Use of direct-acting anticoagulants (DOACs) delays surgery and is associated with increased mortality in hip fracture patients.

PURPOSE: Treatment with direct-acting oral anticoagulants (DOACs) is increasing among hip-fracture patients, with accompanying safety concerns regarding spinal anesthesia (SA). The aim of this study was to investigate if DOAC use is associated with increased waiting time before surgery, increased mortality, or other adverse events. METHODS: Registry data on surgically treated hip-fracture cases at a single hospital between 2015 and 2021 were analyzed. Multivariable regression analyses were performed with DOAC-status and choice of anesthesia as exposures, and waiting time, length of stay, transfusion, and mortality as outcomes. RESULTS: 2885 cases were included, 467 patients (16%) were using DOACs. DOAC users were older (86.3 vs. 82.2 years, p < 0.001), had a higher Charlson Comorbidity Index (2.1 vs. 1.5, p < 0.001) and had longer median time to surgery than non-DOAC cases (36 h vs 17 h, p < 0.001). General anesthesia (GA) was used in 19.3% of DOAC patients and in 3.0% of non-DOAC patients. DOAC-patients had an increased risk of one-month mortality (Adjusted Odds Ratio (AOR) 1.6 (1.1-2.3)) and one-year mortality (AOR 1.4 (1.1-1.8)). There were no differences in risk of blood transfusion. Patients on DOAC operated under GA had a lower risk of one-year mortality (AOR 0.5 (0.3-0.9)), but a similar one-month mortality to DOAC-patients operated under SA. CONCLUSION: DOAC users had a longer waiting time to surgery, indicating postponement of surgery due to concerns of the safety of SA. The clinical practice should be changed to allow earlier surgery for DOAC patients.

Validation of orthopaedic surgeons' assessment of cognitive function in patients with acute hip fracture.

BACKGROUND: About one fourth of patients with hip fracture have cognitive impairment. These patients are at higher risk of surgical and medical complications and are often excluded from participating in clinical research. The aim of the present study was to investigate orthopaedic surgeons' ability to determine the cognitive status of patients with acute hip fracture and to compare the treatment given to patients with and without cognitive impairment. METHODS: The cognitive function of 1474 hip fracture patients reported by the orthopaedic surgeons to the nationwide Norwegian Hip Fracture Register was compared with data registered in quality databases in two hospitals with orthogeriatric service on the same patients. Cognitive function registered in the quality databases was determined either by the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or by pre-fracture diagnosis of dementia. The information registered in the quality databases was defined as the reference standard. Cognitive function in the Norwegian Hip Fracture Register was reported as: Chronic cognitive impairment? "Yes", "Uncertain" or "No" by the orthopaedic surgeons. Sensitivity, specificity, negative and positive predictive values for chronic cognitive impairment reported to the Norwegian Hip Fracture Register by the orthopaedic surgeons was calculated. Baseline data and treatment of hip fractures in patients with and without cognitive impairment in the Norwegian Hip Fracture Register were compared. RESULTS: Orthopaedic surgeons reported chronic cognitive impairment in 31% of the patients. Using documented dementia or IQCODE > 4.0 as the reference, this assessment of cognitive impairment by the orthopaedic surgeons had a sensitivity of 69%, a specificity of 90%, a positive predictive value of 78%, and a negative predictive value of 84% compared to information registered in the two hospital quality databases. There were no differences in type of hip fracture or type of surgical treatment by cognitive function. CONCLUSION: The treatment of hip fractures was similar in patients with chronic cognitive impairment and cognitively well-functioning patients. The surgeons had an acceptable ability to identify and report chronic cognitive impairment in the peri-operative period, indicating that the Norwegian Hip Fracture Register is a valuable resource for future registry-based research also on hip fracture patients with chronic cognitive impairment.

Psychotropics and weak opioid analgesics in plasma samples of older hip fracture patients - detection frequencies and consistency with drug records.

