Age and Ageing 2000; 29: 537±546
#
2000, British Geriatrics Society
SYSTEMATIC REVIEW
Psychiatric illness in hip fracture J OHN D. H OLMES, A LLAN O. H OUSE Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK Address correspondence to: J. D. Holmes. Fax: (q44) 113 243 3719. Email:
[email protected]
Abstract Objective: to review the literature on the prevalence and effect on outcome of psychiatric illness in older people with hip fracture. Methods: searching of medical databases and bibliographies to identify relevant studies. Application of predetermined quality criteria for prevalence and outcome studies. Results: 19 studies met criteria for a prevalence study. Rates of psychiatric illness varied, with depression in 9±47%, delirium in 43±61% and unspeci®ed cognitive impairment in 31±88%. Four studies met criteria for an outcome study. Psychiatric illness resulted in increased mortality and dependence and decreased activities of daily living skills. No individual study examined the prevalences and effect on outcome of depression, delirium and dementia separately. Conclusions: depression, delirium and dementia are common in older people with hip fracture. Further research is required to examine the effect on outcome of psychiatric illness, and the effect of psychiatric interventions in this setting. Keywords: cognitive impairment, dementia, delirium, hip fracture, psychiatric illness
Introduction
Method
Hip fracture in older people results in increased mortality [1], and impaired quality of life and persistent physical morbidity are common [2]. It is associated with high rates of re-admission and institutionalization after surgery [3, 4]. In addition, there is much carer burden [5, 6], and a ®nancial burden: the estimated cost to the National Health Service was £12 000 per hip fracture in 1996 [7] and the cost per case is increasing [8]. The exponential increase in hip fracture incidence with increasing age [9] in an ageing population [10] will have two consequences. First, there will be an increase in hip-fracture-related admissions to hospital. Secondly, there will be a shift towards an older and frailer patient population with more co-morbid conditions. In common with other general hospital populations, the elderly hip fracture population has high reported rates of psychiatric illness, and some studies suggest an adverse effect on several important outcomes. If this is so, then psychiatric intervention may improve these outcomes. In this review, we critically appraise the literature related to the prevalence and impact of psychiatric illness in the elderly hip fracture population.
We identi®ed potential studies for inclusion in the review by a search of the Medline, CINAHL, Psychlit and Embase databases to October 1999 using a search strategy (details available from the authors) designed to identify English-language publications concerning the diagnosis, prevalence or outcome of psychiatric illness in the elderly hip fracture population. We examined abstracts of the papers and obtained and appraised papers that appeared relevant. We obtained and appraised any papers for which the databases did not include an abstract. We also read bibliographies to identify further studies of possible value. Prevalence
We included studies in the review of prevalence if they met the following predetermined quality criteria: examination of subjects with hip fracture; prospective cohort assembly; recruitment of at least 40% of the potential sample; assessment within 2 weeks of the fracture; use of a standardized and validated case-de®ning instrument; and presentation of original research ®ndings.
537
J. D. Holmes, A. O. House Exclusion criteria were: aetiological population or case±control studies; a sample not representative of the general elderly population (such as current inpatients or sufferers of dementia); studies measuring but not reporting prevalence; case series with less than 10 subjects; and non-systematic reviews. We applied inclusion and exclusion criteria in a hierarchical manner. We extracted the following data from included prevalence studies: the location of the study, sample size and proportion of the potential sample recruited, mean age of the sample, signi®cant study exclusions, psychiatric case-®nding instruments used, and the prevalence of psychiatric illness reported. Outcome
We included studies in the review if they satis®ed the following predetermined quality criteria for outcome studies: clearly de®ned outcomes, consideration of appropriate confounding factors and use of multivariate or survival analysis. We extracted the following data from included outcome studies: the psychiatric diagnosis considered, confounding factors measured and the effect on reported outcome measures.
