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Aims: The primary aim of this study is to compare mobility status of patients receiving oral oxycodone with those receiving subcutaneous alfentanil as analgesic methods prior to mobilization to help physiotherapy compliance after hip fracture surgery. The secondary aims are to assess postoperative pain, health-related quality of life, in-hospital length of stay, total use of analgesia over postoperative days 1 and 2 (POD 1 and POD 2), complication rates within 30 days, and 30-day mortality rates. Methods: A single-centre, prospective cohort study of 64 patients will be undertaken. Patients undergoing surgery for femoral neck fractures at the study centre will be recruited. Patients with a hip fracture meeting the inclusion/exclusion criteria will be enrolled on admission. Patients who have been administered oral oxycodone will be compared to those prescribed alfentanil for pain prior to mobilization with physiotherapists on POD 1 and POD 2. Which drug a patient receives is reliant of the prescriptions given by the medical team, and in current practice this varies at approximately 50:50. Mobilization will be defined as the ability to stand on and weightbear both feet with or without assistance. Results: Visual analogue scale pain scores, mobility status, and total analgesia use will be assessed on POD 1 and POD 2. EuroQol five-dimension health questionnaire scores, complication rates, and mortality rates will be assessed up to 30 days following surgery (POD 1, 2, 7, and 30). Conclusion: This study will help to build a wider protocol aiming to improve early mobilization after hip fracture surgery. The results of this study will provide pain scores and mobility status which will either support use of subcutaneous alfentanil as the standard analgesic modality prior to physiotherapy sessions, or highlight its limitations compared to the standard oral oxycodone. Secondary outcomes will also help to assess if early mobilization improves outcomes compared to delayed mobilization. Cite this article: Bone Jt Open 2025;6(1):53–61.

Background Hip fracture has a substantial impact on the health, well-being and independence of patients and their families. In the 12 months after fracture, patients are at increased risk of cognitive and functional decline, admission to long-term care institutions and higher mortality. People with cognitive impairment are among the most vulnerable in acute hospital settings. They have lower short-term survival, with 24% mortality during admission. They are susceptible to suboptimal and inconsistent care standards that contribute to cognitive deterioration, increase risk of postoperative complications, prolong their length of stay and cause loss of independence. Objectives Establish best-practice from a systematic review of literature, observations of practice, perspectives of service users, carers, healthcare professionals, health service managers and experts in the field. Design the care pathway. Determine cultural/organisational changes necessary to implement and maximise adherence to the enhanced recovery pathway in hospital settings. Develop staff training and a training manual. Undertake a feasibility randomised controlled trial and collect outcomes to identify potential clinical and cost-effectiveness of the enhanced recovery pathway. Disseminate the findings and develop a definitive trial bid. Design A programme to develop an enhanced recovery pathway for people with hip fracture and cognitive impairment, tested for implementation and refined in the clinical environment. This refined enhanced recovery pathway was then tested in a feasibility study in 10 hospitals across the UK. Setting Acute care. Participants Hospital staff, people with cognitive impairment and hip fracture, carers and national and international experts in hip fracture or dementia. Interventions An enhanced recovery care pathway with checklist and an implementation process. Main outcome measures Mortality, patient and carer quality of life, cognition, activities of daily living. Data sources Clinical trial. Results A total of 284 participants were recruited, 132 to the PEFECT-ER intervention arm and 150 to the control arm, had good retention in the study and provided data for analysis. There was no evidence of any systematic between group difference at either the point of discharge from hospital or at 1-month follow-up. However, at 3 months, a relatively small effect of around one quarter of a standard deviation (0.071 units), was evidenced with respect to the health-related quality of life of the patient based on the EuroQol-5 Dimensions, five-level version by proxy in the intervention group (95% confidence interval 0.018 to 0.124; p = 0.009). A difference of 0.099 units in favour of the intervention group was also seen at the 6-month follow-up (95% confidence interval 0.001 to 0.198; p = 0.047). ‘Timed Up and Go’ and the Suitable Informant EuroQol-5 Dimensions, five-level version showed a no statistically significant difference except the model for length of stay. Those individuals in the intervention group had significantly longer lengths of stay, on average 1.22 times longer (95% confidence interval 1.02 to 1.45; p = 0.028). Mortality was similar in both groups, with a 6.1% mortality rate by 30 days post surgery. The process evaluation found that patients and carers were unable to comment on receiving the intervention. Limitations This was a feasibility study and was not designed as a definitive evaluation of the intervention. Lack of direct access to patient notes meant that researchers were unable to verify the Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery check listing results. The relationship between changes in documentation of practices and changes in care practices is also unclear. Patient and suitable informants did not assist understandings of implementation, mechanisms of action or experiences of interacting with the intervention. Client Services Receipt Inventory data collection burden was an issue. Conclusions The Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery feasibility trial demonstrated mean recruitment of 1.87 participant per centre per month. Retention at 1 month was over 80% and at 6 months approximately 50%. This information is useful for those wishing to design a definitive clinical trial. Although 30-day mortality was the same in both groups, the potential for reduction, by Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery being implemented, exists from cumulatively increased good practices across a range of care domains. To compare longer-term survival of patients who received the intervention, we would recommend measuring 3-month (110-day) mortality in addition to 30-day mortality. These data are readily available from National Hip Fracture Database and are thus ideal for efficient trial design. Client Services Receipt Inventory can be reduced for a definitive trial, removing equipment questions and some community health use questions. Qualitative interviews with Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery trial patient and carer should not take place. Future work Work to date shows that the intervention pathway for Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery required considerable input from champions for delivery. We are exploring further funding options to facilitate work to understand these mechanisms and further test, pilot and produce the Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery manual. Trial registration This trial is registered as Current Controlled Trials ISRCTN99336264. