence observed in many populations, and global shifts towards an elderly demography, it is vital for health care planners to have an accurate understanding of fracture incidence nationally. We aimed to present up to date fracture incidence data in the UK, stratified by age, sex, geographic location, ethnicity and socioeconomic status. Methods: The Clinical Practice Research Datalink (CPRD) contains anonymised electronic health records for approximately 6.9% of the UK population. Information comes from General Practitioners,

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and covers 11.3 million people from 674 practices across the UK, demonstrated to be representative of the national population. The study population consisted of all permanently registered individuals aged >. 18 years. Validated data on fracture incidence were obtained from their medical records, as was information on socioeconomic deprivation, ethnicity and geographic location. Age- and sex-specific fracture incidence rates were calculated. Results: Fracture incidence rates by age and sex were comparable to those documented in previous studies and demonstrated a bimodal distribution. Substantial geographic heterogeneity in age- and sex adjusted fracture incidence was observed, with rates in Scotland almost 50% greater than those in London and South East England. Lowest rates of fracture were observed in black individuals of both sexes; rates of fragility fracture in white women were 4.7 times greater than in black women. Strong associations between deprivation and fracture risk were observed in hip fracture in men, with a relative risk of 1.3 (95% CI 1.21-1.41) in Index of Multiple Deprivation category 5 (representing the most deprived) compared to category 1. Conclusions: This study presents robust estimates of fracture incidence across the UK, which will aid decisions regarding allocation of healthcare provision to populations of greatest need. It will also assist the implementation and design of strategies to reduce fracture incidence and its personal and financial impact on individuals and health services.

Title: Failure of fracture fixation in osteoporotic bone. Citation: Injury, Jun 2016, vol. 47 Suppl 2, p. S3. Author(s): von Rüden, Christian, Augat, Peter Abstract: This manuscript will provide an overview of how the age and osteoporosis related changes in mechanical properties of bone affect the stability of osteosynthesis constructs, both from a mechanical as well as from a clinical perspective. The manuscript will also address some of the principles of fracture fixation for osteoporotic fractures and discuss applications of osteoporotic fracture fixation at sites typically affected by fragility fractures, namely the distal radius, the proximal humerus, the femur and the spine. The primary aim of operative treatment in elderly individuals is the avoidance of immobilization of the patient. In selected cases conservative treatment might be required. Generally, choice of treatment should be individualized and based on the evaluation of patient-specific, fracture-specific and surgeon-specific aspects. The orthopaedic surgeon plays an essential role in enabling functional recovery by providing good surgery but a multidisciplinary approach is essential in order to support the patient to regain his/her quality of life after fragility fracture. Overall, the therapy of fractures in osteoporotic bone in the elderly requires a multidisciplinary therapeutic acute care concept including treatment of co-morbidities and correct choice of timing, and technique of the operative intervention

Title: Efficacy of Local Administration of Tranexamic Acid for Blood Salvage in Patients Undergoing Intertrochanteric Fracture Surgery. Citation: Journal of orthopaedic trauma, Aug 2016, vol. 30, no. 8, p. 409-414 Author(s): Drakos, Athanasios, Raoulis, Vasilios, Karatzios, Konstantinos, Abstract: The primary aim of this study was to assess whether local administration of tranexamic acid (TXA) reduced the need for a blood transfusion in elderly patients treated with an intramedullary (IM) nail for an intertrochanteric fracture. Randomized prospective

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trial. Academic level 1 trauma center. Two hundred patients (200 fractures) over 65 years with an intertrochanteric fracture treated by IM nail between April 1, 2012, and March 31, 2014. Subfascial administration of 3 g of TXA around the fracture site at the end of the surgical procedure, versus a control group without TXA. Follow-up ranged from 12 to 24 months. Group differences in number of transfused packed red blood cell (PRBC) units, and hematocrit, hemoglobin, and platelet count. There was a 43% reduction in transfusion requirements in the TXA group (P < 0.01). Twenty-seven units of PRBC were transfused in 22/100 patients in the TXA group, whereas 48 PRBC units were transfused in 29/100 patients in control group. There was no difference between the 2 groups in terms of late complications and overall mortality rate. Subfascial administration of TXA around the fracture site in elderly patients undergoing IM nailing for intertrochanteric fractures is safe and cost-effective. A significant reduction in blood loss and transfused blood units, and health care cost can be achieved. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Title: Prevention of hip fracture: An analysis of "pre-admission" and opportunity for intervention Citation: Journal of the American Geriatrics Society, May 2016, vol./is. 64/(S268) Author(s): Pierrie S., Churchill C., Patt J., Seymour R., Karunakar M. Abstract: Background: Hip fractures are associated with significant morbidity and mortality among older adults. While considerable literature exists on the injury burden, loss of independence, and mortality following hip fracture, little attention has been paid in the acute care setting to address primary or secondary prevention in this medically comprised population. The purpose of this study was to describe the incidence of and reasons for emergency department visits or inpatient hospitalizations in the one year prior to admission for hip fracture to identify opportunities for intervention. Methods: A retrospective study of patients aged 55+ with hip fractures treated in our hospital over a one year period was performed. Medical records were reviewed and demographic characteristics as well as reasons for visit, interventions, discharge disposition, and other details of all "pre-admissions", defined as ED visits (excluding those that led to admission) and inpatient admissions for the year prior to the hip fracture, were documented. Results: One hundred fifty-seven patients with an average age of 78.4 years (range, 55-100) were treated for a hip fracture at an urban, academic trauma center during a one-year period. Sixty-six percent were women and 34% were male. 45% (N=70) had a "pre-admission" in the year prior. Of these, 39% (N=27) visited the ED (N=13 with 2+ visits), 37% (N=26) had at least one inpatient stay (N=18 with 2+), and 24% (N=17) with both in the 365 days prior to the hip fracture. Fifty-percent of "pre-admissions" - 35% (N=15) of ED visits and 24% (N=10) inpatient admissions - were due to either mechanical or syncopal falls. The remainder presented for medical issues, including altered mental status (16%, N=11), shortness of breath (19%, N=13), and chest pain (13%, N=9). 75% presented due to an exacerbation of an existing medical illness. Conclusions: 45% of hip fracture patients presented for emergency or inpatient care in the year prior to the injury, presenting an opportunity for intervention. While medical issues are more common, 50% sought care related to a fall. Targeting these patients with programs such as falls education, in-home safety evaluations, and balance training might prevent future fragility fracture.

