Clinical profile and associations of acute confusional states in geriatric patients with hip fractures

Anugrah, Chrispal (2006) Clinical profile and associations of acute confusional states in geriatric patients with hip fractures. Masters thesis, Christian Medical College, Vellore.


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INTRODUCTION : Delirium occurs in up to 50 % of all hospitalized geriatric patients and up to 60% of geriatric patient with hip fractures. Studies indicate numerous recurring, potentially modifiable risk factors for delirium. Their findings indicate several common causes, including fluid and electrolyte abnormalities, infection, underlying dementia, drug toxicity, metabolic disorders, and low cerebral perfusion. Environmental manipulation and supportive reorientation seem to reduce the incidence of delirium and benefit acutely delirious patients. A number of studies have been conducted in the West regarding delirium in geriatric patients with hip fractures but there have been no studies that have been done in India. The Indian patient differs in a number of factors – social support systems, lack of long term care facilities, lack of use of polypharmacy and psychotropic drugs, and probably a younger population base than that of the West. Hence, it is necessary to study the patient profile, incidence and the factors that are responsible for the development of delirium in our population which will then lead to effective interventional programmes that are applicable to the Indian scenario. AIMS AND OBJECTIVES : AIM : To ascertain the incidence of delirium in geriatric patients admitted for the treatment of hip fractures in the Department of Orthopedics of a tertiary care referral center in South India, to delineate their clinical profile and identify probable contributing factors for development of delirium in this group of patients. OBJECTIVES : 1. To outline the clinical profile of geriatric patients who present with hip fractures to the hospital. 2. To identify factors that may predispose these patients to development of delirium post-operatively. 3. To determine the incidence of post-operative delirium among geriatric patients admitted in the orthopedic wards of Christian Medical College and Hospital, Vellore for the treatment of hip fractures (both neck of femur fractures and intertrochanteric fractures). MATERIALS AND METHODS : DESIGN: A prospective descriptive study design to establish important clinical associations seen with post operative delirium. Subjects: Inclusion criteria: 1. Patients above the age of 60 years of age. 2. Admitted to the orthopedic ward with hip fracture – either neck of femur fracture or intertrochanteric fracture. 3. Undergoing hip fracture surgery. Exclusion criteria: 1. Patients under the age of 60 years 2. Those not undergoing hip fracture surgery Location: Orthopedics wards, Christian Medical College and Hospital, Vellore. Duration: From May 1s t 2004 to April 30th 2005 (1 year). Methodology : Between May 1st 2004 and April 30th 2005, 81 patients who had been admitted with hip fracture and planned for surgery were enrolled in the study after consent. • A preoperative assessment was made within 48 hours of admission with regard to existing delirium, prior functional status, existing dementia, and premorbid illness and drug history through interview of the patient and relatives and review of previous medical records if present. • A preoperative cognitive assessment was done using the Confusion Assessment Method (CAM) score for existing delirium. A Mini Mental Status Examination (MMSE) was also done. In view of the fact that the MMSE could be falsely erroneous in the presence of existing delirium an assessment for dementia was made by interviewing the attending relative using the Community screening interview for dementia (CSI’D’) questionnaire. • A post operative assessment was done with a CAM (Confusion Assessment method) score done on 2 consecutive days (24 and 48 hours post operatively). • Data regarding the type of surgery, anesthesia records and duration of surgery was collected. • A statistical comparison was done between the patients with and without delirium regarding the various factors that may have predisposed a patient to the development of delirium. • In those patients in whom delirium was detected a clinical examination and investigations to identify the precipitating factor was done. The investigation included Hemoglobin, total WBC count, serum creatinine, serum electrolytes (sodium, potassium), Arterial Blood Gas, urinalysis, and other details such as presence of fever, drugs used at the time and any evidence of infection. The ongoing event that was diagnosed by the treating orthopedician and physician at the time of delirium was considered as the probable cause of delirium for that particular patient. • Analysis was done to determine the incidence of delirium in the postoperative period and a univariate and multivariate analysis of associated factors that may have predisposed these patients to the development of postoperative delirium. CONCLUSION : 1. Of the 81 patients 21% of the patients developed delirium postoperatively. 7 patients had preoperative delirium and 11 patients had underlying dementia. 2. On univariate analysis the presence of underlying dementia (OR 10.5), low MMSE score (P value 0.021), had an association with postoperative delirium. The presence of underlying illnesses as ischemic heart disease (OR 4.80), diabetes with hypertension (OR 3.03), history of stroke (OR 6.26) and visual impairment (OR 4.28) were also associated with delirium. The presence of postoperative delirium increased duration of hospital stay by 3 days. Patients who developed postoperative delirium had a delay in surgery by almost 2 days as compared to the patients who did not develop delirium (P Value 0.014). Patients who developed postoperative delirium were delayed in arrival at CMC following hip fracture though this was not statistically significant. The type of surgery and anesthesia was not associated with delirium. However, prolonged duration of surgery was associated with postoperative delirium (P value <0.001). A low preoperative PCV was associated with postoperative delirium (P value 0.023), though postoperative PCV or fall in PCV showed no significant association. A high preoperative ASA score >2 was associated with postoperative delirium (P value 0.003). Postoperative delirium was associated with tachypnea, tachycardia and the presence of fever. 3. Of the patients who developed postoperative delirium 5 patients had no ascertainable cause. The other important associated conditions postoperatively were seen to be myocardial events, cerebrovascular events and probably pulmonary embolism. Postoperative delirium was associated with poor ambulation at discharge (OR 6.25). 4. On multivariate analysis the presence of underlying dementia (OR16.97), duration of surgery > 2.5hrs (OR 8.22), preoperative packed cell volume < 25 (OR 8.07) and underlying ischemic heart disease (OR 6.83) were found to be independent risk factors that were associated with the development of postoperative delirium.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Clinical profile ; acute confusional states ; geriatric patients ; hip fractures.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 15 Feb 2018 17:11
Last Modified: 15 Feb 2018 17:11

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