Hundreds of elderly hip fracture patients suffer from undiagnosed delirium every year in Australian hospitals, leaving them vulnerable to serious complications and death, with a report finding that one in four has not been assessed for delirium before surgery.
According to the Australian and New Zealand Hip Fracture Registry, among patients who did undergo cognitive assessment, more than one-third (39%) were diagnosed with delirium. The report is based on 15 300 hip fractures across 93 hospitals in Australia and New Zealand in 2021 and compiled by Neuroscience Research Australia.
The registry’s co-chair and principal research fellow at Neuroscience Research Australia, Professor Jacqueline Close, said the findings confirmed delirium was woefully under-reported.
“It’s not good enough,” Close said of the proportion of patients screened for delirium. “It should be 100%.” She said people underestimated the significance of delirium, reports The Sydney Morning Herald.
“Delirium is essentially a brain attack. It’s an acute state of confusion and medical emergency, just like a heart attack,” she said.
“If you fail to detect and manage it, you end up with patients developing things like pressure injuries, malnutrition, pneumonia from lying in bed … and the worst outcome is death.
“The idea that we would admit somebody to hospital, and we wouldn’t check their heart or their lungs is unthinkable, but we don’t afford the brain the same respect for hip fracture patients.”
The Australian and New Zealand Hip Fracture Registry’s annual report is an audit of hip fracture patients. It is made available to hospital administrators to allow them to compare their results against past performance and other institutions, and make any necessary improvements.
There were huge variations between hospitals in assessing patients, with some evaluating every hip fracture patient for dementia, to one hospital – St Vincent’s Hospital, Darlinghurst – that assessed less than 5%.
St Vincent’s spokesman David Faktor said reducing the incidence of delirium at the hospital was a key priority and cited two recent audits that found 95% and 73% of patients were screened for delirium respectively.
An estimated 20 000 people fracture their hip each year in Australia and New Zealand. As the population ages, those figures are expected to rise.
President of the Australasian Delirium Association and geriatrician Associate Professor Gideon Caplan said most studies of hip fracture patients estimated 50% develop delirium, some before they were admitted to hospital and others after surgery, as a result of anaesthesia and painkillers.
“It can be horrible for these patients to find themselves in hospital, and they don’t recognise where they are. They start to imagine that they are being held prisoner,” Caplan said. “They need frequent reassurance, multiple times, from the people looking after them.”
Delirium is a major risk factor for dementia. A meta-analysis of hip fracture patients co-authored by Caplan found that the risk of developing dementia was 18-fold among patients with delirium.
“It’s important to treat the underlying cause of delirium as soon as possible, if you can,” Caplan said. “You need to look for an infection – usually a urinary or chest infection – or it might be a sedating medication that is too strong.”
The report found COVID-19 restrictions had significantly affected care of hip fracture patients, with many orthopaedic wards converted into COVID wards, and limited access to rehabilitation wards and specialist staff, who were deployed to other roles during the pandemic.
Close said the restrictions on families visiting patients was a “stark reminder” of the crucial role families play in the care of these people.
“We have underestimated how dependent we are on families and carers when people are in hospital. Things like feeding and encouraging patients to get up and walk.”
The report found 22.1% of people with hip fractures die within a year of their injury in 2020, down from 24.8% in 2019. It also found 82% of patients had surgery within 48 hours, up from 81% in 2020, and 92% had a nerve block to help manage their pain before surgery, up from 79% in 2020.
Study details
Persistent delirium in older hospital patients: an updated systematic review and meta-analysis
Jonathan Whitby, Anita Nitchingham, Gideon Caplan, Daniel Davis, Alex Tsui.
Published in Delirium Journal on 11 August 2022
Abstract
Introduction
Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration.
Methods
We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression.
Results
We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months.
Conclusions
This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings.
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