Delirium in Elderly Patients With Trauma of the Hip

Anesthesia Clinical Trial

— DEPTHip  

Official title:

A Multicenter Randomized Controlled Trial in Elderly Patients With Hip Fractures Comparing Continuous Fascia Iliaca Compartment Block to Systemic Opioids and Its Effect on Delirium Occurrence

Clinical Trial Details — Status: Terminated

Administrative data

• NCT number: NCT02689024
• Other study ID #: NL54580.018.15
• Secondary ID: 2015-003650-40
• Status: Terminated
• Phase: Phase 4
• Start date: May 2016
• Est. completion date: July 19, 2023

Study information

• Verified date: August 2023
• Source: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

A broken hip occurs frequently in elderly patients and is often very painful. Side effects of inadequately treated pain as well as the traditional drugs (administered through intravenous catheter) used to treat pain are, among others, a confusional state, called delirium. When pain medication is administered locally, only around the hip joint, pain might be treated more effectively and these side effects could be prevented. This is called a nerve block.

The current study evaluates the use of a continuous nerve block throughout the complete hospital admission with a catheter around the hip joint versus the use of traditionally used pain medication administered though an intravenous catheter in elderly patients with a broken hip. Half of all patients will receive the nerve block while in the emergency department and the other half will receive pain medication through the intravenous access.

Description:

BACKGROUND Hip fractures occur frequently and are usually very painful. Pain itself is an indicator for increased risk of complications. A significant complication is delirium, occurring in up to 25% of all elderly patients with hip fractures. For a large proportion, triggers for development of delirium reaches back to the preoperative phase, where polypharmacy (including opioid use) and inadequately treated pain are major risk factors. Delirium is associated with negative health consequences, increased hospital stay, falls, higher mortality, decreased physical and cognitive function, re-hospitalization, increased risk of dementia and increased societal costs. Therefore, pain should be optimally treated as soon as possible, however the elderly patient poses a challenge in good pain treatment, because of physiological age-related changes, different drug effects, distribution, metabolism and elimination. Opioids frequently lead to respiratory depression, hypotension, nausea/vomiting and sedation in this vulnerable patient group. As a consequence, these drugs are often under dosed and pain treated insufficiently. Besides, drugs as opioids and NSAIDs have been associated with an increased delirium risk. A nerve block could alleviate these clinical issues.

An example of a nerve block frequently utilized in the Emergency Department (ED) is a Fascia Iliaca Compartment Block (FICB), in which local anesthetics are injected underneath the pelvic iliac fascia in order to block femoral, obturator and lateral cutaneous nerves to provide anesthesia of hip, thigh and knee. Case-series and historically controlled cohort studies show a single-shot FICB is a rapid, safe and easy procedure providing excellent analgesia, decreased opioid need and little risk of complications. Delirium as outcome was reported in one RCT; a decreased delirium incidence after using repetitive, blind, single-shot FICBs (not in the acute setting) with pethidine (with increased intrinsic risk of developing delirium) as comparison. In order to prevent the need for repetitive insertions, leaving a catheter would create a route in order to provide continuous analgesia with local anesthetics. Two case series describe this continuous FICB in hip fractures and reported good pain control and decreased length of hospital stay without any infectious complications. No comparison studies have been done with a continuous FICB.

The objective of the current study is to investigate whether the use of a continuous FICB, started early (in the ED) and continued throughout the complete clinical course of a hip fracture, will decrease occurrence of delirium in elderly patients with hip fractures.

METHODS This study is designed as a prospective, open, multi-center, randomized interventional trial. Patients will be allocated to continuous FICB or care as usual (according to national guidelines) in a 1:1 ratio and followed up until three months after hospital discharge.