AIMS: To determine use of psychotropic drugs and weak opioids in hip fracture patients by analysing plasma samples at admission, and compare detected drug frequencies with prescription registry data and drug records. METHODS: Plasma from 250 hip fracture patients aged ≥65 years sampled at hospital admission were analysed by ultra-performance liquid chromatography-tandem mass spectrometry methods for detection of psychotropic drugs and weak opioid analgesics (alcohol also determined). Odds ratios for drugs detected in plasma of hip fracture patients vs. prescription frequencies of the same drugs in an age-, time- and region-matched reference population were calculated. Moreover, recorded and measured drugs were compared. RESULTS: Psychotropic drugs and/or weak opioid analgesics were detected in 158 (63%) of the patients (median age 84 years; 76% females), while alcohol was found in 19 patients (7.6%). The occurrence of diazepam (odds ratio 1.6; 95% confidence interval 1.1-2.4), nitrazepam (2.3; 1.3-4.1), selective serotonin reuptake inhibitors (1.9; 1.3-2.9) and mirtazapine (2.3; 1.2-4.3) was significantly higher in plasma samples of hip fracture patients than in prescription data from the reference population. Poor consistency between recorded and measured drugs was disclosed for z-hypnotics and benzodiazepines; e.g. diazepam was detected in 29 (11.6%), but only recorded in six (2.4%) of the patients. CONCLUSIONS: Plasma analysis shows that use of antidepressants and benzodiazepines in hip fracture patients is significantly more frequent than respective prescription frequencies in the general elderly population. Moreover, consistency between recorded and actual use of psychotropic fall-risk drugs is poor at hospital admission of hip fracture patients.

A restrictive policy for red blood cell transfusion in older hip fracture patients: experiences from a patient register.

BACKGROUND: Allogeneic red blood cell transfusions (ABT) are common in older hip fracture patients. Recent research supports a restrictive transfusion policy. The aim was to study variation in hemoglobin (Hb) concentration, and clinical outcomes in these patients. RESULTS: Cross-sectional study with one-year follow-up in an orthogeriatric unit. Data were obtained from a quality register with demographic and medical information collected by an interdisciplinary team. 106 (22 %) of the 491 patients admitted from September 2011 throughout September 2012 (76 % women, mean age 85 years) received ABT. When given ABT, 80 % had Hb <80 g/l and mean Hb was 78 g/l. Mean Hb, regardless ABT, showed variation from 125 g/l (±16) on admission to 106 g/l (±17), 101 g/l (±16) and 102 g/l (±14) on 1st, 3rd and 5th postoperative day respectively. Patients with per-/subtrochanteric fractures more often received ABT than those with femur neck fractures (p < 0.001), 70 % of the patients receiving ABT had a per-/subtrochanteric fracture. Patients who received ABT were older, had more chronic diseases and lower mean Hb throughout the hospital stay. Length of stay was longer (median 7 vs. 6 days, p = 0.01), and medical complications more common. In-hospital and 30-day mortalities were similar in patients given ABT and in those who were not, but 1-year mortality was higher among patients who were given ABT (p = 0.008). CONCLUSIONS: Hb had a tendency to fall during the three first days after surgery and seemed to be stabilized on day 5. Patients who received ABT had poorer health, but not significantly higher short-term mortality. This study demonstrates a restrictive transfusion policy.

Use of warfarin is associated with delay in surgery for hip fracture in older patients.

INTRODUCTION: Delay in surgery for hip fractures in older patients may affect mortality and the risk of delirium. Delay in surgery may occur as a result of several factors. It has not been established whether certain patient-related factors, such as a high international normalized ratio (INR) caused by warfarin treatment is associated with delay in surgery. The aim of this study was to explore the associations between warfarin treatment, INR, and time from admission to surgery. METHODS: This is an observational study based on data from a database of all hip fracture patients aged ≥ 65 years who were admitted to an orthogeriatric unit. The database included data from 1192 consecutive patients admitted from January 2007 to April 2010. Data were collected during routine work. Use of warfarin, patient characteristics, medical complications, length of stay, and time from admission to surgery were registered from the patients' records, and INR at admission in warfarin users. RESULTS: Warfarin was used by 117 (9.8%) patients at admission, which included more men (n = 42; 14.4%) than women (n = 75; 8.3%) (P = 0.003). The mean age was 85 years, with no difference between users and nonusers. Warfarin users had more comorbid diseases (mean, 2.1 vs 1.8; P = 0.003), poorer health status (American Society of Anesthesiologists score of 3-5 in 77.8% vs 51.0%), and longer waiting time for surgery compared with nonusers (mean, 23 vs 12 hours; P < 0.001). There was no difference in need for blood transfusions (28.2% of users compared with 25.3% of nonusers; P = 0.49). Length of stay was longer among warfarin users compared with nonusers (mean, 14.6 vs 11.7 days; P = 0.002). Warfarin users with an INR of ≥ 2 had a longer waiting time than those with an INR of < 2, but they had a longer waiting time than nonusers. CONCLUSION: Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.