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Title: End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity? Citation: Clinical orthopaedics and related research, Jul 2016, vol. 474, no. 7, p. 1736-1739, Author(s): Dunn, Robin H, Ahn, Jaimo, Bernstein, Joseph Abstract: Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition. We assessed the frequency with which end-of-life care discussions were documented among a sample of geriatric patients admitted for hip fracture surgery. We studied 150 adult patients, 70 years and older, admitted between September 2008 and July 2012 for the care of an isolated low-energy hip fracture, who did not have documented evidence of end-of-life care planning before the time of admission. For each patient, the medical record was scrutinized to identify documentation of end-of-life care discussions, an order changing "code status," or a progress note memorializing a conversation related to the topic of end-of-life care planning. Of the 150 subjects who had no documented evidence of end-of-life care planning at the time of admission, 17 (11%) had their code status changed during the initial hospitalization for hip fracture, and an additional four patients (3%) had a documented conversation regarding end-of-life care planning without a subsequent change in code status. Accordingly, there were 129 (86%) patients who had no record of any attention to end-of-life care planning during the hospital stay for hip fracture surgery. Our findings suggest that physicians may be missing a valuable opportunity to help patients and their families be better prepared for potential future health issues. End-of-life care planning respects patient autonomy and enhances the quality of care. Accordingly, we recommend that discussion of goals, expectations, and preferences should be initiated routinely when patients present with a fragility fracture of the hip. Level IV, therapeutic study.

Title: Associations between hospital-based rehabilitation for hip fracture and two-year outcomes for mortality and independent living: An Australian database study of 1,724 elderly community-dwelling patients. Citation: Journal of rehabilitation medicine, Jul 2016, vol. 48, no. 7, p. 625-631 Author(s): Ireland, Anthony W, Kelly, Patrick J, Cumming, Robert G Abstract: To compare rates of mortality, hospital readmissions and independent living status for 2 years following hip fracture in community-dwelling patients with and without hospital-based rehabilitation. Retrospective cohort study. Administrative data-sets were linked for hospital treatment, residential aged care admissions, selected community services and date of death for community-dwelling hip fracture patients. Mortality, readmissions, residency within aged care facilities and independent living status at intervals up to 2 years were compared in multivariate logistic regression for patients with and without hospital-based rehabilitation. Age, sex and comorbidity distributions were similar for 1,050 patients who received rehabilitation and 674 patients who did not. Rehabilitation added 11 days to total hospital stay and $AUD 12,000 to hospital costs. Mortality at 90 days after hip fracture

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was 4.7% for rehabilitation patients vs 10.7% for others (p < 0.001), and 26.2% vs 37.2% (p < 0.001) at 2 years. Beyond 90 days there was no significant association between receipt of rehabilitation and the proportion of patients meeting criteria for independent living. Hospital readmissions in the year following the index fracture were not significantly different. In-hospital rehabilitation substantially increases total hospital costs. It is associated with improved early and late survival, but not with the likelihood of living independently for up to 2 years after hip fracture.

Title: Diagnosis and Management of Vertebral Compression Fractures. Citation: American family physician, Jul 2016, vol. 94, no. 1, p. 44-50 Author(s): McCarthy, Jason, Davis, Amy Abstract: Vertebral compression fractures (VCFs) are the most common complication of osteoporosis, affecting more than 700,000 Americans annually. Fracture risk increases with age, with four in 10 white women older than 50 years experiencing a hip, spine, or vertebral fracture in their lifetime. VCFs can lead to chronic pain, disfigurement, height loss, impaired activities of daily living, increased risk of pressure sores, pneumonia, and psychological distress. Patients with an acute VCF may report abrupt onset of back pain with position changes, coughing, sneezing, or lifting. Physical examination findings are often normal, but can demonstrate kyphosis and midline spine tenderness. More than two-thirds of patients are asymptomatic and diagnosed incidentally on plain radiography. Acute VCFs may be treated with analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, narcotics, and calcitonin. Physicians must be mindful of medication adverse effects in older patients. Other conservative therapeutic options include limited bed rest, bracing, physical therapy, nerve root blocks, and epidural injections. Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, is controversial, but can be considered in patients with inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life. Family physicians can help prevent vertebral fractures through management of risk factors and the treatment of osteoporosis.

Title: Prophylactic proton pump inhibitors in femoral neck fracture patients - A life - and cost-saving intervention. Citation: Annals of the Royal College of Surgeons of England, Jul 2016, vol. 98, no. 6, p. 371-375 Author(s): Singh, R, Trickett, R, Meyer, Cer, Lewthwaite, S, Ford, D Abstract: Introduction Acute gastrointestinal stress ulceration is a common and serious complication of trauma. Prophylactic proton pump inhibitors (PPIs) or histamine receptor antagonists have been used in poly-trauma, burns and head and spinal injuries, as well as on intensive care units, for the prevention of acute gastric stress ulcers. Methods We prospectively studied the use of prophylactic PPIs in with femoral neck fracture patients, gathering data on all acute gastric ulcer complications, including coffee-ground vomiting, malena and haematemesis. We then implemented a treatment protocol in which all patients were given prophylactic PPIs, again prospectively collecting all data. Results Five hundred and fifteen patients were included. Prior to prophylactic PPI, 15% of patients developed gastric stress ulcer complications, with 3% requiring acute intervention with oesophagogastroduodenoscopy (OGD), 5% requiring transfusions and 4% experiencing

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surgical delays. All patients had delayed discharges. Following PPI implementation, no patients developed gastric stress ulcer complications. Conclusions Femoral neck fracture patients create a substantial workload for orthopaedic units. The increasingly elderly population often have comorbidities, and concomitantly use medications with gastrointestinal side effects. This, combined with the stress of a fracture and preoperative starvation periods increases the risk of gastric ulcers. Here, the use of prophylactic PPIs statistically reduced the incidence of gastric stress ulcers in patients with femoral neck fractures, resulting in fewer surgical delays, reduced length of hospital stay and reduced stress ulcer-related mortality.

