The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial).

Leiv Otto Watne,Vibeke Juliebo,Knut Engedal,Geir Aasmund Hjorthaug,Ingvild Saltvedt,Eva Skovlund,Simon Conroy,Torgeir Bruun Wyller,Frede Frihagen,Anne Cathrine Torbergsen,Johan Raeder

doi:10.1186/1741-7015-12-63

Abstract

BackgroundDelirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline.MethodsThis was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer’s Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation.ResultsA total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04).ConclusionsPre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes.Trial registrationClinicalTrials.gov NCT01009268 Registered November 5, 2009

Highlights

Delirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia
In 2008, we established an orthogeriatric service at our hospital, comprising pre- and postoperative care of hip fracture patients in the acute geriatric ward. We evaluated this model by a randomized controlled trials (RCTs) in which hip fracture patients receiving usual care in the orthopedic ward comprised the control group
Primary outcome - cognitive function four months after surgery The primary outcome could be computed in 228 patients and there was no significant difference between patients treated in the acute geriatric ward and the orthopedic ward after four months (Table 4)

Summary

Introduction

Delirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline. Models range from a limited consultation or liaison service through to integrated orthogeriatric units [5] Few of these models have been evaluated in randomized controlled trials (RCTs), and the heterogeneity of interventions, outcomes and populations makes it difficult to draw conclusions regarding the superiority of one particular model [5,6,7]. Geriatric intervention might be especially beneficial in the vulnerable period prior to surgery, but most studies are limited to postoperative orthogeriatric intervention [8]

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