168 / 210
S160
Symposia / European Geriatric Medicine 6S1 (2015) S157
–
S176
Orthogeriatrics Trial (2014) and the Trondheim Hip Fracture Trial
(2015). The experimental setting included pre- and postoperative
geriatric care in an orthogeriatric ward. Both studies evaluated the
impact of comprehensive geriatric care (CGC) provided throughout
the entire hospital stay, with just fracture evaluation, surgical
treatment and consultative input from orthopedic surgeons.
All patients admitted acutely with a hip fracture were screened.
Patients were excluded if the fracture was a part of a high energy
trauma or if patients were moribund at admittance. In the Oslo
Orthogeriatrics Trial all other hip-fracture patients were eligible. In
the Trondheim Hip Fracture Trial home-dwelling persons
>
70 years
of age, previously able to walk 10 meters, were eligible.
Both studies enrolled and randomized participants in the
Emergency Department to receive treatment in an experimental
geriatric or in a traditional orthopedic ward. In the Oslo study there
was focus on prevention of delirium and the primary outcome was
cognitive function. In Trondheim there was focus on mobility, ADL
and use of health care services. The primary outcome was mobility.
In both centers the patients were assessed at 4 and 12 months
after surgery. Main results for the Oslo study showed no significant
difference in cognition at 4 and 12 months. However, significant
better mobility was found in patients not admitted from nursing
homes. In the Trondheim study statistically significant and clinically
meaningful differences on the primary outcome. A range of
short- and longer-term secondary outcomes were in favour of
treatment in the geriatric ward, being cost-effective, as well.
Invited symposium
S-05
Delirium in elderly patients
B.E. Neerland
University of Oslo, Oslo, Norway
Chair:
Bjørn Erik Neerland, MD and PhD-candidate, Geriatric
Department, University of Oslo, Norway (NO)
Speakers and titles:
– Daniel Davis (UK): Delirium and long-term cognitive impairment:
population insights
– Leiv Otto Watne (NO): CSF studies in delirium – what have we
learned so far?
– Giuseppe Bellelli (IT): Management of delirium in hip fracture
patients (and other geriatric patients)
Delirium is a serious neuropsychiatric condition, characterized
by acute and fluctuating disturbance in attention and awareness,
reduced orientation to the environment and alteration in cognitive
domains [1]. It occurs across all health-care settings and
populations, but it is especially common in acute medical
and surgical patients, and in palliative care services. Delirium
is distressing for patients and caregivers, and independently
associated with a number of adverse clinical outcomes. The
pathophysiology of delirium has not yet been fully elucidated, and
the management of delirium still remains challenging for healthcare
workers.
Delirium and long-term cognitive impairment: population
insights
(Daniel Davis, UK): Though delirium is now established as
a strong predictor of cognitive decline in older adults [2–4], whether
it accounts for additional, inter-related or unexplained pathological
injury contributing to dementia has not been examined. It is
possible that when dementia follows delirium it has a different
pathological profile compared to dementia that develops without
delirium. Therefore, understanding how delirium affects the
evolution of dementia, in the context of a particular burden of
pathology, may offer new insights into independent mechanisms
explaining cognitive decline after delirium.
This talk will present data examining a key hypothesis: that
faster cognitive decline associated with delirium would act
independently of the cognitive decline associated with classical
dementia pathology. Accordingly, we investigated the extent to
which delirium and classical dementia pathology contributed to
associated cognitive decline in three unselected population-based
cohort studies with neuropathology autopsy data (n = 987).
We show that people with both delirium and higher levels
of classical dementia pathology demonstrate the greatest
cognitive decline. Delirium, in the presence of dementia-related
neuropathology, was associated with cognitive decline beyond
that expected for delirium or the neuropathology itself. This
means that delirium may be independently associated with
pathological processes driving cognitive decline which are different
from classical dementia pathology. These findings suggest new
possibilities regarding the pathological correlates of cognitive
impairment, positioning delirium and/or its precipitants as a
critically inter-related mechanism. Showing this in three unselected
samples, further attests to the broad significance of these findings
and their applicability to the wider population.
CSF studies in delirium
–
what have we learned so far?
(Leiv
Otto Watne): Given the magnitude of the problem, delirium
pathophysiology has been greatly understudied and is poorly
understood. In overviews of biomarker studies, the most striking
finding is the low number of patients included [5, 6]. While delirium
is clearly a phenomenon that affects the brain, most biomarker
studies have been done in the periphery (serum or plasma). Analysis
of cerebrospinal fluid (CSF) has great potential, since CSF might
more closely reflect changes in the central nervous system. There
is however ethical and practical difficulties in obtaining CSF from
patients with delirium, and only a few studies exist. One possibility
to obtain CSF is to include patients that undergo surgery in spinal
anesthesia, since such patients will have a lumbar puncture anyway.
Accordingly, most CSF studies in delirium have been done in
patients with hip fracture.
This talk will present the most important findings of the existing
CSF studies in delirium. The talk will also address the some of the
challenges in doing biomarker studies in delirium.
Management of delirium in hip fracture patients (and other
geriatric patients)
(Giuseppe Bellelli): In patients with hip fracture,
the prevalence of preoperative delirium ranges from 15% to 23%,
while the incidence of post-operative from 12 to 53%. Delirium
is potentially preventable, and interventions can be effective
in preventing delirium in adults who are at risk [7]. These
preventative interventions should be tailored to each person’s
needs, based on the results of an assessment for clinical factors
that may contribute to the development of delirium. Such clinical
factors include cognitive impairment, disorientation, dehydration,
constipation, hypoxia, infection or other acute illness, immobility or
limited mobility, pain, effects of medication, poor nutrition, sensory
impairment and sleep disturbance. However, implementation of
standardized nonpharmacological delirium prevention strategies is
challenging and adherence remains low.
This talk will present and discuss the most important studies
on non-pharmacological and pharmacological management of
delirium.
Reference(s)
[1] Inouye SK, Westendorp RG, Saczynski JS: Delirium in elderly people.
Lancet 2014, 383(9920):911–922.
[2] Fong TG, Jones RN, Shi P, Marcantonio ER, Yap L, Rudolph JL, Yang
FM, Kiely DK, Inouye SK: Delirium accelerates cognitive decline in
Alzheimer disease. Neurology 2009, 72(18):1570–1575.
[3] Gross AL, Jones RN, Habtemariam DA, Fong TG, Tommet D, Quach
L, Schmitt E, Yap L, Inouye SK: Delirium and Long-term Cognitive
Trajectory Among Persons With Dementia. ArchInternMed 2012,
172(17):1324–1331.