unspeci®ed cognitive impairment in 31±88%. Prevalences of other psychiatric illnesses were not usually examined. Outcome
Of the 21 studies identi®ed as being of potential importance to the review of outcome, we excluded 17 for the following reasons: one used psychiatric symptoms as the only outcome measure [37]; ®ve did not measure potential confounding factors [73±77]; 10 did not use appropriate statistical techniques [6, 62, 65, 78±84]; and two described intervention studies which did not provide outcome data for individual diagnostic groups [85, 86]. This left four studies satisfying criteria for an outcome study, all of which were also satisfactory prevalence studies. Details and ®ndings of these studies are shown in Table 4. Some studies did not report important outcomes such as mortality. It is not apparent whether this is because such outcomes were not measured, or because statistically insigni®cant results were not reported. The absence of ®gures such as odds ratios with con®dence intervals for several outcomes makes it dif®cult to judge whether the lack of signi®cance for these outcomes is a true ®nding or a type-two statistical error.
Results Prevalence
The literature search revealed 83 studies of potential importance to the review of prevalence. Of these, we excluded 64 for the following reasons. One study examined carers of those with hip fracture [11]; 12 used retrospective methods [12±23], eight described an unrepresentative sample [24±31] and six had recruitment rates of -40% [32±37]; in eight studies participants were not seen at the time of fracture [4, 38±44] and in 15 studies non-standardized or unvalidated case-de®ning instruments were used [45±59]. We excluded three aetiological or case±control studies [60±62], four studies that did not report prevalences [6, 63±65], one small case series [66], one combination of previously published works [67] and ®ve non-systematic reviews [68±72]. Details and ®ndings of the remaining 19 studies are shown in Tables 1±3, where studies are arranged in order of increasing sample size. All studies recruited consecutive admissions and excluded patients with severe physical illness and communication problems due to deafness or dysphasia. Exclusions speci®c to particular studies are indicated in the tables. Some studies reported on only one psychiatric condition, whereas others use casedetermining instruments able to detect a range of psychiatric illnesses. Prevalence rates of psychiatric illness varied considerably, with depression in 9±47%, delirium in 43±61% and
538
Discussion The rates of psychiatric illness we report in this review are much higher than those observed in the community [87, 88]. The four outcome studies that met de®ned criteria reported increased dependence, decreased activities of daily living skills and higher mortality associated with psychopathology. The variation in prevalences reported may have several causes. The exclusion of institutionalized people could result in under-representation of dementia and delirium, since institutionalized elderly populations have high rates of dementia [89], and dementia predisposes to delirium [90]. Several case-de®ning instruments are used, and the timing and frequency of assessments will affect the detection of ¯uctuating conditions such as delirium. Depressive symptoms may alter with pain or distress. There is often no differentiation between dementia and delirium, conditions with markedly different aetiology, management and prognosis. Too many studies examine the prevalence of individual psychiatric diagnoses in isolation, so that, for example, the cognitive impairment seen in depression is reported as being due to dementia or delirium. This concentration on only one psychiatric diagnosis also makes it dif®cult to interpret outcome studies, since depression, delirium and dementia may each act as confounding factors for important outcomes. What do these ®ndings imply for the delivery of health care to this population? Since prevalences are
Table 1. Prevalence of depression in elderly hip fracture patientsa % of potential sample
Mean age (years)
Exclusions
Case-®nding instrument
Prevalence (%)
Comment
24
N/A
N/A
±
DSM-III
38
Anxiety in 29%
UK
50
100
80
-60 years
BAS
26
±
USA
50
94
80
±
28
UK
50
96
81
±
GHQ, ZSRDS, DSM-III GMS
16
Dual diagnosis of depression in over half ±
USA
69
56
78
MMSE -21
GDS-30
47
USA
139
68
N/A
±
GDS-30, DSM-IIIR
UK
270
80
81
±
GDS-15
33
USA
424
49
N/A
Severe dementia, institutionalized
CES-D
32
Author(s)
Country
Levitan & Kornfeld, 1981 [86] Shamash et al., 1992 [81] Billig et al., 1986 [80] Holmes, 1996 [74] Lyons et al., 1989 [94] Strain et al., 1991 [85] Shepherd & Prescott, 1996 [92] Magaziner et al., 1990 [95]
USA
n
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Prevalence 93% if 10/11 cut-off used Includes adjustment disorders
N/A, not available; MMSE, Mini-Mental State Examination; DSM-III(R), Diagnostic and Statistical Manual, third version (revised); BAS, Brief Assessment Schedule; GHQ, General Health Questionnaire; ZSRSD, Zung Self Rating Scale for Depression; GMS, Geriatric Mental State; GDS, Geriatric Depression Scale; CES-D, Center for Epidemiological Survey Depression Subscale. a Studies arranged in order of increasing sample size.