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: DTC-RP-PG-0311-12004) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 1. See the NIHR Funding and Awards website for further award information. Plain language summary What was the problem? Hip fracture and thought/memory (‘cognitive’) impairments, such as dementia and delirium, are major challenges for older patients, their families/carers and the National Health Service and social care. The outcomes of medical treatment for elderly patients with hip fracture are often poor, and worse when patients have memory and thinking problems. There is little research on how best to look after this patient group in hospital. Our previous work shows that patients, families, carers and staff repeatedly seek more sensitive ways to look after this patient group. Staff have also highlighted the need for training to help them work more appropriately to meet these patients’ needs. What did we do? We have created, adapted and piloted a set of care actions called Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery. Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery comprises a best practice checklist, a staff training manual, staff time to put the checklist into practice and to train colleagues, and a process to improve care of this patient group continuously. We tested Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery in five hospitals and asked whether staff found it acceptable. We wanted to find out if Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery could be used in a bigger trial, testing whether Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery improved outcomes for older people with hip fracture and memory problems. What did we find? We found that Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery was practical to use, both in the trial and by ward staff. Some measures we planned to use to calculate its costs were not completed by enough people to analyse in the study, suggesting that a future trial should have different measures. We found that measuring the number of people dying and people’s quality of life should be considered for the trial. What does this mean? Our evidence suggests that Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery can be used in hospitals and was acceptable to staff. There remains a need for a larger evaluation to investigate whether Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery provides benefit for this patient group. Scientific summary Text in this section reproduces material from Cross JL, Hammond SP, Shepstone L, Poland F, Henderson C, Backhouse T, et al. PERFECTED enhanced recovery pathway (PERFECT-ER) versus standard acute hospital care for people after hip fracture surgery who have cognitive impairment: a feasibility cluster randomised controlled trial. BMJ Open 2022;12:e055267. https://doi.org.uea.idm.oclc.org/10.1136/bmjopen-2021-055267. This article is distributed under the terms of the Creative Commons Attribution 4.0 International Licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution and reproduction in any medium, provided that you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate whether changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0) applies to the data made available in this article unless otherwise stated. The text below includes minor additions and formatting changes to the original text. Background This programme of research aimed to develop a best practice care pathway for people with dementia and hip fracture in hospital using the enhanced recovery framework. As the programme progressed, the intervention was adjusted to include all people with cognitive impairment (CI) as we learnt about implementation in practice. Objectives What is the best care practice for people in hospital with dementia who fracture their hip? [work package (WP) 1 phases 1–4] Can an optimised care pathway Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery (PERFECT-ER) be developed for people in hospital with dementia who fracture their hip? (WP1 phase 5) What are the staff training and cultural/organisational changes required to implement and maximise adherence to the optimised care pathway-enhanced recovery pathway (PERFECT-ER) in hospital settings? (WP2) What are the components of a training manual for the enhanced recovery pathway (PERFECT-ER) promoting cultural and organisational changes and maximising adherence? (WP2) What is the feasibility of undertaking a randomised clinical trial (RCT) to assess the clinical and cost-effectiveness of the enhanced recovery pathway (PERFECT-ER) to inform a definitive RCT? (WP3) Methods Work package 1: evidence for best practice This WP generated evidence for best practice from peer-reviewed and grey literature including access to national and international initiatives. We undertook a Cochrane review (CRD42012002047; WP1, phase 1a and b). We collected front-line national and international healthcare professional perspectives on best practice, current practice and explanations for implementation gaps between ‘best’ and ‘current’ practice (WP1, phase 2). We undertook observations of care of delivery (WP1, phase 3) to understand ‘usual care’ and collected the views and opinions of patients, carers and healthcare professionals of regarding current care (WP1, phase 4). From WP 1 phases 1–4 we identified and synthesised components to inform consensus development events attended by a number of experts (both by profession and experience) to develop the PERFECT-ER checklist (WP1, phase 5). Work package 2: optimising care for patients with dementia and hip fracture We used an action research approach, with a mixed-methods case study