Delirium in patients with hip fractures

Author: Tarandeep Oberai

Oberai, Tarandeep, 2024 Delirium in patients with hip fractures, Flinders University, College of Medicine and Public Health

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This thesis is designed to improve understanding, recognition, prevention and management of delirium in hospitalised older patients with hip fracture. Delirium is a preventable neuropsychiatric disorder characterized with acute confusion, disorientation, global cognitive deficit and is multifactorial. Delirium is considered one of the most common post-operative complication in patients with hip fracture. Research suggests that one third of delirium episodes are preventable if the identified factors can be addressed. Early recognition is also considered a key aspect of delirium prevention and management.

The thesis is divided in two parts. Part one sets to enhance our understanding of delirium in Australian and New Zealand population with hip fractures using data from Australia and New Zealand Hip Fracture Registry. We examined consequences and predictors of delirium within this population.

This thesis uses implementation research methodology. Part two focuses on development and implementation of the intervention bundle to reduce incidence of delirium through improved delirium recognition. The systematic review of the literature was performed to investigate the effect of multicomponent interventions on incidence of delirium. Focus groups with multidisciplinary clinicians from orthopaedic were performed to understand their perceptions in relation to recognition, diagnosis and management of delirium. The barriers identified in the focus groups and the best practice evidence identified in the systematic review was used to develop the intervention bundle to improve delirium recognition and care. In brief, the intervention bundle included; education, environmental restructuring, change champions, infographics and audit feedback reports. Prospective data was collected using Interrupted time series methodology to understand the efficacy of this delirium prevention bundle.

In the pre-intervention phase a gap in nurses’ knowledge of delirium was identified as one of the areas for improvement hence education was one of the key components of the intervention bundle. The three-step education intervention was offered as part of the intervention strategies based on the nationally recommended Delirium Care Guidelines from the Australian Commission of Safety and Quality. The pre-existing knowledge survey was used to test nurse’s knowledge delirium. The survey was developed by Researchers in Western Australia and had been used widely globally by other researchers for the same purpose. However, the psychometric properties had not been tested. We utilised the responses from the pre-intervention and post-intervention phase to validate the survey. Consequently, a shorter validated survey has been developed.

This thesis demonstrated that a well-considered intervention bundle only had a mixed impact on decreasing incidence of delirium. This project also highlighted the significance of aligning clinical service improvement goals with the wider goals of the organisation.

We have formed international research collaboration (Australia, Europe and United States) based on this project. We are exploring the concept of machine learning for preoperative prediction of postoperative delirium in patients with hip fractures.

Keywords: Hip, hip fracture, delirium, cognitive impairment, cognitive decline

Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2024
School: College of Medicine and Public Health
Supervisor: Ruurd Jaarsma