Karin Björkelund

Acute confusional state in elderly hip fracture patients. Identification of risk factors and intervention from an anesthesiological nursing perspective. 

Acute confusional state (ACS) in connection with acute illness in elderly has especially during the last decades been recognised as a serious and common care problem. Previous studies have estimated ACS to occur in 14% to 63% of elderly, hospitalised patients. ACS is associated with increased rates of postoperative complications, functional decline, longer and more costly hospitalisations, and increased nursing home placements following the acute care. Elderly patients with hip fracture constitute a special group at risk of developing ACS post-operatively where factors as trauma, pain, operation and anaesthesia as well as old age, the use of several drugs and infection is of importance for developing ACS.  Patients with hip fractures occupy around 25 percent of all bed days in orthopedic departments in Sweden. During the last twenty years the incidence of hip fracture has doubled in persons above 80 years of age. In Sweden 18.000 persons yearly are treated due to a hip fracture. This increase will continue because of an increasing number of elderly persons in the population and an increase in the risk of hip fractures, particularly in the oldest persons, those above 80 years. 
  
The aims of this research project were, by an intervention program including prehospital, pre-, intra- and post-operative care, to reduce the incidence of acute confusional states (ACS) among elderly, hospitalized patients with hip fracture, and to increase the number of patients returning to previous form of living and functional ability.
 
The project included four studies. The first study was prospective, descriptive, including patient data from Swedish National Hip Fracture Register (Rikshöft/SAHFE) and the Anesthetic register, and retrospective, including data from patient journals of 428 patients with a hip fracture (65+ years), cared for at the University Hospital of Lund during the same four months, 1999, 2000 and 2001 with focus on factors at admission associated with 4 months outcome in elderly patients with hip fracture. The second study was based on the data of the same 428 patients, now with the focus on the influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture. The third study was a review of a Swedish rating scale, The OBS Scale, for assessing mental status in elderly people. The fourth study was prospective, with a quasi-experimental design, in which a consecutive sample of 132 patients (control group), and 131 patients (intervention group) with hip fracture (65+), cared for at the University Hospital of Lund during 12 months 2003-04 were included. The aim of this study was to investigate whether an implementation of a multi-factorial program including intensified pre-hospital and peri-operative treatment and care could reduce the incidence of ACS in elderly patients with hip fracture, lucid at admission to the hospital.
A total of 263 patients with hip fracture (≥65 years), lucid at admission, were consecutively included between April 2003 and April 2004. On October 1st 2003 a new program was introduced. All patients were screened for lucidity within 30 min after admission to the emergency department using The Short Portable Mental Status Questionnaire (SPMSQ). To screen for ACS, patients were tested within four hours of admission and thereafter daily, using the Organic Brain Syndrome Scale (OBS scale).
The result showed that the number of patients who developed ACS decreased from 45 (34 %) to 29 (22 %) (p=0.031) which points out the beneficial effect of the use of the multi-factorial intervention program reducing the incidence of ACS by 35 % emphasizes the need for an early treatment with supplemental oxygen, i.v. fluids and blood transfusions to maintain normal circulatory parameters and oxygen delivery, adequate pain treatment and improved transfer logistics. 

Elderly patients with hip fracture constitute one of the most resource demanding groups in medical care. The care is dominated by the demand that the patients shall be able to return to pre-fracture functional level and preferably to an independent, mobile life without pain. By early identification of the elderly patients’ cognitive and physical state, using a standardised instrument, patients at risk for developing ACS could be identified. By this identification the patients can be offered specific treatment to reduce the risk for prolonged hospitalisation and increased suffering but also increased costs for the society.