SAMPLE SIZE AND DATA ANALYSIS The primary outcome (occurrence of delirium) is expected to be distributed normally. Although evidence to prevent delirium is scarce, an absolute reduction of 13% incidence has been reported previously after an intervention. The estimated delirium incidence according to literature is 25%. The hypothesis is that by using a continuous FICB administered very early in the clinical course in the ED, the incidence can be decreased from 25 to 12%. Superiority of the FICB versus usual care will be tested using the Chi Square Test. In order to detect a clinically relevant between-group-difference of 13% decrease in incidence, a significance level of 0.05 and 80% power will be used. For this analysis, each group will have 154 patients. When accounting for 10% loss to follow-up after three months, a total study population of 340 will be needed.

The primary analysis will be based on the intention to treat principle. Per protocol analysis will be performed to check robustness of results. Baseline characteristics will be presented using descriptive statistics. Ordinal data will be analyzed using Chi Square Test or Fisher exact test. Continuous data will be assessed by a Student's t-test if normally distributed or Mann Whitney U test if otherwise. Missing data will be corrected by multiple imputation.

An economic evaluation will be performed focusing on possible gained benefits of pain management with a continuous FICB compared to care as usual and the related health care costs. The economic evaluation will be performed from a societal perspective with a time horizon of three months and capturing the value of all resources utilized. The economic evaluation will be set up as a Cost-Effectiveness Analysis (CEA). Besides a CEA, a Budget Impact Analysis (BIA) will be performed according to the ISPOR Task Force principles.

Recruitment information / eligibility

• Status: Terminated
• Enrollment: 239
• Est. completion date: July 19, 2023
• Est. primary completion date: July 19, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 55 Years and older

Eligibility

Inclusion Criteria:

• adult patients aged = 55 years with

• a radiographically confirmed hip fracture

Exclusion Criteria:

• multiple injuries (polytrauma patients)

• previous adverse reaction or known allergy to local anaesthetics or opioids or paracetamol

• skin infection in proximity of injection site

• delirious state at presentation in the ED

Related Conditions & MeSH terms

• Anesthesia
• Delirium
• Hip Fractures

Intervention

Drug:
• Bupivacaine
Local anesthetic: amide group ATC code N01BB01
• Acetaminophen
Analgesic drug: Acetanilide derivate with analgetic and antipyretic properties ATC code N02BE01
• Diclofenac
Non-Steroidal Anti-Inflammatory Drug: Acetic acid derivative ATC code M01AB05 Usual dosage is 50 mg t.i.d. orally or 75 mg b.i.d. intramuscularly. In the Netherlands, intravenous administration is not used.
• Ibuprofen
Non-Steroidal Anti-Inflammatory Drug: Propionic acid derivative ATC code M01AE01 Usual dosage is 400 mg t.i.d. or q.i.d. orally.
• Naproxen
Non-Steroidal Anti-Inflammatory Drug: Propionic acid derivative ATC code M01AE02 Usual dosage is initially 500 mg orally, followed by 250 mg b.i.d. or t.i.d.
• Dipyrone
Analgesic drug: Pyrazolone derivate with analgetic, antipyretic and antiphlogistic properties ATC N02BB02 Usual dosage is 1000 mg t.i.d. or q.i.d. orally and intravenously
• Fentanyl
Opioids: Phenylpiperidine derivative. Short-acting opioid. ATC code N02AB03 Usual dosage is 1 ug/kg intravenously and titrated guided by pain scores and possible side effects. Above the age of 60, dosages are usually divided in two in order to prevent adverse events.
• Morphine
Opioids: Natural opium alkaloid. Longer-acting opioid. ATC code N02AA01 Usual dosage is 0.1 mg intravenously and titrated guided by pain and possible side effects. Above the age of 60, dosages are usually divided in two in order to prevent adverse events.
• Levobupivacaine
Local anesthetic: amide group ATC code N01BB10
• Ropivacaine
Local anesthetic: amide group ATC code N01BB09

Locations

Country	Name	City	State
Netherlands	Meander Medical Center	Amersfoort
Netherlands	Academic Medical Center	Amsterdam
Netherlands	Slotervaart Medical Center	Amsterdam
Netherlands	VU Medical Center	Amsterdam
Netherlands	Tergooi Ziekenhuis	Hilversum	Noord Holland

