Frailty and post-operative delirium influence on functional status in patients with hip fracture: the GIOG 2.0 study.

BACKGROUND: This study analyzes the effect of frailty and Post-Operative Delirium (POD) on the functional status at hospital discharge and at 4-month follow-up in patients with hip fracture (HF). METHODS: Multicenter prospective observational study of older patients with HF admitted to 12 Italian Orthogeriatric centers (July 2019-August 2022). POD was assessed using the 4AT. A 26-item Frailty Index (FI) was created using data collected on admission. The outcome measures were Cumulated Ambulation Score (CAS) ≤ 2 at discharge and a telephone-administered CAS ≤ 2 after 4 months. Poisson regression models were used to assess the effect of frailty and POD on outcomes. RESULTS: 984 patients (median age 84 years, IQR = 79-89) were recruited: 480 (48.7%) were frail at admission, 311 (31.6%) developed POD, and 158 (15.6%) had both frailty and POD. In a robust Poisson regression, frailty alone (Relative Risk, RR = 1.56, 95% Confidence Intervals, CI 1.19-2.04, p = 0.001) and its combination with POD (RR = 2.57, 95% CI 2.02-3.26, p < 0.001) were associated with poor functional status at discharge. At 4-month follow-up, the combination of frailty with POD (RR 3.65, 95% CI 1.85-7.2, p < 0.001) increased the risk of poor outcome more than frailty alone (RR 2.38, 95% CI 1.21-4.66, p < 0.001). CONCLUSIONS: POD development exacerbates the negative effect that frailty exerts on functional outcomes in HF patients.

Three-year National report from the Gruppo Italiano di Ortogeriatria (GIOG) in the management of hip-fractured patients.

BACKGROUND: Hip fractures (HF) are a major issue worldwide. We aimed at evaluating the practices in delivering care to patients with HF among several Italian Orthogeriatric centers. METHODS: The study took place from February 2016 to July 2018. Seven performance indicators (pre-surgical cognitive assessment, surgery performed ≤ 48 h from fracture, removal of urinary catheter/absence of delirium/start of physiotherapy on the first post-operative day, prescription of bone protection at discharge, and discharge toward rehabilitation) were collected. RESULTS: The 14 participating hospitals totally recruited 3.017 patients. Patients were old (median age 86 years; Inter Quartile Range [IQR] 80-90), mostly females (77%). Nearly 55% of them were already impaired in mobility and about 10% were nursing home residents. Median time-to-surgery was 41 h (IQR 23-62). Models of care greatly varied among centers, only 49.3% of patients being co-managed by geriatricians and orthopedics. There was high variability across centers in four indicators ("pre-surgical cognitive assessment", "bone protection prescription", "use of urinary catheter" and "start of physiotherapy"), moderate in two indicators ("surgery performed ≤ 48 h from fracture" and "discharge toward rehabilitation" and low in one ("absence of delirium on day following surgery"). Comparison with international studies suggests very different ways of providing care to HF Italian patients. CONCLUSIONS: The study results suggest high inter-center variability in the key-performance indicators, and different approaches in providing care to our HF patients in comparison to other countries. A National debate on the topic is required in Italy to harmonize practices of orthogeriatric care.

The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients.

BACKGROUND: Delayed surgery (ie, >48 hours from arrival in hospital) and pre-fracture disability are thought to be long-term risk factors for mortality in patients with hip fracture (HF). However, the combined effect on mortality of these two conditions has not been satisfactorily assessed in previous studies. OBJECTIVE: To assess the combined effect of pre-fracture disability and delayed surgery on 12-month mortality in a population of elderly patients after HF surgical treatment. DESIGN: Retrospective cohort study with 12-month follow-up. SETTING: An orthogeriatric unit (OGU) in a university hospital in Italy. METHODS: All patients (n = 390) admitted to an OGU from March 2007 to December 2010 who underwent proximal HF surgery and who were not transferred to other hospitals were considered for the analyses. Pre-fracture disability was defined as having an impairment in more than one activity of daily living (ADL). The 12-month mortality was assessed by a Kaplan-Meyer analysis and by a Cox proportional hazards regression models adjusting for relevant potential confounders. RESULTS: After adjusting for potential confounders, patients with both delayed surgery and pre-fracture disability had a significantly higher 12-month mortality (hazard ratio [HR] = 5.80; 95% confidence interval [CI] = 2.11-15.92) than patients with neither delayed surgery nor disability (reference group). Patients with disability but not delayed surgery had a nearly 4-fold increased mortality risk (HR, 3.98; 95% CI 1.41-11.27) than patients in the reference group. CONCLUSIONS: Patients with both pre-fracture disability and delayed HF surgical treatment had a nearly six-fold increased 12-month mortality risk than did patients with neither disability nor delayed surgery.

A comparison between two co-managed geriatric programmes for hip fractured elderly patients.

BACKGROUND AND AIMS: Hip fracture in older people is an event associated with a high incidence of morbidity and mortality. In this study we compared the clinical outcomes of two groups of orthogeriatric patients in an orthogeriatric care (OC) programme. The OC course, developed into the GeriatricWard, starts from the Emergency Department (OC-1, n=174) or from the Orthopaedic Department after surgery (OC-2, n=87). METHODS: For this purpose, OC patients were prospectively enrolled from March 2007 to June 2009, following OC criteria. Door-to-bed time, time to surgery, mobilisation time, length of stay, and post-operative complications were compared between the OC groups. RESULTS: OC-1 patients differ from OC-2 ones only for residence at admission (14.4% vs 4.6% lived in nursing homes, p=0.02). Concerning outcomes, in the OC-1 group only mobilization time was significantly lower (p=0.01). No differences were observed in post-operative complications. CONCLUSIONS: In frail older people, hip fracture co-management, with the geriatrician as primary attendant, leads to satisfying outcomes. The OC-1 and OC-2 courses exhibit similar clinical results. An improvement in several organisational aspects, including coordination between hospital and rehabilitation services, is warranted.