The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial)

Abstract

BackgroundDelirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline.MethodsThis was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer’s Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation.ResultsA total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04).ConclusionsPre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes.Trial registrationClinicalTrials.gov NCT01009268 Registered November 5, 2009

Hvorfor ortogeriatri?

“…Nylig er to randomiserte, kontrollerte studier av ortogeriatriske modeller i Norge publisert (8,9). I begge studiene testet man modeller der intervensjonspasientene primaert var innlagt i geriatriske sengeposter og fikk ortopedisk tilsyn ved behov.…”

“…Den andre studien ble gjennomført i Oslo, og omfattet både hjemmeboende hoftebruddspasienter og pasienter som kom fra sykehjem (9). Hovedmålsettingen med denne studien var å undersøke om en ortogeriatrisk modell kunne forebygge delirium og akselerert kognitiv svikt.…”

Blood-Cerebrospinal Fluid Barrier Integrity in Delirium Determined by Q-Albumin

“…CSF was, when feasible, collected just before the onset of spinal anaesthesia (up to 1 ml in polystyrene tubes) before administration of the spinal anaesthetic agent [16,20]. Albumin levels in serum and CSF were analysed consecutively at the Department of Medical Biochemistry, Oslo University Hospital.…”

“…All patients in this study were participants in the Oslo Orthogeriatric Trial, which was run in the period from September 2009 to January 2012 [16]. All patients with a fracture of the proximal femur were suitable for inclusion, regardless of age, pre-fracture function, and cognitive status.…”

Geriatric Patients With Cognitive Impairment

“…Reported results of treatment on specialized wards have been inconsistent to date because of wide disparities among national health systems and among patterns of hospital admission (19)(20)(21)(22)(23)(24)(25)(26)(27).…”