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Clinical Decisionmaking

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Studies suggest better ways to manage elderly hip fracture patients with delirium and end-stage dementia

Elderly hip fracture patients can fall into many clinical categories. Some are in good health and their only problem is a fractured hip. Some patients develop perioperative delirium, a condition that usually resolves spontaneously by hospital discharge. This type of delirium is clearly distinct from that suffered by medically ill patients and should be managed differently, according to a recent study. On the other hand, patients with end-stage dementia who are in the hospital for hip fracture repair don't fare very well. In fact, their poor prognosis may call for more comfort care than life-saving technologies, according to a second study. Both studies, which were supported in part by the Agency for Healthcare Research and Quality (HS09459), are described here.

Brauer, C., Morrison, S., Silberzweig, S.B., and Siu, A.L. (2000, June). "The cause of delirium in patients with hip fracture." Archives of Internal Medicine 160, pp. 1856-1860.

Delirium strikes 11 to 42 percent of the hospitalized elderly, but it affects one-fourth to half of elderly patients hospitalized for hip fracture. Delirium is associated with increased risk of death, delayed rehabilitation, prolonged hospital stays, poorer posthospital functioning, and an increased risk of nursing home placement. However, delirium affecting patients hospitalized for hip fracture repair surgery is different from that suffered by hospitalized medically ill patients and should be managed differently, concludes this study.

Mount Sinai School of Medicine researchers found, for example, that delirium tended to resolve spontaneously without intervention by the time of discharge in 74 percent of hip fracture patients. In contrast, the literature suggests that medically ill patients tended to have more prolonged courses. Finally, the researchers identified a definite cause of the delirium in only 7 percent of patients. They identified a probable cause in 20 percent of patients and a possible cause in 11 percent of patients. In 61 percent of episodes, delirium was attributed to one or more comorbid conditions. The only other large study of medically ill patients identified a definitive or probable cause of delirium in 56 percent of cases.

Rather than focusing mainly on pursuing the cause of the dementia in hip fracture patients, doctors should manage the symptoms of the delirious episode using environmental, behavioral, and pharmacologic interventions (for example, major tranquilizers), conclude the researchers. Their findings were based on a review of medical charts and daily interviews with 571 hip fracture patients (50 years of age and older) admitted to four New York City hospitals.

Morrison, R.S., and Siu, A.L. (2000, July). "Survival in end-stage dementia following acute illness." Journal of the American Medical Association 284(1), pp. 47-52.

Nearly 2 million people in the United States are in the final stages of a dementing illness such as Alzheimer's disease. They cannot recognize family members, depend on others for help with daily activities, are unable to communicate, and suffer from repeated infections and other complications. This study shows that when elderly patients with end-stage dementia were hospitalized for hip fracture or pneumonia they didn't fare well. They had a four-fold increase in 6-month mortality compared with elderly cognitively intact adults with the same diagnoses (53 vs. 13 percent for pneumonia patients and 55 vs. 12 percent for hip fracture patients).

Despite these large differences in mortality between cognitively intact and demented patients, care for these two groups of patients varied little. That's unfortunate, say the Mount Sinai School of Medicine researchers who conducted the study. They recommend that care for demented patients should focus more on comfort care and minimize burdensome "life-saving" interventions. They argue that these interventions are especially burdensome for those with dementia because they cannot understand the reasons for tests or treatments, prepare for them emotionally, refuse them if desired, or request analgesia.

Their study found that hip fracture and pneumonia patients with end-stage dementia received just as many burdensome procedures (for example, arterial blood gas measurement, phlebotomy, and urinary catheter insertion) as cognitively intact patients, and only 7 percent of them had a documented decision to forego a life-sustaining treatment other than cardiopulmonary resuscitation (CPR). Only 24 percent of patients with end-stage dementia and hip fracture, a very painful condition, received a standing order for pain killers (analgesics). Finally, there were few discussions with family members about the goals of hospital care. These findings are based on a prospective 6-month study of 59 cognitively intact and 39 demented elderly hip fracture patients and 39 cognitively intact and 80 demented pneumonia patients in a large hospital in New York City between September 1996 and March 1998.

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