Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Jun 16;4(6):447-456.
doi: 10.1302/2633-1462.46.BJO-2023-0045.R1.

Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services

Rose S Penfold  1   2 , Andrew J Hall  2   3   4 , Atul Anand  5   6 , Nick D Clement  2   4 , Andrew D Duckworth  4   7 , Alasdair M J MacLullich  1   2
Affiliations

Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services

Rose S Penfold et al. Bone Jt Open. .

Abstract

Aims: Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Methods: This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A's Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade.

Results: A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041).

Conclusion: Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care.

PubMed Disclaimer

Conflict of interest statement

R. S. Penfold is a fellow on the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust [223499/Z/21/Z]. R. S. Penfold is also an Editorial Fellow and Editorial Board member for Age and Ageing (unpaid). A. M. J. MacLullich is the main author of the 4AT delirium assessment tool, and has no current or future financial conflicts of interest. A. J. Hall is Deputy Chair of the Scottish Hip Fracture Audit Research Group (unpaid). A. D. Duckworth reports research grants from NIHR, OTA, SORT-IT, Stryker, Smith & Nephew, and Acumed, book royalties from Taylor & Francis and Elsevier, a lecture payment from AgNovos Healthware, payment for an educational event from Smith & Nephew, all of which are unrelated to this study. A. D. Duckworth is also a member of the OTA and OTS Research Committees, an Editorial Board member of The Bone & Joint Journal, Bone & Joint Research, and Bone & Joint 360, and an Associate Editor for Trials, OTAI, and JBJS Case Connector. N. D. Clement is an Editorial Board member of The Bone & Joint Journal, Bone & Joint Research, and Arthroplasty (BMC). A. Anand is a co-investigator into multimorbidity and delirium, funded through institutional payments from NIHR and Dunhill Medical Trust, unrelated to this study.

Figures

Fig. 1
Fig. 1
Flow chart demonstrating inclusion and exclusion of patients in the study. ED, emergency department.
See this image and copyright information in PMC

References

    1. Lisk R, Yeong K, Enwere P, et al. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing. 2020;49(3):411–417. doi: 10.1093/ageing/afz161. - DOI - PubMed
    1. No authors listed Hip fracture: management. National Institute for Health and Care Excellence. 2011. [25 May 2023]. https://www.nice.org.uk/guidance/cg124 date last. accessed. - PubMed
    1. No authors listed Scottish Standards of Care for Hip Fracture Patients 2019. Scottish Government. [23 May 2023]. https://www.shfa.scot.nhs.uk/_docs/2019/Scottish-standards-of-care-for-h... date last. accessed.
    1. Griffiths R, Babu S, Dixon P, et al. Guideline for the management of hip fractures 2020. Anaesthesia. 2021;76(2):225–237. doi: 10.1111/anae.15291. - DOI - PubMed
    1. Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry. 2015;30(9):900–910. doi: 10.1002/gps.4233. - DOI - PMC - PubMed