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Cited by 21Intensive Care Unit Cognitive DisordersHip and Femur FracturesEmergency and Acute Care Studies

Risk factors associated with acute in-hospital delirium for patients diagnosed with a hip fracture in the emergency department.

Open access
Thompson, Cameron, Brienza, Vince J.M., Sandre, Aislinn, Caine, Sean, Borgundvaag, Bjug, McLeod, Shelley·2018·CJEM
DOI 10.1017/cem.2018.427
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Abstract

CLINICIAN’S CAPSULE: What is known about the topic? Delirium, or acute confusion, occurs in up to 62% of patients who have experienced a hip fracture. What did this study ask? What risk factors are associated with acute in-hospital delirium for ED patients diagnosed with a hip fracture? What did this study find? History of neurodegenerative disease or dementia, age>75 years, and absence of analgesia in the ED were associated with acute in-hospital delirium. Why does this study matter to clinicians? Although many variables associated with delirium may not be easily modified, more careful attention to ED pain management and the provision of better analgesia are important.

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  3. Reference list17 references found
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  6. Claims36 claims anchored to a quote
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Registry

Crossref · 10.1017/cem.2018.427

Cites

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Statistics

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Claims the paper makes

0 of 13 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Patients who received ≥1.5 mg morphine equivalents of analgesics per hour in the ED were significantly less likely to develop delirium within 72 hours of ED arrival.

    “Patients who received ≥ 1.5 mg of morphine equivalents of analgesics per hour in the ED were significantly less likely to develop delirium within 72 hours of ED arrival.”
    • Also stated in: § DISCUSSION · plain
      “Receiving opioid medications at a rate of at least 1.5 mg of meq per hour significantly reduced the likelihood of developing delirium; however, the optimal dose of opioids for prevention of delirium is not known.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patients who developed delirium within 72 hours of ED arrival were less likely to receive any pain management in the ED (68.5% vs 83.6%; Δ15.1%; 95% CI 7.8%-22.8%).

    “Patients who developed delirium with 72 hours of ED arrival were less likely to receive any pain management in the ED (68.5% receiving analgesia v. 83.6% in the no-delirium group; Δ 15.1%; 95% CI: 7.8% to 22.8%).”
    Quote in the paperSubstantial claim
  • Findingown data

    Overall, 138 (20.6%) hip fracture patients did not receive either opioid analgesic or regional anesthesia while in the ED.

    “Overall, 138 (20.6%) hip fracture patients did not receive either opioid analgesic or regional anesthesia while in the ED.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patients who did not develop delirium received a higher dose of opioid analgesia compared with those who developed delirium.

    “In our study, patients who did not develop delirium received a higher dose of opioid analgesia compared with those who developed delirium.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patients who developed delirium had a longer hospital length of stay than those who did not (12.8 vs 10.1 days; Δ2.7; 95% CI 1.9-4.5).

    “Patients who developed delirium had a longer hospital length of stay compared with patients who did not develop delirium (12.8 v. 10.1 days; Δ 2.7; 95% CI: 1.9 to 4.5 days).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 13
  • The quote only partly states this claim. 1
  • May combine two claims. 12

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Femoral nerve blocks were rarely performed by ED physicians (35/668; 5.2%).

    “Femoral nerve blocks were rarely performed by ED physicians (35/668; 5.2%).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Among ED patients aged 65 years and older with a hip fracture, 181 of 668 (27.1%) developed delirium within 72 hours of ED arrival.

    “Of the total number of patients, 181 (27.1%) patients diagnosed with a hip fracture from the ED developed delirium within 72-hours of ED arrival.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only one site used the CAM score to screen for acute confusion at triage, and only 28.4% of patients had a completed CAM score recorded.

    “However, in our study, only one site used the CAM score to screen for acute confusion at triage, with only 28.4% of patients having a completed CAM score recorded, suggesting future efforts should focus on initiatives to improve delirium screening compliance by ED personnel.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The multivariable model achieved good discrimination (AUC = 0.76) and was well fit to the data (Hosmer-Lemeshow chi-squared = 3.77, p = 0.44).

    “The model achieved good discrimination (area under the receiver-operating characteristic curve = 0.76), and the Hosmer-Lemeshow goodness-of-fit chi-squared value was 3.77 (p = 0.44), indicating that the model was well fit to the data.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    CAM scores were used at only one of the two included sites, so the incidence of delirium may not have been consistently documented between the two hospitals.

    “Additionally, CAM scores were used at only one of the two included sites, so the incidence of delirium may not have been consistently documented between the two hospitals.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The impact of ED management may have been confounded by inpatient variables, including surgery.

