Delirium is independently associated with poor functional recovery after hip fracture
Delirium is independently associated with poor functional recovery after hip fracture
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DOI：
10.1111/j.1532-5415.2000.tb04718.x
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发表时间：
2000-06-01
影响因子：
6.3
通讯作者：
Resnick, NM
中科院分区：
文献类型：
--
作者：
Marcantonio, ER;Flacker, JM;Resnick, NM
目的：评估谵妄在髋部骨折术后功能恢复自然史中的作用，与骨折前状态无关。设计：前瞻性队列研究。地点：大型学术三级医院的骨科手术服务，随访范围延伸到康复医院、疗养院和社区。参与者：126 名同意的年龄超过 65 岁的受试者（平均年龄 79 岁） +/- 8 岁，79% 女性）因髋部骨折手术修复而紧急入院。测量：入组时进行详细评估，通过与患者和指定代理人面谈以及回顾病历来确定骨折前状态。访谈包括标准化工具的管理（日常生活活动（ADL）量表、幸福痴呆评定量表、谵妄症状访谈）以及步行评估和骨折前生活状况。从医疗记录中获取医疗合并症、髋部骨折的性质以及手术修复情况。所有受试者在住院期间接受每日访谈，包括简易精神状态检查和谵妄症状访谈，并使用混乱评估方法算法诊断谵妄。骨折后 1 个月和 6 个月重新联系患者和代理人，并接受与入组时类似的访谈，以确定死亡、持续性谵妄、ADL 功能下降、行走能力下降或新的疗养院安置。 结果：52/126 (41%) 的患者发生谵妄，出院时 20/52 (39%) 持续存在谵妄，出院 1 个月时为 15/52 (32%)， 6 个月时为 3/52 (6%)。 80岁或以上的患者、骨折前认知障碍、ADL功能障碍和高合并症的患者更容易发生谵妄。然而，调整这些因素后，谵妄仍然与髋部骨折后 1 个月功能恢复不良的结果显着相关：ADL 下降（比值比 (OR) = 2.6；95% 置信区间 (95% CI)，1.1-6.1）、活动能力下降（OR = 2.6；95% CI，1.03-6.5）以及死亡或新的疗养院安置（OR = 3.0；95% CI，1.1-8.4）。谵妄持续 1 个月的患者比谵妄已经缓解的患者预后更差。结论：谵妄很常见、持续，并且与髋部骨折后 1 个月的功能恢复不良独立相关，即使在调整骨折前虚弱后也是如此。需要进一步的研究来确定谵妄导致功能恢复不良的机制，并确定旨在预防或减少谵妄的干预措施是否可以改善髋部骨折后的恢复。
OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status.DESIGN: Prospective cohort study.SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community.PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture.MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement.RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, acid those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip Fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved.CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.