Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture

Abstract

BACKGROUND: Post–hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed. METHODS: The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model. RESULTS: Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78–10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05–2.76], 3 points); (3) age (reference, 60–69 years of age) (age 70–79: aOR, 1.60 [95% CI, 1.20–2.12], 2 points; age 80–89: aOR, 2.09 [95% CI, 1.59–2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82–3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13–1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III–V (aOR, 1.40 [95% CI, 1.14–1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17–1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07–1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09–1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14–1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76–0.78) and 0.77 (95% CI, 0.76–0.78), respectively, with similar results in the validation cohort. CONCLUSIONS: A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy.

The risk factors for postoperative delirium in adult patients after hip fracture surgery: a systematic review and meta‐analysis

“…In this meta-analysis, we divided risk factors for POD into individual as well as anesthetic and operative factors, and detected that individual factors, including advanced age, male, ASA score≥III, lower BMI, smoking, function dependency, visual impairment, preoperative delirium, dementia, hypertension, and COPD, as well as anesthetic and operative factors, including regional anesthesia, transfusion, and elective surgery could promote the development of POD in adult patients after hip fracture surgery. Compared with previous published meta-analysis, 6,7 we add the latest clinical trials data 3,4,13,17,20,22,23,[27][28][29]34,37,38,41,43,50,51,53 and provided updated evidences for clinician.…”

“…15,56,58,59 Among medical comorbidities, we found that the preexisting dementia, delirium, hypertension, and COPD are contributors of POD after hip surgery, which keeps line with previous studies. 6,9,54,55 In addition, we resolved the heterogeneity by excluding the study of Kim et al 28 and found the effect of heart failure on POD incidence to F I G U R E 3 Forest plots of significative anesthetic and operative factors associated with POD after hip fracture surgery. Patients with risk factors for (A) regional anesthesia, (B) transfusion, (C) emergency surgery [Colour figure can be viewed at wileyonlinelibrary.com] be significant, which suggests the study of Kim et al 28 might be the source of heterogeneity.…”

“…6,9,54,55 In addition, we resolved the heterogeneity by excluding the study of Kim et al 28 and found the effect of heart failure on POD incidence to F I G U R E 3 Forest plots of significative anesthetic and operative factors associated with POD after hip fracture surgery. Patients with risk factors for (A) regional anesthesia, (B) transfusion, (C) emergency surgery [Colour figure can be viewed at wileyonlinelibrary.com] be significant, which suggests the study of Kim et al 28 might be the source of heterogeneity. In fact, Smith et al 6 identified cardiac failure as a risk factors for POD, but combined with the results of our study, we suggested that the effects of heart failure on POD incidence should be explained prudently.…”

“…A total of 19 papers 3,4,14,17,23,24,[26][27][28][29]31,37,38,42,44 studied the association between ASA score and the incidence of POD. Our study classifies ASA scores into two categories, which are ASA≤II and ASA≥III, respectively, and the pooled results show that patients with ASA≤II are less likely to sustain POD (RR 0.56, 95% CI: 0.51, 0.59, P<0.001, Figure 2C), with no heterogeneity (P=0.55, I 2 = 0%, Table 2).…”

Procedure for Femoral Intertrochanteric Fractures using the “Three‐Finger Method” Assisted by Proximal Femoral Nail Antirotation

“…Hip fractures represent a major public health problem for older adults compounded by the problems of aging. The annual incidence of hip fractures is increasing rapidly and is projected to surpass 6.3 mn by 2050.…”