Sponsors (2)

Lead Sponsor	Collaborator
Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)	ZonMw: The Netherlands Organisation for Health Research and Development

Country where clinical trial is conducted

Netherlands, 

References & Publications (22)

Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, Menon MR, Majumdar SR, Wilson DM, Karkhaneh M, Mousavi SS, Wong K, Tjosvold L, Jones CA. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011 Aug 16;155(4):234-45. doi: 10.7326/0003-4819-155-4-201108160-00346. — View Citation

Adunsky A, Levy R, Heim M, Mizrahi E, Arad M. Meperidine analgesia and delirium in aged hip fracture patients. Arch Gerontol Geriatr. 2002 Nov-Dec;35(3):253-9. doi: 10.1016/s0167-4943(02)00045-6. — View Citation

Bruce AJ, Ritchie CW, Blizard R, Lai R, Raven P. The incidence of delirium associated with orthopedic surgery: a meta-analytic review. Int Psychogeriatr. 2007 Apr;19(2):197-214. doi: 10.1017/S104161020600425X. Epub 2006 Sep 14. — View Citation

Candal-Couto JJ, McVie JL, Haslam N, Innes AR, Rushmer J. Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique. Injury. 2005 Apr;36(4):505-10. doi: 10.1016/j.injury.2004.10.015. — View Citation

Cole MG. Delirium in elderly patients. Am J Geriatr Psychiatry. 2004 Jan-Feb;12(1):7-21. — View Citation

Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg. 1989 Dec;69(6):705-13. Erratum In: Anesth Analg 1990 Apr;70(4):474. — View Citation

Dochez E, van Geffen GJ, Bruhn J, Hoogerwerf N, van de Pas H, Scheffer G. Prehospital administered fascia iliaca compartment block by emergency medical service nurses, a feasibility study. Scand J Trauma Resusc Emerg Med. 2014 Jun 23;22:38. doi: 10.1186/1757-7241-22-38. — View Citation

Dulaney-Cripe E, Hadaway S, Bauman R, Trame C, Smith C, Sillaman B, Laughlin R. A continuous infusion fascia iliaca compartment block in hip fracture patients: a pilot study. J Clin Med Res. 2012 Feb;4(1):45-8. doi: 10.4021/jocmr724w. Epub 2012 Jan 17. — View Citation

Godoy Monzon D, Iserson KV, Vazquez JA. Single fascia iliaca compartment block for post-hip fracture pain relief. J Emerg Med. 2007 Apr;32(3):257-62. doi: 10.1016/j.jemermed.2006.08.011. Epub 2007 Feb 8. — View Citation

Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, Likourezos A. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med. 2012 Oct;43(4):692-7. doi: 10.1016/j.jemermed.2012.01.050. Epub 2012 Apr 9. — View Citation

Hanna L, Gulati A, Graham A. The role of fascia iliaca blocks in hip fractures: a prospective case-control study and feasibility assessment of a junior-doctor-delivered service. ISRN Orthop. 2014 Mar 4;2014:191306. doi: 10.1155/2014/191306. eCollection 2014. — View Citation

Hogh A, Dremstrup L, Jensen SS, Lindholt J. Fascia iliaca compartment block performed by junior registrars as a supplement to pre-operative analgesia for patients with hip fracture. Strategies Trauma Limb Reconstr. 2008 Sep;3(2):65-70. doi: 10.1007/s11751-008-0037-9. Epub 2008 Sep 2. — View Citation

Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998 Apr;13(4):234-42. doi: 10.1046/j.1525-1497.1998.00073.x. — View Citation

Krogseth M, Wyller TB, Engedal K, Juliebo V. Delirium is a risk factor for institutionalization and functional decline in older hip fracture patients. J Psychosom Res. 2014 Jan;76(1):68-74. doi: 10.1016/j.jpsychores.2013.10.006. Epub 2013 Oct 16. — View Citation

Lees D, Harrison WD, Ankers T, A'Court J, Marriott A, Shipsey D, Chaplin A, Reed MR. Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites. Eur J Emerg Med. 2016 Feb;23(1):12-8. doi: 10.1097/MEJ.0000000000000167. — View Citation

Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008 Jan 14;168(1):27-32. doi: 10.1001/archinternmed.2007.4. — View Citation

Leslie DL, Zhang Y, Holford TR, Bogardus ST, Leo-Summers LS, Inouye SK. Premature death associated with delirium at 1-year follow-up. Arch Intern Med. 2005 Jul 25;165(14):1657-62. doi: 10.1001/archinte.165.14.1657. — View Citation

Lopez S, Gros T, Bernard N, Plasse C, Capdevila X. Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med. 2003 May-Jun;28(3):203-7. doi: 10.1053/rapm.2003.50134. — View Citation

McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc. 2003 Nov;51(11):1539-46. doi: 10.1046/j.1532-5415.2003.51509.x. — View Citation

Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, Strauss E, Siu AL. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003 Jan;58(1):76-81. doi: 10.1093/gerona/58.1.m76. — View Citation

Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol. 2009 Sep;10(3):127-33. doi: 10.1007/s10195-009-0062-6. Epub 2009 Aug 19. — View Citation

Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010 Jul 28;304(4):443-51. doi: 10.1001/jama.2010.1013. — View Citation

* Note: There are 22 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	occurrence of delirium	Diagnosis will be based on DSM-IV criteria. During hospital admission screening is actively. After discharge, information is gathered by contacting patients and family members, general practitioners or nursing facilities	three months
Secondary	duration of delirium	duration is defined as the total number of days with delirium.	three months
Secondary	severity of delirium	severity is defined as percentage of patients with delirium duration > 2 days.	three months
Secondary	NRS pain scores	NRS pain scores during complete hospital stay, NRS pain scores will be recorded in the Emergency Department before the intervention as well as after the intervention at 30-minutes time intervals (this is according standard protocol in case opioids are administered). During hospital stay, during each nursing shift, a minimum of one NRS pain score is documented.	from hospital admission until 48 hours after surgery
Secondary	need for additional analgesia	need for rescue analgesia will be documented during complete Emergency Department and hospital stay.	hospital admission until 48 hours after surgery
Secondary	patient satisfaction	satisfaction of patients and health care staff regarding efficacy of pain treatment and method of pain treatment is recorded in the Emergency Department and daily during hospital admission (5-point Likert scales and reference questions).	from hospital admission until 48 hours after surgery
Secondary	length of hospital stay	defined as total consecutive days admitted in the hospital.	from hospital admission until discharge; an average of 9 days
Secondary	ICU admission	binary endpoint, whether patient is admitted to the ICU at any moment during hospital stay.	from hospital admission until discharge; an average of 9 days
Secondary	ICU length of stay	defined as total days admitted to the ICU department.	from hospital admission until discharge; an average of 9 days
Secondary	hospital re-admission rate	a re-admission occurs when a patient is admitted to the hospital within three months after initial discharge (from hip fracture related admission).	three months
Secondary	medical complications	all events regarding infections, renal- or pulmonary function and cardiovascular events will be accounted for.	three months
Secondary	surgical complications	defined as dislocations and fractures.	three months
Secondary	mortality	all cause in-hospital-mortality and mortality after hospital discharge.	three months
Secondary	activities of daily living	15-item modified Katz Index of Activities of Daily Living at three months after discharge. Baseline will be 2 weeks before presentation.	three months
Secondary	generic quality of life	generic HRQol (Euroqol - EQ-5D-5L) at three months after discharge. Baseline will be 2 weeks before presentation.	three months
Secondary	Oxford hip score	Oxford Hip Score after 3 months.	three months
Secondary	cognitive function with Mini Mental State Examination	Mini Mental State Examination at inclusion in the study, at hospital discharge and at three months after discharge.	three months
Secondary	cost effectiveness analysis	primary focus on direct medical costs, direct non-medical costs, indirect costs and productivity loss.	three months

External Links

•   European Union Clinical Trials Register
•   Study website