The effect of a pre- and post-operative orthogeriatric service on cognitive function in patients with hip fracture. The protocol of the Oslo Orthogeriatrics Trial

Torgeir Bruun Wyller,Frede Frihagen,Ingvild Saltvedt,Leiv Otto Watne,Simon Conroy,Knut Engedal,Eva Skovlund,Vibeke Juliebø,Johan Ræder,Anne Torbergsen

doi:10.1186/1471-2318-12-36

Abstract

BackgroundHip fractures mainly affect older people. It is associated with high morbidity and mortality, and in particular a high frequency of delirium. Incident delirium following hip fracture is associated with an increased risk of dementia in the following months, but it is still not firmly established whether this is an association or a causal relationship. Orthogeriatric units vary with respect to content and timing of the intervention. One main effect of orthogeriatric care may be the prevention of delirium, especially if preoperative and postoperative care are provided. Thus, the aim of Oslo Orthogeriatric Trial, is to assess whether combined preoperative and postoperative orthogeriatric care can reduce the incidence of delirium and improve cognition following hip fracture.Methods/designInclusion and randomisation will take place in the Emergency Department, as soon as possible after admission. All patients with proximal femur fractures are eligible, irrespective of age, pre-fracture function and accommodation, except if the fracture is caused by a high energy trauma or the patient is terminally ill. The intervention is pre-and post-operative orthogeriatric care delivered on a dedicated acute geriatric ward. The primary outcome measure is a composite endpoint combining the Clinical Dementia Rating Scale (CDR) and the 10 word memory task at four months after surgery. Secondary outcomes comprise incident delirium, length of stay, cognition, mobility, place of residence, activities of daily living and mortality, measured at 4 and 12 months after surgery. We have included 332 patients in the period 17th September 2009 to 5th January 2012.DiscussionOur choice of outcome measures and our emphasis of orthogeriatric care in the preoperative as well as the postoperative phase will enable us to provide new knowledge on the impact of orthogeriatric care on cognition.Trials registrationClinicalTrials.gov NCT01009268

Highlights

Residential status at 4 and 12 months and number of days in own home during the first four months. This is based upon best available information from patient, family, or the local municipality
The main focus of the Oslo Orthogeriatrics Trial is on cognition, in particular delirium prevention and thereby potentially beneficial long-term cognitive effects of orthogeriatric care
We have chosen this primary outcome because delirium is extremely common in hip fracture patients [7], there is increasing evidence that delirium may have long-term negative consequences upon cognition [9,10], and such consequences are devastating

Summary

Introduction

Delirium as a complication of hip fracture In a retrospective cohort study of 364 patients with hip fracture, the prevalence of delirium on admission was 21.1%, and the incidence of postoperative delirium among those who were non-delirious preoperatively was 36.4% [7] Amongst those without evidence of any cognitive decline before the fracture (measured using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) [8], the risk of dementia at six months was strongly associated with perioperative delirium, suggesting a possible causal relationship between delirium and the development of dementia [9], in keeping with several other studies [10,11,12]. We have chosen mobilisation and nutrition as areas of special interest for process monitoring

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