Title: Patient Comorbidity Status and Incremental Total Hospitalization Costs in Elective Orthopedic Procedures. Citation: Orthopedics, Jul 2016, vol. 39, no. 4, p. 237-246, Author(s): Nichols, Christine I, Vose, Joshua G Abstract: This study examined the correlation between patient comorbidity status, hospitalization length of stay (LOS), and cost for total knee arthroplasty (TKA), total hip arthroplasty (THA), and 1- to 3-level lumbar spinal fusion procedures. Using the Premier Perspective Database, adults older than 18 years who underwent primary unilateral TKA, THA, or spinal fusion between January 1, 2008, and June 30, 2014, were identified. Generalized linear models controlling for age, sex, region, hospital size, academic status, payor, and procedure year predicted the incremental total hospitalization cost among the sickest patients (Charlson Comorbidity Index [CCI] ≥3) vs healthy controls (CCI=0). The study cohort included 536,582 TKAs, 275,953 THAs, and 177,493 spinal fusion procedures. The percentages of patients with a CCI of 3 or greater were 5.4%, 4.7%, and 4.3%, for TKA, THA, and spinal fusion procedures, respectively. Mean (SD) LOS was longer by 0.9 (1.5), 1.4 (2.3), and 2.3 (3.8) days for patients with a CCI of 3 or greater vs 0 for TKA, THA, and spinal fusion procedures, respectively. Unadjusted total hospitalization costs were $17,512 for TKA, $18,915 for THA, and $32,932 for spinal fusion procedures; generalized linear models showed an incremental total hospitalization cost for CCI scores of 3 or greater of $2211, $3041, and $3922 vs CCI equal to 0 for each procedure type, respectively. Although representing a relatively small proportion of all patients undergoing elective orthopedic procedures, highly comorbid patients were associated with a greater total hospitalization cost burden. With the average patient comorbidity burden growing nationally, this study warrants further examination of improved standards of care for comorbid patients undergoing elective orthopedic procedures.

Title: Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study. Citation: Geriatric orthopaedic surgery & rehabilitation, Jun 2016, vol. 7, no. 2, p. 81-85, Author(s): Kalmet, P H S, Koc, B B, Hemmes, B, Ten Broeke, R H M, Dekkers, G, Hustinx, P, Abstract: The use of a multidisciplinary clinical pathway (MCP) for patients with hip fracture tends to be more effective than usual care (UC). The aim of this study was to evaluate the effects of an MCP approach on time to surgery, length of stay, postoperative complications, and 30-day mortality, compared to UC. This multicenter retrospective cohort study included patients aged 50 years or older with a proximal hip fracture who underwent surgery in one

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of the 6 hospitals in the Limburg trauma region of the Netherlands in 2012. Data such as demographics, process outcome measures, and clinical outcome were collected. This study included a total of 1193 patients (665 and 528 patients in the MCP and UC groups, respectively). There were no differences in patient demographics present. Time to surgery was significantly shorter in the MCP compared to the UC group (19.2 vs 24.4 hours, P < .01). The mean length of stay was 10 versus 12 days (P < .01). In the MCP group, significantly lower rates of postoperative complications were observed and significantly more patients were institutionalized than in the UC group. Mortality within 30 days after admission was comparable between the groups (overall mortality 6%). An MCP approach is associated with reduced time to surgery, postoperative complications, and length of stay, without a significant difference in 30-day mortality. The institutionalization rate was significantly higher in the MCP group.

Title: Comparison of Outcomes of Intertrochanteric Fracture Fixation Using Percutaneous Compression Plate Between Stable and Unstable Fractures in the Elderly. Citation: Journal of orthopaedic trauma, Jun 2016, vol. 30, no. 6, p. e201., Author(s): Carvajal-Pedrosa, Cristina, Gómez-Sánchez, Rafael C, Hernández-Cortés, Pedro Abstract: To evaluate the outcomes of treatment with a percutaneous compression plate (PCCP) in stable and unstable intertrochanteric hip fractures. Clinical prospective nonrandomized cohort study. San Cecilio University Hospital, Granada (Spain). A tertiary-care hospital. Patients older than 65 years undergoing surgery for an intertrochanteric hip fracture (n = 657) were divided according to the OTA/AO classification, into stable (31-A1) (group A, n = 363) and unstable fractures (31-A2) (group B, n = 294). Osteosynthesis with a PCCP (Orthofix Inc). Blood loss, wound complications, postoperative pain, operative and fluoroscopy time, functional outcomes, device-related complications, consolidation time, and mortality. Patients with unstable fractures were significantly worse with respect to postoperative pain, immediately (P = 0.020), at 6 weeks (P = 0.0001), and at 3 months (P = 0.009), and with respect to independent walking ability at 6 weeks. No other significant differences were observed. The outcomes of osteosynthesis with PCCP seem to be equally satisfactory in stable and unstable intertrochanteric fractures, with stable fractures having less pain and a greater ability to walk earlier. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Title: A national quality registers as a tool to audit items of the fundamentals of care to older patients with hip fractures. Citation: International journal of older people nursing, Jun 2016, vol. 11, no. 2, p. 85-93, Author(s): Hommel, Ami, Bååth, Carina Abstract: The Swedish healthcare system has a unique resource in the national quality registers. A national quality registry contains individualised data concerning patient problems, medical interventions and outcomes after treatment, within all healthcare settings. Many healthcare settings face challenges related to the way they deliver the fundamentals of care, therefore, it is important to audit the outcome. It is estimated that the number of people aged 80 years or older will have almost quadrupled between 2000 and 2050. Hip fracture has been recognised as the most serious consequence of osteoporosis because of the risk of its complications, which include pain, acute confusional

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state, pressure ulcers, infections, disability, diminished quality of life and mortality. The aim of this study was therefore to explore if and how a national quality register can be used as an audit tool for the fundamentals of care when it concerns older patients suffering from a hip fracture. For this study we retrospectively selected and audited variables retrieved from the national quality hip fracture register. The audit included 1083 patients 80 years and older, consecutively admitted to a university hospital in the south of Sweden, in 2011-2013. Nearly half of the patients were admitted from their own homes and were living alone. Almost half of the patients could walk outdoors before the fracture occurred. After 4 months, 28.5% of the patients walked outdoors. Additionally, after 4 months about 30% of the patients were still suffering from pain after hip fracture surgery and still using analgesics. There was a reduction in length of stay between 2011 and 2013. As a part of the national quality register the questions from EQ5D were used before surgery and after 4 months. Before discharge from hospital there were less registered complications in 2012 and 2013 compared with 2011. The national hip fracture quality register allows healthcare staff to analyse nursing outcomes and to highlight some fundamental aspects of care. Greater awareness, among hospital staff, of risk factors for complications in hip fracture patients may lead to improved patient care. Through registration in a quality register and working with the results we as Registered Nurses can ensure quality health care for older adults

