Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium

Anne Jh Vochteloo,Sophie Moerman,Maarten De Boo,Mark R De Vries,Boudewijn Ls Borger Van Der Burg,Dieu-Donné Niesten,Peter Pilot,Wim E Tuinebreijer,Rob Ghh Nelissen

doi:10.1186/1471-2318-11-39

Anne Jh Vochteloo, Sophie Moerman + Show 7 more

Open Access

https://doi.org/10.1186/1471-2318-11-39

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Abstract

BackgroundDelirium in patients with hip fractures lead to higher morbidity and mortality. Prevention in high-risk patients by prescribing low dose haloperidol is currently under investigation.MethodsThis prospective cohort surveillance assessed hip fracture patients for risk of developing a delirium with the Risk Model for Delirium (RD) score. High-risk patients (score ≥ 5 points) were treated with a prophylactic low-dose of haloperidol according to hospital protocol. Primary outcome was delirium incidence. Secondary outcomes were differences between high- and low-risk patients in delirium, length of stay (LOS), return to pre-fracture living situation and mortality. Logistic regression analysis was performed with age, ASA-classification, known dementia, having a partner, type of fracture, institutional residence and psychotropic drug use as possible confounders.Results445 hip fracture patients aged 65 years and older were admitted from January 2008 to December 2009. The RD-score was completed in 378 patients, 173 (45.8%) high-risk patients were treated with prophylactic medication. Sensitivity was 71.6%, specificity 63.8% and the negative predictive value (NPV) of a score < 5 was 85.9%.Delirium incidence (27.0%) was not significantly different compared to 2007 (27.8%) 2006 (23.9%) and 2005 (29.0%) prior to implementation of the RD- protocol.Logistic regression analysis showed that high-risk patients did have a significant higher delirium incidence (42.2% vs. 14.1%, OR 4.1, CI 2.43-7.02). They were more likely to be residing at an alternative living situation after 3 months (62.3% vs. 17.0%, OR 6.57, CI 3.23-13.37) and less likely to be discharged from hospital before 10 days (34.9% vs. 55.9%, OR 1.63, CI 1.03-2.59). Significant independent risk factors for a delirium were a RD-score ≥ 5 (OR 4.13, CI 2.43-7.02), male gender (OR 1.93, CI 0.99-1.07) and age (OR 1.03, CI 0.99-1.07).ConclusionsIntroducing the delirium prevention protocol did not reduce delirium incidence.The RD-score did identify patients with a high risk to develop a delirium. This high-risk group had a longer LOS and returned to pre-fracture living situation less often.The NPV of a score < 5 was high, as it should be for a screening instrument. Concluding, the RD-score is a useful tool to identify patients with poorer outcome.

Highlights

Delirium in patients with hip fractures lead to higher morbidity and mortality
In 2008 we introduced an integrated hip fracture care pathway that included a Risk Model for Delirium [9]
Due to the inability of patients to participate or a patient-to-nurse ratio that was too high at some moments, the Risk Model for Delirium (RD)-score was incomplete or not performed in 67 patients

Summary

Introduction

Delirium in patients with hip fractures lead to higher morbidity and mortality. Prevention in high-risk patients by prescribing low dose haloperidol is currently under investigation. Delirium is a common and serious complication in hip fracture patients It leads to lower functional abilities, longer hospital stay, impaired cognitive function, more admissions to long term special care facilities and higher mortality rates [1,2,3,4,5]. This advocates the importance of preoperative delirium risk assessment. Reported post-operative incidence rates range widely from 16 to 62% [6] This broad range can be explained by patient inclusion criteria and different scoring methods for delirium. Delirium is frequently undetected or misdiagnosed [7]

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