    “The impact of ED management may have been confounded by inpatient variables, including the surgery; however, our interest was in establishing the impact of analgesia provided during the ED stay.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study estimated that 25% of ED patients with a hip fracture would experience delirium within 72 hours, and with up to 12 covariates, the required sample size was 480 patients.

    “We estimated that 25% of ED patients with a hip fracture would experience delirium within 72 hours of ED arrival, consistent with previous studies, 6,8,16 resulting in an estimated sample size of 480 patients.”
    • Also stated in: § Sample size · hedged
      “Based on a priori knowledge of delirium risk factors, it was unlikely that more than 12 covariates would be included in the final model.”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites Peduzzi et al. (1996) source
    • cites [6] 6. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol 2003;58(1):76-81. source
    • cites [8] 8. Bruce AJ, Ritchie CW, Blizard R, et al. The incidence of delirium associated with orthopedic surgery: a meta- analytic review. Int Psychogeriatr 2007;19(2):197-214. source
    • cites [16] 16. Oh ES, Sieber FE, Leoutsakos J, et al. Sex differences in hip fracture surgery: preoperative risk factors for delirium and postoperative outcomes. J Am Geriatr Soc 2016;64:1616-21.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    It is possible that some patients experienced delirium that was undocumented and therefore not captured in the study.

    “It may be possible that some patients experienced delirium, which was undocumented in the chart and therefore not captured in our study.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Of 750 ED patients with a hip fracture, 82 were excluded, leaving 668 patients included in the analyses.

    “During the study period, there were 750 ED patients with a hip fracture between the two sites.Eighty-two patients were excluded, leaving 668 patients included in the analyses (Figure 1).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Fifty charts were independently reviewed by two study investigators to ensure consistency in the delirium assessment.

    “Fifty charts were independently reviewed by two study investigators to ensure consistency in the delirium assessment.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Due to the retrospective nature of the study, the authors could only report what was documented in the patient record.

    “Due to the retrospective nature of the study, we can only report what was documented in the patient record.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Advanced age and signs of dementia or neurodegenerative disease are predictors of 72-hour delirium that can be screened for during triage.

    “Advanced age and signs of dementia or neurodegenerative disease are predictors of 72-hour delirium that can be screened for during triage.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Some of the observed variation in the collected data may have been influenced by error or bias from the data abstractor, who was not blinded to the objective of the study.

    “It is also possible that some of the observed variation in the collected data were influenced by error or bias from the data abstractor, who was not blinded to the objective of this descriptive study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A systematic review found evidence from four randomized controlled trials (n=461) and two cohort studies (n=634) that nerve blocks are effective for relieving acute pain and reducing delirium in hip fracture patients.

    “Abou-Setta et al. conducted a systematic review of the comparative effectiveness of pain management strategies for hip fracture and found evidence from four randomized controlled trials (n = 461) and two cohort studies (n = 634) to suggest that nerve blocks are effective for relieving acute pain and reducing delirium in hip fracture patients.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] 12. Abou-Setta AM, Beaupre LA, Rashiq S, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med 2011;155 (4):234-45. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Untreated pain has been associated with delirium in older adults undergoing elective surgery.

    “Untreated pain has also been associated with delirium in older adults undergoing elective surgery.6,11”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] 6. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol 2003;58(1):76-81. source
    • cites [11] 11. Morrison RS, Magaziner J, Koval KJ, et al. The impact of post-operative pain on outcomes following hip fracture. Pain 2003;103:303-11. source

  • May combine two claims.

    Premisecitation

    Previous studies on postoperative delirium did not specifically address factors related to emergency department management and did not exclusively include hip fracture patients.

    “However, these studies did not specifically address factors related to emergency department (ED) management and did not exclusively include hip fracture patients.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4][5][6][7][8]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Delirium may be a preventable condition amenable to hospital-based prevention strategies, which could be implemented in the ED.

    “Delirium may be a preventable condition amenable to hospital-based prevention strategies, which could be implemented in the ED.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Among older adults in the ED, delirium typically occurs as the hypoactive variety and is easily missed if not routinely screened for.

    “Amongst older adults in the ED, delirium typically occurs as the hypoactive variety where patients may appear depressed, sedated, or lethargic and therefore easily missed if not routinely screened for.5,6”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] 5. Yang Y, Zhao X, Dong T, et al. Risk factors for post- operative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res 2017;29:115-26. source
    • cites [6] 6. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol 2003;58(1):76-81. source

  • May combine two claims.