539
Psychiatric illness in hip fracture
Approximate prevalence derived from bar chart Larger study but only 49% given CES-D
% of potential sample
n
Mean age (years)
Author(s)
Country
Gardner, 1984 [84] Levitan & Kornfeld, 1981 [86] Milisen et al., 1998 [83] Shamash et al., 1992 [81] Billig et al., 1986 [80] Holmes, 1996 [74] Williams et al., 1985 [73] Lyons et al., 1989 [94] de Jaeger et al., 1994 [96] Strain et al., 1991 [85] Williams et al., 1985 [97] Stromberg et al., 1997 [82] Shepherd & Prescott, 1996 [92] Withey et al., 1995 [99] Magaziner et al., 1990 [95] Parker & Palmer, 1993 [100]
Australia
12
60
USA
24
N/A
N/A
Belgium
26
N/A
79
UK
50
100
USA
50
UK
Exclusions
Case-®nding instrument
Prevalence (%)
Comment
MMSE
25
Post-operative assessment
DSM-III
42
±
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
74
MMSE -27, -60 years ±
MMSE
66
Four assessments in total
80
Dementia, depression -60 years
BAS
42
±
94
80
±
MMSE
40
50
96
81
±
GMS, MMSE
42
Dual diagnosis of depression in nearly half ±
USA
57
N/A
N/A
±
SPMSQ
44
±
USA
102
83
78
±
MMSE
31
MMSE cut-off 20/21
France
120
N/A
N/A
Institutionalized
MMSE
88
Letter with little detail given
USA
139
68
N/A
±
MMSE
54
±
USA
237
N/A
N/A
SPMSQ
52
Sweden
243
N/A
81
SPMSQ
46
Four hospitals and 3 cohorts combined Same cohort as [98]
UK
270
80
81
-60 years, severe dementia Severe dementia, institutionalized ±
AMTS
33
UK
375
87
80
-60 years
MMSE
58
USA
424
49
N/A
MMSE
44
UK
882
N/A
N/A
Severe dementia, institutionalized ±
AMTS
35
Approximate prevalence derived from bar chart Cut-off 21/22 Larger study but only 49% had MMSE ±
N/A, not available; MMSE, Mini-Mental State Examination; DSM-III(R), Diagnostic and Statistical Manual, third version (revised); BAS, Brief Assessment Schedule; GMS, Geriatric Mental State; SPMSQ, Short Portable Mental Status Questionnaire; AMTS, Abbreviated Mental Test Score. a Studies arranged in order of increasing sample size.
J. D. Holmes, A. O. House
540 Table 2. The prevalence of unspeci®ed cognitive impairment in elderly hip fracture patientsa
Table 3. The prevalence of delirium in elderly hip fracture patientsa % of potential sample
Mean age (years)
17
N/A
80
Sweden
35
67
Sweden
57
Sweden
111
Author(s)
Country
Bowman, 1997 [77] Brannstrom et al., 1989 [78]
Canada
n
Exclusions
Case-®nding instrument
Prevalence (%)
Comment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Berggren et al., 1987 [75] Gustafson et al., 1988 [101]
DSM-III
47
Several assessments made
78
Dementia, MMSE -24 ±
OBSS, DSM-IIIR
43
N/A
N/A
Not fully lucid
OBSS, DSM-IIIR
44
N/A
79
±
OBSS, DSM-IIIR
61
Several assessments made; study of nursing problems encountered with delirious patients Several assessments made; trial of anaesthetic regimes Several assessments made 33% prior to surgery, 28% post-surgery; dementia in 15%
541
Psychiatric illness in hip fracture
N/A, not available; MMSE, Mini-Mental State Examination; DSM-III(R), Diagnostic and Statistical Manual, third version (revised); OBSS, Organic Brain Syndrome Scale. a Studies arranged in order of increasing sample size.
