Acute Confusional State in Elderly Patients with Hip Fracture. Identification of risk factors and intervention using a prehospital and perioperative management program Björkman Björkelund, Karin

................................................................................................................... 7 ABBREVIATIONS ........................................................................................................ 8 ORIGINAL PAPERS...................................................................................................... 9 INTRODUCTION ........................................................................................................ 10 BACKGROUND .......................................................................................................... 10 Acute Confusional State (ACS) ................................................................................ 10 Definition of ACS.................................................................................................. 12 Terms and symptom profiles ............................................................................. 12 Etiology and underlying mechanisms of ACS................................................... 13 Postoperative cognitive dysfunction, POCD ..................................................... 13 Dementia ............................................................................................................ 14 The aging brain .................................................................................................. 14 Cognition ........................................................................................................... 14 Elderly patients...................................................................................................... 15 Elderly patients’ experiences of having ACS.................................................... 15 Risk factors for ACS ............................................................................................. 15 Elderly patients with hip fracture .......................................................................... 16 Swedish National Hip Fracture Register ........................................................... 17 Fall and fracture type ......................................................................................... 18 ASA risk classification ...................................................................................... 19 Anesthesia.......................................................................................................... 20 Timing of surgery .............................................................................................. 21 Pain .................................................................................................................... 21 Hypoxemia......................................................................................................... 22 Anemia............................................................................................................... 22 Hypotension ....................................................................................................... 22 Dehydration and malnutrition............................................................................ 23 Drugs.................................................................................................................. 23 Outcome after hip fracture .................................................................................... 24 Intervention studies ............................................................................................... 25 Documentation ...................................................................................................... 26 Cognitive tests ....................................................................................................... 26 RATIONALE FOR THE THESIS ............................................................................... 29 AIMS............................................................................................................................. 30 METHODS ................................................................................................................... 31 Design and study description .................................................................................... 31 Study population ....................................................................................................... 31 Data collection........................................................................................................... 33 Study I and II ......................................................................................................... 33 Study III................................................................................................................. 34 Study IV................................................................................................................. 34 Assessments in study IV.................................................................................... 36 Intervention in study IV..................................................................................... 37 DATA ANALYSIS....................................................................................................... 40 Study I, II and IV....................................................................................................... 40 Study III..................................................................................................................... 41 ETHICAL CONSIDERATIONS.................................................................................. 43 FINDINGS.................................................................................................................... 46 Study I, Factors at admission associated to 4-months outcome in elderly patients with hip fracture ........................................................................................................ 46 Study II, The influence of perioperative care and treatment on 4-months outcome in elderly patients with hip fracture............................................................................... 46 Study III, The Organic Brain Syndrome (OBS) Scale: a systematic review ............ 54 Study IV, Reducing Acute Confusional State in elderly patients with hip fracture: a multi-factorial intervention study.............................................................................. 59 DISCUSSION............................................................................................................... 63 Methodological considerations ................................................................................. 64 The findings of the studies ........................................................................................ 69 Risk factors for ACS ............................................................................................. 69 Prevalence of ACS ................................................................................................ 70 Morbidity and mortality after ACS ....................................................................... 72 ACS assessment..................................................................................................... 73 Reduction of ACS by a multi-factorial intervention program............................... 73 Clinical implications ................................................................................................. 74 CONCLUSIONS........................................................................................................... 75 FUTURE RESEARCH ................................................................................................. 76 POPULÄRVETENSKAPLIG SAMMANFATTNING ............................................... 77 ACKNOWLEDGEMENTS.......................................................................................... 80 REFERENCES ............................................................................................................. 82 APPENDIX I III PAPER I IV