RecommendationHealthcare professionals should deliver care that minimises the patient's risk of delirium and maximises their independence, by:
  • actively looking for cognitive impairment when patients first present with hip fracture
  • reassessing patients to identify delirium that may arise during their admission
  • offering individualised care in line with ‘Delirium’ (NICE clinical guideline 103)
Relative values of different outcomesPatients with memory problems make up a substantial proportion of admissions, and face increased risk of delirium, medical complications, mortality, prolonged length of stay, and failure to return to pre-fracture independence.

The GDG considered medical complications, mortality, length of stay and discharge destination as the most important outcomes.
Trade off between clinical benefits and harmsPatients with memory problems are known to benefit from acute comprehensive geriatric assessment and targeted intervention as a means of reducing their risk of delirium and severe delirium, which are significant contributors to increased length of stay and increased risk of morality at 6 months 150,150, as well as being a source of profound distress for patients, their families and carers 203,203.

In addition, intensive rehabilitation has been shown to be effective in improving outcome in terms of independent living among patients with mild to moderate cognitive impairment 157,157.

No evidence of harm was found and the GDG would not expect harm. Although no evidence met our inclusion criteria for this area, GDG consensus is that the potential benefits include avoidance of the distress that delirium causes to patients, their family, carers, and other inpatients, along with avoidance of the persistent reduction in cognitive function that can follow an episode of delirium, and of the increased length of stay and mortality associated with delirium.

The avoidance and management of delirium in patients with hip fracture is specifically addressed in the NICE Guideline on Delirium224.
Economic considerationsThe decision model from the NICE guideline on Delirium (CG103) found that the tailored multi-component intervention package was cost-effective for hip fracture patients (£8,000 per QALY gained), as this care would lead to a reduced risk of long-term institutional care placement, lower incidence of other medical complications and lower length of hospital stay for these patients.
Quality of evidencePatients with cognitive impairment are usually a group excluded from studies. Over 60% of the papers reviewed either excluded patients with cognitive impairment and/or dementia, or made no specific comments relating to this subgroup. The studies that specifically analysed this subgroup157,203 are of moderate quality.
Other considerationsFor patients whose hip fracture occurs in the context of dementia, please see the NICE guidance on dementia224.

Identification of cognitive impairment is a key part of assessment, and a number of tools have been used in patients with hip fracture. The Abbreviated Mental Test (AMT) score is often used, and forms part of the National Hip Fracture Database's dataset, but the GDG did not examine the choice of tool or approach to assessment.

Assessment of mental state can be complex in patients who are in pain, or who have received strong analgesia at the time of presentation. Approaches to the prevention and management of delirium require much more than screening for cognitive impairment at admission, and must include a sensitivity to changes in mental state and an awareness that delirium may arise at any stage of a patient's stay.

Delirium is not confined to patients with pre-existing cognitive problems, and its incidence will be reduced most effectively by the provision of continuous orthogeriatric support to all patients203. Evidence on the effectiveness of models to prevent and manage delirium following hip fracture were key to the recommendations made in the NICE Guideline on Delirium224, and that Guideline should be read alongside our own when developing services for patients with hip fracture.

From: 12, Multidisciplinary management

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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