Predictors of mortality in older hip fracture inpatients admitted to an orthogeriatric unit in oslo, norway.

OBJECTIVES: To identify to which degree patient-related factors (age, gender, place of residence, general health condition, comorbidity) and hospital-related factors (waiting time for surgery, type of surgery, in-hospital complications, length of stay) may predict 1-year mortality in elderly hip fracture patients in an orthogeriatric unit, to optimize treatment and care. METHOD: In-hospital patient information was routinely collected by multidisciplinary staff and entered into a database. Information about mortality was obtained for 567 patients aged 65 and above. Multivariate logistic regression was performed. RESULTS: Overall mortality was 23.5%, but there was a large variation in mortality according to age, gender, comorbidity, and place of residence. Independent predictors of mortality were admittance from nursing home (risk ratio [RR] = 3.24, 95% confidence interval [CI] = 2.37-4.43 compared with home dwellers) and a higher American Society of Anesthesiologists (ASA) score (RR = 1.75 and 95% CI = 1.24-2.46, for ASA ≥ 3 compared with ASA ≤ 2). Male gender, increasing age, increasing number of comorbid conditions, and having fallen indoors were indicators, but not independent predictors, of higher mortality. DISCUSSION: Almost one fourth of older hip fracture patients in this unit died within a year. The most important predictor was admittance from nursing home, which was associated with comorbidity and frailty. More attention to patients from nursing homes is needed in the health care system.

Older hip fracture patients: three groups with different needs.

BACKGROUND: Norway, and particularly Oslo, has the highest reported incidence of hip fractures in the world. It is increasingly common to care for older hip fracture patients in orthogeriatric units where orthopaedic care is combined with interdisciplinary geriatric care. The characteristics and needs of older hip fracture patients are poorly described. The aim of this paper is to describe the characteristics of these patients in order to better understand their need for care and rehabilitation. METHODS: This is an observational study based on a quality register for all patients 65+ years in an orthogeriatric unit who are operated for a hip fracture. The unit covers 250,000 inhabitants in Oslo. Patient data were collected in the aim of quality control. The quality database includes demographic, medical, and functional data collected from routine assessment by the interdisciplinary team. RESULTS: From January 2007 to September 2009, 1010 patients, included 241 (24%) from long-term care institutions, were enrolled in the database. Mean age was 85.1 years (SD 7.1), 76% were female, and 83% had experienced an indoor fall. Chronic diseases were registered in 88%, and 38% of the community-dwelling patients had pre-fracture cognitive impairment defined as IQCODE-SF > 3.6. Complications were observed in 51% of the patients, of which the most common were a need for blood transfusion, delirium, and urinary tract infections. Post-operative orthopaedic infections were rare (3.1%). Patients from long-term care were older, (87 vs. 84 years, p < 0.001), more had American Society of Anaesthesiologists (ASA) score >/= 3 (67% vs. 48%, p < 0.001) and a higher number of chronic medical conditions (mean 2.2 vs. 1.6, p < 0.001). Among community-dwelling patients, those who had fallen indoors were older, more often female, had ASA score >/= 3, chronic medical conditions, impairment in pre-fracture ADL and cognitive function, and more complications during hospital stay. CONCLUSIONS: Older hip fracture patients in this orthogeriatric unit may be divided into three groups; patients who are relatively fit and have experienced outdoors falls (17%), frail community-dwelling patients who have fallen indoors (59%), and patients from long-term care institutions (24%). Different caring pathways are needed for these groups.