Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture

Abstract

Study objective: To identify modifiable preoperative factors that might influence the morbidity and mortality associated with non-elective, inpatient hip fracture surgeries in the geriatric surgical population.

Design: Retrospective database analysis from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project.

Setting: Inpatient, perioperative.

Patients: Geriatric patients undergoing surgery.

Interventions: Non-elective hip repair surgery.

Measurements: Preoperative demographic, medical, surgical, and anesthetic variables; post-operative rates of delirium, decline in functional status, and 30-day mortality.

Main results: The 1261 patients in this study were predominantly female (74%), white (89%), and non-Hispanic (92%). Ages were distributed across groups from 65 to over 90 years. Most patients were categorized as American Society of Anesthesiologists Physical Status class 3 (64%). General anesthesia (57%) was the most common anesthetic, followed by spinal (38%). Preoperative functional status was recorded in 79% as independent in activities of daily living (ADLs). About one third of patients had baseline dementia. Post-operatively, 42% experienced delirium, and most patients required partial or total assistance with ADLs (72% and 12%, respectively). Reoperation was required in 2.8% of cases. Mortality at 30 days was 5.0%. In the multivariable analysis, risk factors associated with post-operative delirium included dementia and lack of competency to sign consent. In the analysis for postoperative decline in functional status, the major risk factor was a history of falls, while emergently performed surgery was protective. The analysis for mortality at thirty days was under-powered.

Conclusions: Hip fractures remain a major source of morbidity in geriatric patients. Baseline dementia and inability to sign surgical consent are significant risk factors for adverse outcomes after hip fractures and should be considered in the informed consent process. Data from this study and currently ongoing randomized trials will help guide reductions in morbidity and mortality in this population.

Keywords: Delirium; Dementia; Functional status; Geriatric; Hip fracture; Mortality; Outcomes.