Title: Pre-fracture quality of life predicts 1-year survival in elderly patients with hip fracture-development of a new scoring system Citation: Osteoporosis International, June 2016, vol./is. 27/6(1979-1987), Author(s): Bliemel C., Sielski R., Doering B., Dodel R., Balzer-Geldsetzer M., Ruchholtz S., Abstract: Summary: Hip fractures are common in elderly people. Despite great progress in surgical care, the outcome of patients with hip fracture remains disappointing. This study determined four prognostic factors (lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender) to predict 1-year survival in patients with hip fracture. Introduction: This study determined the prognostic factors for 1-year survival in patients with hip fracture. Based on these predictors, a scoring system was developed for use upon patients' admission to the hospital. Methods: Hip fracture patients, aged >60 years, were prospectively enrolled. Upon admission, patients' sociodemographic data, type of fracture, American Society of Anesthesiologists (ASA) score, health-related quality of life scores (EQ-5D index) and Mini-Mental State Examination (MMSE) scores were recorded, among other parameters. Correlational analysis was performed on all potential variables to identify relevant predictor variables of 1-year survival. Univariate regression analysis was performed on all selected variables, followed by a multivariate analysis for variables that were significant in the univariate analysis. The final score was developed by converting the beta-coefficients of each variable from the multivariate analysis into a scoring system. Results: For 391 hip fracture patients, complete data were available at the time of the 1-year follow-up. In multivariate regression analysis, independent predictors of 1-year survival were lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender. The different variables were weighted according to their beta-coefficient to build the prognostic score, which ranged from 0 to 10 points. The ROC curve for 1-year mortality after hip fracture showed an area under the curve of 0.74 (R² = 0.272; 95 % CI 0.68-0.79; p < 0.001). Conclusions: With only four instruments, the new score represents a

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useful tool for estimating 1-year survival in elderly patients with hip fractures. At present, the score is limited due to a lack of validation. A validation study is currently underway to prove its reliability.

Title: The Radiographic Union Score for Hip (RUSH) Identifies Radiographic Nonunion of Femoral Neck Fractures Citation: Clinical Orthopaedics and Related Research, June 2016, vol./is. 474/6(1396-1404) Author(s): Frank T., Osterhoff G., Sprague S., Garibaldi A., Bhandari M., Slobogean G.P. Abstract: Background: The Radiographic Union Score for Hip (RUSH) is a previously validated outcome instrument designed to improve intra- and interobserver reliability when describing the radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining nonunion in clinical trials and predicting patients who will likely require additional surgery to promote fracture healing. We sought to investigate the utility of the RUSH score to define femoral neck fracture nonunion. Questions/purposes: (1) What RUSH score threshold yields at least 98% specificity to diagnose nonunion at 6 months postinjury? (2) Using the threshold identified, are patients below this threshold at greater risk of reoperation for nonunion and for other indications? Methods: A representative sample of 250 out of a cohort of 725 patients with adequate 6-month hip radiographs was analyzed from a multinational elderly hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the 6-month postinjury radiographs and interrater reliability was assessed with the interclass correlation coefficient (ICC). There was substantial reliability between the reviewers assigning the RUSH scores (ICC, 0.81; 95% confidence interval [CI], 0.76-0.85). The RUSH score is a checklist-based system that quantifies four measures of healing: cortical bridging, cortical fracture disappearance, trabecular consolidation, and trabecular fracture disappearance. Fracture healing was determined by two independent methods: (1) concurrently by the treating surgeon using both clinical and radiographic assessments as per routine clinical care; and (2) retrospectively by a Central Adjudication Committee using complete obliteration of the fracture line on radiographs alone. Receiver operating characteristic tables were used to define a RUSH threshold score that was > 98% specific for fracture nonunion. Results: A threshold score of < 18 was associated with a 100% specificity (95% CI, 97%-100%) and a positive predictive value of 100% (95% CI, 73%-100%) for radiographic nonunion. In contrast, using the fracture healing assessments of the treating surgeons failed to identify a useful discriminatory nonunion threshold and the highest positive predictive value was 43%. With respect to complications, patients with RUSH scores below 18 had greater risk of undergoing reoperation for nonunion (reoperation when < 18: six of 13 [46%]; reoperation when > 18: 11 of 237 [54%]; relative risk [RR], 9.9 [95% CI, 4.4-22.7]; p < 0.001) and for all indications (reoperation when < 18: eight of 13 [62%]; reoperation when > 18: 54 of 237 [38%]; RR, 2.7 [95% CI, 1.7-4.4]; p = 0.004). Conclusions: The 6-month RUSH score is a reliable method for assessing radiographic healing. Our results highlight the discordance between radiographic determinations and clinician assessments of fracture healing and stress the need for clinical data to be incorporated in research studies evaluating fracture healing. Level of Evidence: Level III, diagnostic study.

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Title: Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study Citation: Osteoporosis International, June 2016, vol./is. 27/6(1999-2008) Author(s): Burgers P.T.P.W., Hoogendoorn M., Van Woensel E.A.C., Poolman R.W., Abstract: Summary: The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were 26,399. These results contribute to cost awareness. Introduction: The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. Methods: The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data. Results: Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was 15,216. After 1 and 2 years of follow-up the mean total costs were 23,869 and 26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %. Conclusions: The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

Title: The administration of intermittent parathyroid hormone affects functional recovery from trochanteric fractured neck of femur: a randomised prospective mixed method pilot study. Citation: The bone & joint journal, Jun 2016, vol. 98-B, no. 6, p. 840-845 Author(s): Chesser, T J S, Fox, R, Harding, K, Halliday, R, Barnfield, S, Willett, K, Lamb, S, Abstract: We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks. We undertook a pilot study comparing the functional recovery after trochanteric hip fracture in patients 60 years or older, admitted with a trochanteric hip fracture, and potentially eligible to be randomised to either standard care or the administration of subcutaneous PTH for six weeks. Our desired outcomes were functional testing and measures to assess the feasibility and acceptability of the study. A total of 724 patients were screened, of whom 143 (20%) were eligible for recruitment. Of these, 123 were approached and 29 (4%) elected to take part. However, seven patients did not complete the study. Compliance with the injections

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was 11 out of 15 (73%) showing the intervention to be acceptable and feasible in this patient population. Only 4% of patients who met the inclusion criteria were both eligible and willing to consent to a study involving injections of PTH, so delivering this study on a large scale would carry challenges in recruitment and retention. Methodological and sample size planning would have to take this into account. PTH administration to patients to enhance fracture healing should still be considered experimental.

