Ontario Hip Fracture Program: A Toolkit to Improve Delirium, Dementia and Depression Management 

Janet McMullan
Project Manager
&
Rhona McGlasson
Project Director
Bone & Joint Health Network, Ontario 

It is estimated that 30,000 Canadians will suffer a hip fracture in the next year. Our treatment of these patients can and must be improved if we are to decrease the significant mortality, morbidity and loss of independence associated with this orthopaedic injury. Recent advances in hip fracture care have demonstrated that with standardized protocols to address the often neglected aspects of hip fracture care that occur outside the operating room, improvements in care can be initiated and sustained.

The Ontario Orthopaedic Expert Panel through the Bone and Joint Health Network continues to progress in its efforts to implement the provincial hip fracture model of care across Ontario through local hospital and regional Local Health Integration Networks initiatives. The model focuses on the provision of optimal care for patients using standardized care maps and improving patient flow through the system to achieve reduced surgery wait times of 48 hours or less, and new and earlier access at Day 5 postoperatively to inpatient rehabilitation for all medically stable patients regardless of cognitive impairment. Patients coming from the community have new access to the rehabilitation that they have previously been denied and for most patients, this means new opportunities to return home.

A hip fracture toolkit is being developed to support optimum practice using the new hip fracture model of care. Care maps for acute care, inpatient rehabilitation and community care have been developed. These include an important focus on specific interventions in the prevention, screening and management of cognitive impairments that may be exhibited as delirium, an existing dementia and/or complicated by depression. Management of these challenging issues in hip fracture care requires a multidisciplinary approach that is based on appropriate knowledge and skills. Care needs to include targeted nursing and rehabilitation interventions to assess and treat cognitive issues on a daily basis, and in severe cases, pharmacological management through either the surgeon or another physician.

Effective 3D Management and Hip Fracture Care
Delirium, dementia and depression (the 3D's) are significant issues for hip fracture patients who are often older people where by their complex and multi-faceted nature contribute to these conditions being unrecognized, occurring frequently, and often being poorly managed. The 3D's are often considered together since it is difficult to recognize the differences between them, and many of the symptoms and behaviours may occur together. They are thought to significantly influence rehabilitation gains and are known to affect length of stay in hospital and discharge disposition. Below are some facts about the 3D's and how their management is significant to optimum care for hip fracture patients.

Facts about the 3D's and Hip Fracture Care
Delirium

• Occurs in 65% of cases and is frequently underappreciated in its clinical consequences¹.
• Contributes to mortality, functional decline, length of hospital stay and early placement into long-term care^2,3,4 .
• Prevention and management through a comprehensive standardized protocol can reduce delirium in one-third and severe delirium in one-half of cases⁴.

Dementia

• Occurs frequently amongst patients that come from community living situations (17% of patients), and many are diagnosed after admission to hospital⁵.
• Leading risk factor for delirium, and is underlying in two thirds of delirium cases².
• Significant factor for patients seeking rehabilitation as managing the cognitive and behavioral symptoms of dementia is perceived to influence health care professionals' abilities to effectively deliver care^6,7.
• Relational and environmental approaches are effective in influencing and modifying cognitive and behavioural issues, and health care professionals can successfully care for these patients after learning these knowledge and skills⁸.

Depression

• Depression occurs in 10-30% of hospitalized older persons and is frequently mis-diagnosed, under-diagnosed and missed all together^9,10. This can slow the recovery process¹¹.
• Symptoms of depression amongst older persons are unique with complaints that focus on somatic rather than physical symptoms. Since patients often demonstrate an inability to concentrate, they can present as if they have memory impairment or cognitive dysfunction¹².
• Early detection through screening is important to differentiate depression from cognitive decline through delirium and dementia. Appropriate management of depression can lead to improved clinical outcomes and shorter lengths of stay^13,14.