    Interpretationown data

    Advanced age and history of neurodegenerative disease or dementia are associated with increased risk of confusion, which complicates and prolongs hospital length of stay.

    “The results of this study suggest that patients at an advanced age and those with a history of neurodegenerative disease or dementia are at increased risk for confusion, which complicates and prolongs hospital length of stay.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Perioperative use of regional anesthesia independently reduced the severity and duration of delirium, and preoperative administration was more effective than postoperative administration.

    “The authors also concluded that perioperative use of regional anesthesia independently reduced the severity and duration of delirium and that preoperative administration was more effective than postoperative administration.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] 12. Abou-Setta AM, Beaupre LA, Rashiq S, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med 2011;155 (4):234-45. source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Early identification of confusion through routine delirium screening would allow for hospital-based delirium prevention approaches that could be implemented in the ED.

    “Early identification of confusion through routine delirium screening would allow for hospital-based delirium prevention approaches, which could be implemented in the ED.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Many studies, including those in the systematic review by Oh et al., demonstrate the feasibility of preoperative cognitive testing in the ED setting.

    “However, many studies, including those in the systematic review by Oh et al., demonstrate the feasibility of preoperative cognitive testing in the ED setting.16”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] 16. Oh ES, Sieber FE, Leoutsakos J, et al. Sex differences in hip fracture surgery: preoperative risk factors for delirium and postoperative outcomes. J Am Geriatr Soc 2016;64:1616-21.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Baseline cognitive impairment is an important risk factor for postoperative delirium, but cognitive assessment is not routinely conducted prior to emergency hip fracture repair.

    “Although baseline cognitive impairment is an important risk factor for postoperative delirium, cognitive assessment is not routinely conducted prior to emergency hip fracture repair.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] 16. Oh ES, Sieber FE, Leoutsakos J, et al. Sex differences in hip fracture surgery: preoperative risk factors for delirium and postoperative outcomes. J Am Geriatr Soc 2016;64:1616-21.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

23 of 23

  • The authors state this as an assumption.

    Pain management for ED hip fracture patients has not changed since 2014–2015.

    “The data included in this study are from 2014 to 2015, but we do not believe that the pain management for ED hip fracture patients has changed.”

  • The paper relies on this without support.

    The association between absence of analgesia in the ED and delirium reflects a causal effect of analgesia on delirium risk.

    “Our findings indicate that appropriate pain management in the ED, through the use of opioid medications or regional anesthesia, may reduce the risk of in-hospital delirium for patients diagnosed with a hip fracture.”

  • The paper relies on this without support.

    The observed association between ED analgesia and delirium is not confounded by inpatient variables such as surgery.

    “The impact of ED management may have been confounded by inpatient variables, including the surgery; however, our interest was in establishing the impact of analgesia provided during the ED stay.”
3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Operating-room time difference has the opposite sign

    Minor

    Subtracting the second reported median from the first gives −0.1 hours, whereas the stated difference is +0.1 hours.

    Reported 0.1 · recomputed -0.1

1 of 1

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Authors
Thompson, C., Brienza, V. J. M., Sandre, A., Caine, S., Borgundvaag, B., & McLeod, S.
Affiliations
University of Toronto (CA)
Corresponding author
McLeod, Shelley
ORCID
Venue
CJEM
Publisher
Springer Science and Business Media LLC
Published
2018-09-11
Volume
20
Issue
6
Pages
911-919
ISSN
  • 1481-8035 (ISSN-L)
  • 1481-8043
DOI
10.1017/cem.2018.427
OpenAlex
W2616012442
Cited by
21
References
17
Citations by year
2026: 1 · 2025: 2 · 2024: 3 · 2023: 3 · 2022: 3 · 2021: 3 · 2020: 3 · 2019: 2 · 2018: 1
FWCI
1.88
Type
journal article
Language
en
Open access
Licence
www.cambridge.org/core/terms (unspecified)
Locations
  • Canadian Journal of Emergency Medicine (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
  • Health Sciences › Medicine › Surgery › Hip and Femur Fractures
  • Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
Keywords
hip fracture, risk factors, emergency department, older adults, dementia, neurodegenerative diseases, analgesia, opioid analgesia, femoral nerve block, pain management, old age, delirium screening
MeSH terms
Acute Disease, Age Factors, Aged, Aged, 80 and over, Delirium, Emergency Service, Hospital, Female, Follow-Up Studies, Hip Fractures, Humans, Inpatients, Male, Ontario, Retrospective Studies, Triage, Incidence, Risk Assessment

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