Postoperative delirium

Title: Is preoperative state anxiety a risk factor for postoperative delirium among elderly hip fracture patients? Citation: Geriatrics & gerontology international, Aug 2016, vol. 16, no. 8, p. 948-955, Author(s): Van Grootven, Bastiaan, Detroyer, Elke, Devriendt, Els, Sermon, An, Deschodt, Abstract: To determine if preoperative state anxiety is a risk factor for postoperative delirium in older hip fracture patients. A secondary data analysis comprising data from a prospective non-randomized trial including 86 patients with a hip fracture aged 65 years and older was carried out. State anxiety was measured preoperatively using the State-Trait Anxiety Inventory. Delirium and its severity was measured pre- and postoperatively (day 1, 3, 5, 8) by trained research nurses using the Confusion Assessment Method and Delirium Index. A total of 24 patients (27.9%) developed delirium postoperatively. Preoperative state anxiety (State-Trait Anxiety Inventory) was not associated with postoperative delirium (rb = 0.135, P = 0.353), duration of postoperative delirium (rho = 0.038, P = 0.861) or severity of postoperative delirium (rho = 0.153, P = 0.160). Independent predictors of postoperative delirium were lower MMSE scores (OR 0.75, 95% CI 0.60-0.95, P = 0.015), osteosynthesis surgery (OR 3.66, 95% CI 1.02-13.15, P = 0,047) and lowest intraoperative diastolic blood pressure (OR 0.92, 95% CI 0.85-0.99, P = 0.031). No relationship between state anxiety and postoperative delirium was found, but significant methodological hurdles were observed and discussed providing important groundwork for further research in this area. Further research should focus on reliable measurement of state anxiety in cognitively impaired older populations.

Title: Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment. Citation: Aging clinical and experimental research, Aug 2016, vol. 28, no. 4, p. 729-736, Author(s): Liu, Yongzhe, Ma, Li, Gao, Minglong, Guo, Wenzhi, Ma, Yaqun Abstract: Postoperative delirium (POD) is a common and serious surgical complication among the elderly, especially in those with amnestic mild cognitive impairment (aMCI). Dexmedetomidine (DEX) is neuroprotective for delirium. In this study, we determined the effect of intravenously administered DEX during general anesthesia on POD in elderly aMCI patients undergoing elective hip joint or knee joint or shoulder joint replacement surgery. This was a prospective, randomized parallel-group study of aMCI (n = 80) and normal elderly patients (n = 120). Prior to surgery, all subjects underwent neuropsychological assessment and were assigned to one of four groups: the aMCI DEX group (MD group, n = 40), the aMCI normal saline group (MN group, n = 40), the control DEX group (CD group, n = 60), and the

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control normal saline group (CN group, n = 60). The confusion assessment method was used to screen POD on postoperative days 1, 3, and 7. We found patients age was positively correlated with POD incidence in the MN group (p < 0.05) but not in the CN group (p < 0.05). DEX treatment significantly decreased POD incidence in both control and aMCI groups relative to their respective placebo groups (all p < 0.05). The fraction of patients whose normal cognitive function was not restored by day 7 after surgery was significantly higher in the MN group than the MD and CN groups (all p < 0.05). These findings suggested that DEX treatment during surgery significantly reduced POD incidence in both normal and aMCI elderly patients, suggesting that it may be an effective option for the prevention of POD.

Title: Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. Citation: Journal of the American Geriatrics Society, Jul 2016, vol. 64, no. 7, p. 1456-1463 Author(s): Neerland, Bjørn Erik, Hall, Roanna J, Seljeflot, Ingebjørg, Frihagen, Frede, Abstract: To examine whether delirium in individuals with hip fracture is associated with high C-reactive protein (CRP), interleukin-6 (IL-6), and soluble IL-6 receptor (sIL-6R) levels in the cerebrospinal fluid (CSF). Prospective cohort study. Two university hospitals in Oslo, Norway, and Edinburgh, United Kingdom. Individuals admitted with acute hip fracture (N = 151). Participants were assessed for delirium pre- and postoperatively using the Confusion Assessment Method. Prefracture cognitive impairment was detected using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Serum was collected preoperatively and CSF just before the onset of spinal anesthesia. Cytokine levels in serum and CSF samples were determined using an enzyme-linked immunosorbent assay. Student t-tests or Mann-Whitney U-tests were used for between-group comparisons. Spearman rho was used for correlations. Sixty participants had prior cognitive impairment (IQCODE score ≥3.44). Delirium was diagnosed in 46 participants (77%) with prior cognitive impairment and 25 (29%) without. In participants without prior cognitive impairment, CSF CRP levels were higher in participants with delirium (median 0.05 μg/mL, interquartile range (IQR) 0.02-0.12 μg/mL) than in those without delirium (median 0.01 μg/mL, IQR 0.00-0.06 μg/mL) (P = .01); there were no differences in participants with prior cognitive impairment. In secondary analyses, in participants with prior cognitive impairment, the concentration of CSF sIL-6R was higher in those participants who developed delirium than in the other subgroups, but this difference was not statistically significant. Serum levels of CRP, IL-6, and sIL-6R were not different according to delirium in participants with or without prefracture cognitive impairment. High CSF levels of CRP and sIL-6R may be associated with delirium. Different pathophysiological mechanisms may operate in different subgroups, notably in relation to the presence of prior cognitive impairment. © 2016, Copyright the Authors Journal compilation

Title: Psychometric evaluation of the DMSS-4 in a cohort of elderly post-operative hip fracture patients with delirium. Citation: International psychogeriatrics / IPA, Jul 2016, vol. 28, no. 7, p. 1221-1228, Author(s): Adamis, Dimitrios, Scholtens, Rikie M, de Jonghe, Annemarieke, van Munster, Abstract: Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more

