66INTRODUCING A NATIONAL PROGRAMME OF SCREENING WITH THE 4A TEST TO IDENTIFY DELIRIUM - THE COMMONEST COMPLICATION OF HIP FRACTURE SURGERY

Abstract

Introduction: Delirium is often poorly recognised by staff looking after patients with hip fracture. The National Hip Fracture Database (NHFD) have therefore adopted the 4A test (4AT) to encourage routine assessment and help improve staff understanding of a complication that can dominate patients' hospital stay and recovery (Bellelli et al. Age Ageing 2014). Method(s): We examined NHFD data on the 63,471 patients who presented to 175 acute trauma units in England, Wales and Northern Ireland during the 2017 calendar year. The NHFD asks for the 4AT to be performed in the week following hip fracture surgery. We compared 4AT results for patients of different ages, in those with different fracture types and comorbidities, and examined the impact of delirium on patients' recovery and outcome. Result(s): The 4AT was completed in all but 8,698 people (13.7%). Half (51.1%) scored 0, while 24% scored 1-3, and 24.9% scored 4+ 'possible delirium'. Those with an abnormal Abbreviated Mental Test score on presentation were more likely (55.8% vs. 7.4%) to develop post-operative delirium - emphasising the importance of using the AMT to identify at risk patients. Only 10.9% of people were recorded as exhibiting 'Acute change'. The 'AMT4' and 'Attention' elements of 4AT were often abnormal - minor abnormality in these meaning that the commonest abnormal score was 1-2. Abnormal 'Alertness' was seen in 6.8%, suggesting 'hypoactive delirium' - a subtype with a poor prognosis and which is easily overlooked. The importance of post-op. delirium is shown by its relationship with the outcome of patient stay. People who were admitted from their own home but developed post-operative delirium (a 4AT of 4+) were 2.0 times more likely to die as inpatients, and 2.9 and 3.9 times more likely to end up in a residential or nursing home respectively, when compared to people with a 4AT of 0. Conclusion(s): Awareness of delirium is improving, but greater sensitivity to features such as acute change and fluctuation in patients' mental state is vital, and depends on trauma ward teams actively seeking collateral history from patients' families, usual carers and hospital night staff. As a result NHFD figures probably still underestimate the overall incidence of delirium.