Author(s)
n
Magaziner et al., 1990 [95]
424
Psychiatric diagnosis
Confounding factors
Outcome (at 1 year)
Comment
Age, sex, severity of physical illness, dementia, poor sight, fracture type, social support
Walking ability decreased, physical dependence increased, instrumental dependence increased
No OR or relative risks given so dif®cult to determine effect size; depression not included; mortality either not included or not analysed No OR or relative risks given so dif®cult to determine effect size; cognitive impairment not included; mortality either not included or not analysed
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cognitive impairment Depression
Physical dependence signi®cantly increased
Withey et al., 1995 [99]
375
Cognitive impairment
Age, sex, severity of physical illness, fracture type, surgeon grade, anaesthetist grade, pre-fracture ADL, medication
Increased mortality OR [2.33 (95% CI 1.32±4.00)]; poor activities of daily living 3 months post-fracture OR [5.51 (95% CI 3.16±9.60)]
Depression not examined
Parker & Palmer, 1995 [102]
643
Cognitive impairment
Age, sex, severity of physical illness, living alone, mobility
Mortality increased, institutionalization increased
Parker & Palmer, 1993 [100]
882
Cognitive impairment
Mobility
Positive predictive value 0.54 for mortality
No OR or relative risks given so dif®cult to determine effect size; depression not examined Only one confounding variable considered; unusual statistical technique, depression not examined
OR, odds ratio; CI, con®dence interval.
J. D. Holmes, A. O. House
542 Table 4. Effect of psychiatric illness on outcome in elderly hip fracture patients
Psychiatric illness in hip fracture high, and there is some evidence of adverse effects on outcomes, screening for psychiatric illness in hospitalized older people with hip fracture has been recommended [91]. Screening is well tolerated [92], but unfortunately does not often take place. Failure to identify cases [67] means that treatment opportunities are missed. Even where psychiatric illness is recognized, lack of knowledge about behavioural, environmental and pharmacological management strategies may result in sub-optimal or inappropriate treatment, which may consequently delay rehabilitation. Research into service models in this area has concentrated on collaboration between orthopaedic surgeons and geriatricians, and is inconclusive [93]. Despite the high levels of psychiatric morbidity in the elderly hip fracture population, the routine delivery of psychiatric care by psychiatric staff in the orthopaedic setting is rare. The main problem is the lack of well-described, reproducible models of psychiatric intervention that are proven in this setting. We detected only two psychiatric interventions in this review: one was a service description, and the other was a screen±treat intervention that suggested bene®t, including cost-bene®t, but had an unde®ned intervention [85]. Several service models are applicable to the management of psychiatric illness in hip fracture. The reactive consultation model adopted by most UK old-age psychiatry services results in low rates of detection, referral and review, and thus does not adequately meet psychiatric care needs. Nor can these needs be met in a psychiatric setting because of the high levels of physical dependency and illness encountered. A proactive, liaison psychiatry model could incorporate routine screening for psychiatric illness together with protocol-driven investigation and psychological, social, environmental and pharmacological treatment strategies where such illness is detected. Such a model would entail psychiatric staff becoming part of the interdisciplinary team delivering care in the general hospital. Our ®ndings point to the need for further research in this important area. For outcome studies, attention must be paid to methodological issues. In particular, confounding must be adequately controlled for, and depression, delirium and dementia should each be examined as a risk factor. If the case for psychiatric intervention is established, service models incorporating psychiatric care delivery in orthopaedic settings should be evaluated as a priority. This will provide us with evidence for new models of multidisciplinary working in the general hospital that are designed to meet the complex physical and psychiatric care needs of this disadvantaged population.
Key points
. Psychiatric illness is common after hip fracture. . The evidence for adverse effects on outcome is poor.
. Treatable psychiatric conditions may be unrecognized
or inappropriately managed.
. Psychiatric interventions may be bene®cial in ortho-
paedic wards.
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