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targeted research efforts. We explored the concordance in attribution of motor subtypes between the Delirium Motor Subtyping Scale 4 (DMSS-4) and the original Delirium Motor Subtyping Scale (DMSS) (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI). We included 113 elderly patients developing DSM-IV delirium after hip-surgery [mean age 86.9 ± 6.6 years; range 65-102; 68.1% females; 25 (22.1%) had no previous history of cognitive impairment]. Concordance for the first measurement was high for both the DMSS-4 and original DMSS (k = 0.82), and overall for the DMSS-4 and DSI (k = 0.84). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.90). The DSI more often allocated an assessment to "no subtype" compared to the DMSS-4 and DMSS-11, which showed higher inclusion rates for motor subtypes. The DMSS-4 provides a rapid method of identifying motor-defined clinical subtypes of delirium and appears to be a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4, so far translated into three languages, can be readily applied to further studies of causation, treatment and outcome in delirium.

Title: Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery. Citation: Geriatric orthopaedic surgery & rehabilitation, Jun 2016, vol. 7, no. 2, p. 100-105 Author(s): Rizk, Paul, Morris, William, Oladeji, Philip, Huo, Michael Abstract: Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

Title: Is longer storage time of red blood cells really not associated with risks of delirium and complications after hip fracture surgery? Citation: Injury, June 2016, vol./is. 47/6(1359-1360) Author(s): Xue F.-S., Liu G.-P., Yang G.-Z., Sun C.

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Publication Type: Journal: Letter

Title: Cognitive Reserve and Postoperative Delirium in Older Adults. Citation: Journal of the American Geriatrics Society, Jun 2016, vol. 64, no. 6, p. 1341-1346 Author(s): Tow, Amanda, Holtzer, Roee, Wang, Cuiling, Sharan, Alok, Kim, Sun Jin, Abstract: To examine the role of cognitive reserve in reducing delirium incidence and severity in older adults undergoing surgery. Prospective cohort study. Hospital. Older adults (mean age 71.2, 65% women) undergoing elective orthopedic surgery (N = 142). Incidence (Confusion Assessment Method) and severity (Memorial Delirium Assessment Scale) of postoperative delirium were the primary outcomes. Predictors included early- (literacy) and late-life (cognitive activities) proxies for cognitive reserve. Forty-five participants (32%) developed delirium. Greater participation in cognitive activity was associated with lower incidence (odds ratio = 0.92 corresponding to increase of 1 activity per week, 95% confidence interval (CI) = 0.86-0.98, P = .006) and severity (B = -0.06, 95% CI = -0.11 to -0.01, P = .02) of delirium after adjustment for age, sex, medical illnesses, and baseline cognition. Greater literacy was not associated with lower delirium incidence or severity. Of individual leisure activities, reading books, using electronic mail, singing, and computer games were associated with lower dementia incidence and severity. Greater late-life cognitive reserve was associated with lower delirium incidence and severity in older adults undergoing surgery. Interventions to enhance cognitive reserve by initiating or increasing participation in cognitive activities may be explored as a delirium prophylaxis strategy.

Title: Cerebrospinal fluid levels of neopterin are elevated in delirium after hip fracture Citation: Journal of Neuroinflammation, June 2016, vol./is. 13/1(no pagination) Author(s): Hall R.J., Watne L.O., Idland A.-V., Raeder J., Frihagen F., MacLullich A.M.J. Abstract: Background: The inflammatory cell product neopterin is elevated in serum before and during delirium. This suggests a role for disordered cell-mediated immunity or oxidative stress. Cerebrospinal fluid (CSF) neopterin levels reflect brain neopterin levels more closely than serum levels. Here we hypothesized that CSF neopterin levels would be higher in delirium. Methods: In this prospective cohort study, 139 elderly patients with acute hip fracture were recruited in Oslo and Edinburgh. Delirium was diagnosed with the confusion assessment method performed daily pre-operatively and on the first 5 days post-operatively. Paired CSF and blood samples were collected at the onset of spinal anaesthesia. Neopterin levels were measured using high-performance liquid chromatography. Results: Sixty-four (46 %) of 139 hip fracture patients developed delirium perioperatively. CSF neopterin levels were higher in delirium compared to controls (median 29.6 vs 24.7 nmol/mL, p = 0.003), with highest levels in patients who developed delirium post-operatively. Serum neopterin levels were also higher in delirium (median 37.0 vs 27.1 nmol/mL, p = 0.003). CSF neopterin remained significantly associated with delirium after controlling for relevant risk factors. Higher neopterin levels were associated with poorer outcomes (death or new institutionalization) 1 year after surgery (p = 0.02 for CSF and p = 0.03 for serum). Conclusions: This study is the first to examine neopterin in CSF from patients with delirium. Our findings suggest potential roles for activation of cell-mediated

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immune responses or oxidative stress in the delirium process. High levels of serum or CSF neopterin in hip fracture patients may also be useful in predicting poor outcomes.

Title: Prevalence and Characteristics of Pre-Operative Delirium in Hip Fracture Patients Citation: Gerontology, June 2016, vol./is. 62/4(396-400) Author(s): Freter S., Dunbar M., Koller K., MacKnight C., Rockwood K. Abstract: Background: Delirium is a common complication of hip fracture and is associated with negative outcomes. Previous studies document risk factors for post-operative delirium but have frequently excluded patients with pre-operative delirium. Objective: This study endeavours to document prevalence and risk factors for pre-operative delirium in hip fracture patients and compares risk factor profiles and outcomes between pre- and post-operative delirium. Methods: 283 hip fracture patients were assessed pre-operatively with the Delirium Elderly At Risk (DEAR) instrument, Mini-Mental State Examination (MMSE), and Confusion Assessment Method (CAM). They were followed on post-operative days 1, 3, and 5 for the presence of delirium. Doses of opioids were recorded. Wait time to surgery, length of stay, and discharge site were noted. Results: Delirium was present in 57.6% patients pre-operatively and 41.7% post-surgery. Not all patients (62%) with pre-operative delirium also had post-operative delirium. There was a considerable overlap in risk factors, with some differences. Wait time to surgery, number of comorbidities, and total pre-operative opioid and lorazepam doses were associated with pre- but not post-operative delirium. Negative outcomes were more closely associated with post-operative delirium. Conclusion: Delirium is common in pre-hip fracture surgery patients, and not all patients with pre-operative delirium go on to have post-operative delirium. Risk factor profiles are not identical, raising the possibility of identifying and intervening in patients at high risk of delirium pre-operatively.

