The last two decades have different models of orthogeriatric care been in use at Oslo University Hospital - Ullevaal.
1997 - 2002 HOBRUS: postoperative rehabilitation in the geriatric ward
This was the first model where the Department of Orthopedic Surgery and Department of Geriatric Medicine started to collaborate in the treatment of hip fracture patients. From the autumn 1997 was a model implemented where patients were transferred to the geriatric ward five days after surgery. A nurse was assigned to assess which patients were most likely to profit from such rehabilitation. This model was not scientifically evaluated, but in a report written for the hospital administration it is concluded that this model functioned satisfactory and that the quality of care had been improved. Total LOS in the hospital was reduced by 25 % after implementation of the model.
March 2004 - December 2006: “Eldre med brudd” (Kammerlander model 2)
“Eldre med brudd” (“Elderly with fractures”) was a project carried out in collaboration between Department of Orthopedic Surgery and Department of Geriatric Medicine. In this model, 10 beds in the orthopedic ward were reserved for elderly patients with fractures (not only hip fractures). A geriatric team (geriatrician, nurse and physiotherapist) assessed the patients daily, and had the day to day responsibility for the patients. The team was not available in the evenings or in the weekends. This is in line with a Kammerlander model 2.
This model was also not scientifically tested, but the conclusion from the health care personnel involved was that this model improved quality of care. It was, however, acknowledged as a problem that there was a geriatric service only at daytime. In the termination of the project the plan was to make a joint effort to establish a separate orthogeriatric unit with shared care (in line with Kammerlander model 4). Due to administrative challenges regarding financing, this was never achieved.
June 2008 - January 2012: Hip fracture patients in the acute geriatric ward (Kammerlander model 3)
In connection with a re-organization of the acute geriatric ward in 2008, it was decided that four beds should be reserved for hip fracture patients. The patients were admitted to the ward directly from the ER and the geriatricians had the primary medical responsibility for the patients the entire stay. This is in line with Kammerlander model 3. The allocation to the acute geriatric ward was based primarily on availability of beds. The new service had capacity to serve approximately half of the hip fractures admitted to the hospital, and it was thus decided to randomly allocate patients to the acute geriatric ward and the orthopedic ward in order to evaluate the new service in an RCT. The first patient was included in the RCT in September 2009, and this serve as the foundation for this PhD.
2 Aims of the study
Based on the knowledge gaps regarding delirium prognosis, delirium pathophysiology and the impact on delirium by different models of care, three main aims emerged for this thesis:
I. To investigate the effect of delirium on cognitive trajectories (paper I)
II. To evaluate the effect of the orthogeriatric model (Kammerlander model 3) in use at Oslo University hospital - Ullevaal from June 2008 to January 2012 (paper II)
3 Patients and methods
Participants
3.1
The patients came from four different patient samples (flowchart). For patients included in the RCT (paper II, sample 1), I had the daily responsibility for running the study and collecting data. I was also involved in planning and organization of the inclusion and data collection in sample 4. I have not been involved in collection or planning of sample 2 and sample 3. This chapter will describe the different patient samples. Most details will be given for sample 1.
Sample 1(Watne): 329 hip fracture patients were included between September 2009 and
January 2012 at Oslo University Hospital, Ullevaal. Inclusion and randomisation took place in the ER by the orthopaedic surgeon on call. Patients were randomised to treatment and care in an acute geriatric ward or standard orthopaedic ward. The patients had their entire hospital stay in the same ward except for surgery and a few hours in the postoperative care unit. The patients were assessed four and twelve months after surgery by research nurses blinded to allocation. The main objective of the study was to evaluate the orthogeriatric service in use at the hospital from June 2008 to January 2012. CSF was collected from 143 patients at the onset of anesthesia, and has been analyzed in order to investigate pathophysiological mechanisms in delirium.
Sample 2 (Juliebø/Krogseth): 364 hip fracture patients were included between September
2005 and December 2006 at Oslo University Hospital, Ullevaal and Diakonhjemmet Hospital in Oslo. A research team of two researchers and three study nurses performed daily reviews of the patient registries to identify patients with hip fracture. Eligible patients were included within 48 hours of admission. The main objective was to prospectively investigate the prevalence of pre- and postoperative delirium, and to identify important risk factors(Juliebo et al., 2009). One-hundred-seventy-four of the included patients were assessed six months after surgery by a physician (Maria Krogseth) blinded to delirium status, in order to explore the effect of delirium in patients with (paper I) and without prefracture cognitive
impairment(Krogseth et al., 2011).
Sample 3 (Hall): 108 hip fracture patients were included at the Royal Infirmary, Edinburgh,
Orthopedic Unit by a geriatrician (Roanna Hall). The patients were closely monitored for delirium during a two-week perioperative period, and assessed 3, 6 and 12 months after surgery. CSF was collected at the onset of anesthesia, and the main objective was to assess the role of cortisol and inflammation in delirium. The study design was similar to the RCT (Sample 1), with the same measurements of prefracture cognitive status (IQCODE) and delirium (CAM). Data from Oslo and Edinburgh could therefore be pooled (paper III and IV).
Sample 4 (Idland): 155 Patients above 65 years of age scheduled for elective orthopedic,
gynecologic or urologic surgery in spinal anesthesia were recruited at three different hospitals in Oslo between February 2012 and June 2013 (Oslo University Hospital - Aker, Oslo University Hospital - Ullevaal, Diakonhjemmet hospital). The patients were thoroughly cognitively tested some days before surgery and CSF was collected at the onset of spinal anesthesia. The patients will be followed up with cognitive tests once a year for five years. The main objective with this study was to collect serum and CSF from cognitively healthy elderly patients that can serve as a reference material for studies on delirium and dementia pathology.
The selection of patients in the different studies was as follow: