Impacto do delirium sobre mortalidade e desempenhos cognitivo e funcional em idosos com fratura de fêmur

OBJECTIVE: To evaluate the evolution of cognitive and functional performance and mortality among elderly patients who were delirious during hospitalization due to femoral fracture. STUDY TYPE: Prospective cohort. LOCATION: Orthopedics and Traumatology Institute of HC-FMUSP; geriatric orthopedic ward. PATIENTS: 103 patients, aged 60 years or over, who were hospitalized in the geriatric orthopedics ward with femoral fracture in 2001-2002. Thirty of them (29.1%) presented with delirium during their hospital stay and were compared with another 73 (70.9%) who did not present with delirium. There were six deaths, and 97 patients were discharged from the hospital. We obtained information on 85 of these patients four years after discharge; 42 patients were still alive and 43 had died at the time of the evaluation. METHODS: Data on vital status was obtained for 85 patients. For the 42 survivors, we acquired information on their basic activities of daily living (ADL), instrumental activities of daily living (IADL), and cognitive performance (BDRS) by means of telephone interview with the same caregivers who had provided information at the time of the hospitalization. We compared this data with that obtained during their hospitalizations four years prior. For the 43 patients who died, we obtained information regarding their deaths and used this data in the analysis of mortality. RESULTS: No relationships were observed between delirium and mortality, delirium and cognitive loss, or delirium and functional loss, after four years from discharge of elderly patients with hip fractures. An initial cognitive deficit was a predictor for mortality (RR = 2.54; p = 0.016), functional loss (OR = 1.80; p = 0.027) and cognitive loss (OR = 1.53; p = 0.024). Cognitive loss was also related to age. CONCLUSIONS: Delirium had no impact on mortality or functional or cognitive losses in long term evolution (2 years) among elderly patients with femoral fractures. An initial cognitive impairment may identify patients at risk of mortality, functional and cognitive losses over the long term evolution.OBJETIVO: Avaliar efeito do delirium na mortalidade e na evolução dos desempenhos cognitivo e funcional em idosos com fratura de fêmur, 4 anos após a alta hospitalar. ESTUDO: coorte, prospectivo. LOCAL: Instituto de Ortopedia e Traumatologia do HC-FMUSP; Enfermaria de Ortopedia Geriátrica. PACIENTES: 103 pacientes com 65 anos ou mais, consecutivos, internados em 2001-2002, na enfermaria de ortopedia geriátrica, por fratura de fêmur. 30 idosos (29,1%) apresentaram delirium durante a internação e foram comparados com os 73 que evoluíram sem delirium (30 casos x 73 controles). Houve 6 óbitos, 97 receberam alta hospitalar. O estudo atual mostra reavaliação de 85 desses pacientes. MÉTODOS: Dentre os 85 pacientes, temos 43 óbitos e 42 sobreviventes. Foram obtidos dados de atividades básicas de vida diária (ADL), atividades instrumentais de vida diária ( IADL), desempenho cognitivo (Blessed), referentes aos sobreviventes, através de entrevista telefônica com os mesmos cuidadores que forneceram as informações durante a internação . Comparamos esses dados com aqueles de 4 anos atrás (42 pacientes). Dos pacientes que foram a óbito, obtivemos data e causa de óbito. Dados referentes aos 85 pacientes entraram na análise de mortalidade. RESULTADOS: Não foram observadas relações entre delirium e mortalidade, delirium e perda cognitiva, delirium e perda funcional. Déficit cognitivo inicial foi preditor de mortalidade (RR= 2,54 ; p=0,016), perda funcional (OR=1,80; p=0,027) e perda cognitiva(OR=1,53; p=0,024). CONCLUSÕES: Delirium não teve impacto sobre mortalidade e perdas funcional e cognitiva na evolução tardia de idosos com fratura de fêmur. O déficit cognitivo inicial pode identificar pacientes em risco para mortalidade, perda funcional e perda cognitiva futuras em idosos com fratura de fêmur. A fragilidade e heterogeneidade da nossa amostra pode ter atenuado o poder preditor de mau prognóstico do delirium

Prognostic Factors for Mortality Among Patients Above the 6th Decade Undergoing Non-Cardiac Surgery: (Cares – Clinical Assessment and Research in Elderly Surgical Patients)

PURPOSE: To ascertain perioperative morbimortality and identify prognostic factors for mortality among patients >55 years who undergo non-cardiac surgery. METHODS: A retrospective cohort of 403 patients relating to perioperative morbidity-mortality. Data were collected from a standardized protocol on gender, age, comorbidities, medications used, smoking, alcohol abuse, chronic use of benzodiazepine, nutritional status, presence of anemia, activities of daily living, American Society of Anesthesiology classification, Detsky's modified cardiac risk index - American College of Physicians, renal function evaluation, pulmonary risk according to the Torrington scale, risk of thromboembolic events, presence of malignant disease and complementary examinations. RESULTS: The mean age of the subjects was 70.8 ± 8.1 years. The "very old" (>80 years) represented 14%. The mortality rate was 8.2%, and the complication rate was 15.8%. Multiple logistic regression showed that a history of coronary heart disease (OR: 3.75; p=0.02) and/or valvular heart disease (OR: 31.79; p=0.006) were predictors of mortality. The American Society of Anesthesiology classification was shown to be the best scale to mark risk (OR: 3.01; p=0.016). Nutritional status was a protective factor, in which serum albumin increases of 1 mg/dl decreased risk by 63%. DISCUSSION: The results indicate that serum albumin, coronary heart disease, valvular heart disease and the American Society of Anesthesiology classification could be prognostic predictors for aged patients in a perioperative setting. In this sample, provided that pulmonary, cardiac and thromboembolic risks were properly controlled, they did not constitute risk factors for mortality. Furthermore, continuous effort to learn more about the preoperative assessment of elderly patients could yield intervention possibilities and minimize morbimortality