Title: Auditing postoperative delirium on a surgical high dependency unit Citation: Anaesthesia, June 2016, vol./is. 71/(30), Author(s): MacDonald J., Lowndes R., Ariff A.A., Shah T. Abstract: Delirium is under recognised and common in postoperative older surgical patients. It has an acute onset developing over 1-2 days [1, 2]. Risk factors include: > 65 years old, cognitive impairment or dementia diagnosis, current hip fracture, comorbidities, polypharmacy and severe illness [1-3]. There is a considerable burden associated with delirium and if recognised early, postoperative delirium can be prevented and treated, decreasing length of hospital stay, hospital acquired complications and infections, incidence of dementia and mortality [1]. Our aim was to identify patients at risk of developing postoperative delirium on the Step Down Unit (SDU) which has level 1 & 2 beds, enabling a strategy for early identification to reduce and prevent delirium as a postoperative complication. Methods We audited 52 consecutive patients over the age of 65 years during 7 weeks with a validated delirium assessment tool, the 4AT score. Data were collected on day 1 and day 3 of the in-patient stay. Other information collected included medications, location of patient on the SDU, and type of surgery. Results Delirium was identified in 13% of patients. Three of these seven patients remained on SDU on day 3; two continued to score 4 or more indicating delirium was still present. No additional patients had developed delirium on day 3. Eighty-six percent of patients with delirium had undergone emergency

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general surgery. Seventy-five percent of patients identified were aged 75-84 years. Patients' location in the unit had no correlation with incidence of delirium. All patients' with delirium were prescribed opioid analgesia and two had benzodiazepines prescribed. Discussion The presence of delirium was identified effectively using the 4AT score. This scoring system was easy and quick to use and has been shown to be a validated assessment tool that is sensitive and specific for screening for the presence of delirium in hospitalised patients [4]. The highest incidence of delirium was detected in those patients undergoing emergency surgery. This may be as a result of not having time to be optimised for surgery. In addition the need for emergency surgery tends to suggest the patient is in a poorer clinical condition prior to their surgery with more predisposing risk factors for developing delirium such as infection, abnormal biochemistry and an underlying metabolic acidosis [5]. The incidence of delirium increases with advancing age. Therefore, it should be those patients over 75 years admitted to SDU that are recognised to be at risk of delirium and consequently assessed to prevent delirium. (Figure Presented) .

Other

Title: Factors associated with the course of health-related quality of life after a hip fracture. Citation: Archives of orthopaedic and trauma surgery, Jul 2016, vol. 136, no. 7, p. 935-943 Author(s): Moerman, Sophie, Vochteloo, Anne J H, Tuinebreijer, Wim E, Maier, Andrea B, Abstract: The number of hip fracture patients is expected to grow the forthcoming decades. Knowledge of the impact of the fracture on the lives of elderly could help us target our care. The aim of the study is to describe HRQoL (Health-Related Quality of Life) after a hip fracture and to identify factors associated with the course of HRQoL in the first postoperative year. 335 surgically treated hip fracture patients (mean age 79.4 years, SD 10.7, 68 % female) were included in a prospective observational cohort. HRQoL was measured with the SF-12 Health Survey, composed of the Physical and a Mental Component Summary Score (PCS, MCS), at admission (baseline) and at 3 and 12 months postoperatively. Eleven predefined factors known to be associated with the course of HRQoL were recorded: age, gender, physical status, having a partner at admission, living in an institution, prefracture level of mobility, anemia, type of fracture and treatment, delirium during hospital stay and length of stay. HRQoL declined between baseline and 3 months, and recovered between three and 12 months. PCS HRQoL did not recover to baseline values, MCS HRQoL did. Age younger than 80 years, ASA classification I and II, higher prefracture level of mobility, intracapsular fracture and treatment with osteosynthesis (compared to arthroplasty) were associated with greater initial decline in PCS HRQoL, none of the recorded factors were significant for decline in MCS HRQoL. Both PCS and MCS HRQoL declined after a hip fracture and PCS did not recover to baseline values. Healthier patients may need extra care to prevent them from having a steep decline in postoperative PCS HRQoL and arthroplasty should be considered with low threshold.

Title: Factors associated with the course of health-related quality of life after a hip fracture. Citation: Archives of orthopaedic and trauma surgery, Jul 2016, vol. 136, no. 7, p. 935-943,

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Author(s): Moerman, Sophie, Vochteloo, Anne J H, Tuinebreijer, Wim E, Maier, Andrea B, Abstract: The number of hip fracture patients is expected to grow the forthcoming decades. Knowledge of the impact of the fracture on the lives of elderly could help us target our care. The aim of the study is to describe HRQoL (Health-Related Quality of Life) after a hip fracture and to identify factors associated with the course of HRQoL in the first postoperative year. 335 surgically treated hip fracture patients (mean age 79.4 years, SD 10.7, 68 % female) were included in a prospective observational cohort. HRQoL was measured with the SF-12 Health Survey, composed of the Physical and a Mental Component Summary Score (PCS, MCS), at admission (baseline) and at 3 and 12 months postoperatively. Eleven predefined factors known to be associated with the course of HRQoL were recorded: age, gender, physical status, having a partner at admission, living in an institution, prefracture level of mobility, anemia, type of fracture and treatment, delirium during hospital stay and length of stay. HRQoL declined between baseline and 3 months, and recovered between three and 12 months. PCS HRQoL did not recover to baseline values, MCS HRQoL did. Age younger than 80 years, ASA classification I and II, higher prefracture level of mobility, intracapsular fracture and treatment with osteosynthesis (compared to arthroplasty) were associated with greater initial decline in PCS HRQoL, none of the recorded factors were significant for decline in MCS HRQoL. Both PCS and MCS HRQoL declined after a hip fracture and PCS did not recover to baseline values. Healthier patients may need extra care to prevent them from having a steep decline in postoperative PCS HRQoL and arthroplasty should be considered with low threshold.