BJHN Hip Fracture Toolkit for the 3D's
The BJHN hip fracture toolkit for delirium, dementia and depression has been developed to provide information for health care professionals about the prevention, screening and management of these challenging and complex cognitive issues. Specific resources were built with input from the Regional Geriatric Program of Ontario and include:

• Overview of geriatric assessment tools including the Confusion Assessment Method (CAM), Mini Mental Status Exam (MMSE), and Geriatric Depression Scale (GDS).
• Delirium protocols with comprehensive approaches to address patient needs for orientation, fluid enhancement, mobility enhancement, vision and hearing aids, non-pharmacological sleep enhancement.
• Delirium algorithms to support referral to geriatrics when appropriate.
• Education tools to train health care professionals to have the knowledge to effectively manage the 3D's i.e. 3D's Assessment Tools; Delirium Management, and Behavioral Symptom Management.

The hip fracture is a common and catastrophic event that frequently occurs amongst older people, and for many, may impact their future independence and ability to live at home. For older patients with a hip fracture, the 3D's becomes a common issue that requires comprehensive and optimal practice to prevent complications and improve outcomes. The BJHN hip fracture tool kit is bringing forward information and resources for health care professionals to use and improve their practice surrounding 3D management to limit patient complications and improve outcomes.   

If you have any questions about the Bone and Joint Health Network or would like to receive information on any our resource materials please feel free to contact Dr. James Waddell, Chair of the Orthopaedic Expert Panel, at This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; or at the Bone and Joint Health Network, Rhona McGlasson, Project Director at This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; or Janet McMullan, Project Manager for the Hip Fracture Initiative at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Gleason, O.: Delirium. Am. Fam. Physic. 2003;67(5):1027-1034.
2. Innouye, S.K., Rushing, J.T., Foreman, M.D., et al: Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J. of Gen. Int. Med. 1998;13(4):234-242.
3. Foreman, M.D., Wakefield, B., Culp, K., et al: Delirium in elderly patients: an overview of the state of the science. J. of Gerontol. Nursing. 2001;27(4):12-20.
4. Marcantonio, E.R., Flacker, J.M., Wright R.J., et al: Reducing delirium after hip fracture: a randomized trial. J. Am. Geriontol. Soc. 2001;49;516-522.
5. Wiktorowicz, M.E., Goeree, R., Papaioannou, A., et al: Economic implications of hip fracture: health service use, institutional care and cost in Canada. Osteop. Int. 2001;12:271-278.
6. McGilton K., Wells J., Teare G., et al: Rehabilitating patients with dementia who have had a hip fracture part II: cognitive symptoms that influence care. Topics in Geriatri. Rehab. 2007;223(2):174-182.
7. McGilton K., Wells J., Teare G., et al: Rehabilitating patients with dementia who have had a hip fracture part I: behavioral symptoms that influence care. Topics in Geriatri. Rehab. 2007;223(2):161-173.
8. Mahomed, N., Flannery, J., McGlasson, R., et al: An Integrated Model of Care for Patients with a Hip Fracture. 2008. Available at: http://www.totaljointnetwork.org.
9. Koenig, H., George, L., Peterson B.L.: Depression in medially ill hospitalized older adults: prevalence, characteristics and course of symptoms. Am. J. of Psych. 1997;154: 1376-1383.
10. Harman, J.S., Reynolds, C.F.: Removing the barriers to effective depression treatment in old age. J. Am. Geriatr. Soc. 2000;48(8);871-878.
11. Kane, R.L., Ouslander, J.G., & Abrass, I.B.: Essentials of clinical geriatrics. (3 ed.) New York: McGraw-Hill, 1994.
12. Katz, I.: On the inseparability of mental and physical health in aged persons: Lessons from depression and medical comorbidity. Am. J. of Geriatri. Psych. 1996;4(1):1-16.
13. Costa, P.T. Jr., Williams, T.F., Somerfield, M., et al.: Recognition and initial assessment of Alzheimer's disease and related dementias. In Clinical practice guideline No. 19. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Policy and Research, 1996.
14. Scottish Intercollegiate Guidelines Network. Interventions in the management of behavioral and psychological aspects of dementia. Scottish Intercollegiate Guidelines Network. 1998. Available at: http://www.show.nhs.uk/sign/home.htm