Title: Mortality after hip fracture in the elderly: The role of a multidisciplinary approach and time to surgery in a retrospective observational study on 23,973 patients. Citation: Archives of gerontology and geriatrics, Sep 2016, vol. 66, p. 13-17, Author(s): Forni, Silvia, Pieralli, Francesca, Sergi, Alessandro, Lorini, Chiara, Abstract: Since most hip fractures occur in fragile patients, an important step forward in the treatment may be a co-managed, multidisciplinary treatment approach with orthopaedic surgeons and geriatricians. This multidisciplinary care model (MCM) is implemented in some Tuscan hospitals, while in hospitals with the usual care model (UCM) medical consultation is required only as deemed necessary by the admitting surgeon. The primary aim of this study was to assess the effect of the MCM on 30-day mortality, compared with the UCM. A retrospective study was conducted on patients with main diagnosis of hip fracture, as reported in the hospital admission discharge reports, aged 65 years and older, who underwent surgery in Tuscan hospitals from 2010 to 2013. A multilevel logistic regression model was performed to assess the effect of the MCM vs the UCM. The Charlson Comorbidity Index (CCI) was used as a proxy for case mix complexity. 23,973 patients were included: 23% men and 77% women; the mean age was 83.5 years. The multilevel analysis showed that mortality was significantly higher in the UCM, after adjusting for gender, age, comorbidity and timing of surgery (OR=1.32; 95% CI 1.09-1.59; p=0.004). Surgical delay was not significantly associated with higher mortality rates. A co-managed approach to hip fracture, with orthopaedic surgeons and geriatricians, offers a multidisciplinary pathway for the elderly and leads to a reduction in mortality after hip fracture surgery.

Title: 188 Morbidity and Mortality Associated With Operative Management of Traumatic C2 Fractures in Octogenarians.

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Citation: Neurosurgery, Aug 2016, vol. 63 Suppl 1, p. 174-175, Author(s): Winkler, Ethan A, Yue, John K, Burke, John Frederick, Mummaneni, Praveen V, Abstract: The management of axis fractures and particularly of odontoid fractures in the elderly remains controversial. As a greater segment of the US population lives past 80, it is becoming increasingly evident that published morbidity and mortality profiles of C2 fractures in younger cohorts (55+) are not applicable to octogenarians. Consequently, there is a need for further study in this specific population. Using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), we performed a retrospective analysis of patients with age = 80 years and traumatic C2 fracture. Demographics, inpatient complications, and the outcome end points of mortality, hospital length of stay (LOS), and discharge disposition were described between nonoperative and operative cohorts. Multivariable regression analyses were performed. From 2003 to 2012, 3847 people met inclusion criteria, which represents 17 702 incidents nationally. The overall incidence of operative management was 10.3%. Operative management was associated with increased risk of pneumonia (10.1% vs 5.9%, P < .001), acute respiratory distress syndrome (6.0% vs 2.3%, P < .001), and decubitus ulcer (4.8% vs 1.3%, P < .001). Inpatient mortality was 12.8% for all subjects and was not significantly different between nonoperative and operative cohorts (nonoperative 13%; operative 10.3%; P = .120). Overall hospital LOS was 8.31 ± 9.32 days (nonoperative 7.78 ± 9.21; operative 12.86 ± 9.07; P < .001) and showed an adjusted mean increase of 5.68 days with operative management (95% confidence interval [CI], 4.74-6.61). Of patients who survived to discharge, 26% returned home (nonoperative 26.8%; operative: 18.8%; P = .001). Patients who underwent operative management were less likely to return home (odds ratio, 0.59; 95% CI, 0.44-0.78). The present study confirms that operative management of traumatic C2 fractures in octogenarians does not significantly affect inpatient mortality and increases the rate of discharge to institutionalized care. Patients undergoing surgery are more likely to require longer hospitalization and experience higher rates of medical complications during their stay.

Title: Decreased glomerular filtration rate estimated by 2009 CKD-EPI equation predicts mortality in older hip fracture population. Citation: Injury, Jul 2016, vol. 47, no. 7, p. 1536-1542 Author(s): Pajulammi, Hanna M, Luukkaala, Tiina H, Pihlajamäki, Harri K, Nuotio, Maria S Abstract: We examined estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology equation (eGFRCDK-EPI), removal of urinary catheter during hospitalization and polypharmacy as predictors of mortality in older hip fracture patients. Population-based prospective data were collected on 1425 consecutive hip fracture patients aged ≥65 years. Outcome was mortality at one year. Independent variables were age, sex, body mass index, fracture type, American Society of Anesthesiology score, delay to surgery, urinary catheter removal during acute hospitalization, eGFRCDK-EPI, number of daily medications, diagnosis of memory disorder, prefracture mobility and living arrangements. Of the 1425 patients, 567 (40%) had renal dysfunction on admission, 526 (37%) had their urinary catheters removed during hospitalization and 1177 (83%) were taking ≥4 medications regularly before the fracture. In the multivariate analyses with the Cox proportional hazards model adjusted simultaneously for all the independent variables, eGFRCDK-EPI 30-44ml/min/1.73m(2) (HR 1.91, 95% CI 1.44-2.52) and <30ml/min/1.73m(2)

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(HR 1.95, 95% CI 1.36-2.78), non-removal of the urinary catheter (HR 1.45, 95% CI 1.12-1.88) and large number of daily medications (4-10 HR 1.81, 95% CI 1.78-2.79, >10 HR 2.21, 95% CI 1.38-3.54) were associated with mortality. In older hip fracture patients, moderate to severe level renal dysfunction measured by eGFRCDK-EPI, non-removal of urinary catheter before discharge and polypharmacy increase mortality after hip fracture. Careful assessment of renal function and medications and following the care protocols on urinary catheter removal are essential in the care of geriatric hip fracture patients.

Journal Tables of Contents

The most recent issues of the following journals:

Bone and Joint Journal (UK)

Osteoporosis International

Click on the journal links for the most recent tables of contents. If you would like any of

the papers in full text then get in touch: Library@uhbristol.nhs.uk

Bone and Joint Journal (UK)

Vol. 98-B, iss. 4, May 2016

http://www.bjj.boneandjoint.org.uk/content/98-B/5?current-issue=y

Osteoporosis International

Vol. 27, iss. 6, June 2016

http://link.springer.com/journal/198/27/6/page/1

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