design to study implementation on an orthopaedic ward in each of three hospitals, using a series of plan, do, study, act (PDSA) cycles. Work package 3: feasibility trial We undertook a feasibility, multicentre, cluster RCT with integral economic evaluation. In line with Medical Research Council guidance for complex interventions, we also conducted an integrated multimethod multiperspective (from patients, suitable informants and NHS professionals) process evaluation. The trial ran from November 2016 to August 2018 in 11 hospitals in England and Scotland. Results (research findings) Work package 1 key findings Work package 1 phase 1a Our systematic review indicated that there was insufficient quality research on the rehabilitation of people living with CI following hip fracture surgery. Of the literature reviewed, the majority focused on people with mixed CI status and/or people with CI and hip fracture as a subgroup of larger studies. Studies lacked power to detect differences between intervention groups. The review suggested that models of rehabilitation could decrease the length of hospital stay and reduce admissions to care. No cost-effectiveness studies were located. We found that people living with CI are at greater risk of postoperative complications and higher mortality 12 months postoperatively. We also found uncertainty around rehabilitation provision, with no guidelines based on UK or international policy on how to deliver care to people living with CI following hip fracture. Components of enhanced care identified included screening for delirium and assessing pain for people with CI and hip fracture. Work package 1 phase 1b Our Freedom of Information Act survey highlighted the policy priorities that NHS trusts emphasised for people with dementia and hip fracture in March 2014. Numerous hospitals disclosed global dementia strategies and geriatric acute hip fracture pathways. However, no hospital disclosed an integrated dementia and hip fracture pathway or other documentation. Major themes affecting care elements were identified: antipsychotics, behaviours that challenge, cost consequences, communication (between staff and patients, between staff and carers/family, between staff), consenting, constipation, delirium, dementia assessment, deprivation of liberties, discharge processes, end-of-life care, falls, hydration, identification of patients with dementia, incontinence, involving carers, manual handling, minimising ward changes, non-pharmacological interventions, nutrition, pain relief, pressure ulcers, safeguarding vulnerable adults, training in dementia care and ward environment. These themes were then aligned with corresponding elements described in the enhanced recovery after surgery literature (admission, preoperative, intraoperative, postoperative, rehabilitation, discharge). Work package 1 phase 2 The telephone survey investigated domestic and international healthcare professionals’ perspectives on the care pathways and costs, length of stay in hospital and discharge destinations for people with dementia and hip fracture. The participants identified diverse needs for patients with dementia in acute settings but supplied documentation that was largely dementia or hip fracture focused but not integrated. Participants described that training to provide colleagues with the skills to care for this patient group was generic and ‘tick box’. They also found that outcome metrics such as length of hospital stay did not help in recognising recovery in this patient group. The documents received through the survey were coded using a developed coding matrix to identify potential intervention components. This provided initial insights into what participants perceived as current and best practice. Implementation gaps they identified helped generate the observation topic guides used in WP1 phase 3. Work package 1 phase 3 Key themes identified specific interruptions (‘disjunctures’) in routines or planned sequences in caregiving as: Disruptions – when usual or expected practices were interrupted impacting on the ease with which staff manage care delivery. Discontinuities – when divisions in culture, spaces and timing interrupt the smooth delivery of tasks. Dispersions – occasions when environment artefacts [object(s) and/or people] are displaced from designated space. Work package 1 phase 4 The staff focus groups and interviews reported emotive experiences, fatigue and constraints that staff reported experienced on a daily basis. Many participants identified failing to deliver appropriate care to patients with dementia in several ways, including: lack of staff and/or time required combined organisational barriers care spaces not fit for these patients care needs. Carer experiences supported these staff views. Some carers felt under pressure to assist staff, whom they perceived as needing help, to relieve shortages. Carers did not view this as empowering them to produce co-delivered care. The patients were mostly full of praise for staff efforts, in improvising to meet ongoing disjunctures in workflow by re-prioritising tasks. Work package 1 phase 5 The intervention PERFECT-ER was developed through stakeholder consensus events. Work package 2 key findings In WP2 we identified common barriers, facilitators, underlying mechanisms and work of service improvement leads (SILs) and PERFECTED process leads (PPLs) entailed in embedding PERFECT-ER across distinct hospital settings. While this proved challenging, staff found different ways to implement changes within their settings. It became clear that the practices surrounding such changes could easily break down. Components of PERFECT-ER that aligned to context-specific motivations, including the National Hip Fracture Database (NHFD) best practice tariff or trust policies, were easier to implement and longer lasting. WP2 enabled us to refine the PERFECT-ER intervention and develop its training manual, understanding the requirements of the SIL, PPL roles and using the checklist as part of the PDSA cycle. This informed implementation aspects of the trial (WP3) and the process evaluation. Work package 3 feasibility key findings We recruited 282 participants, 132 from intervention sites and 150 from control sites. The average recruitment rates did not differ between intervention and control sites, ranging between 1.2 and 2.7 participants per month. Average recruitment of 1.87 per month contrasted with the expected 4 per site per month anticipated. There was no evidence of any systematic between group difference at either the point of discharge from hospital or at 1-month follow-up. At 3 months, however, a potential beneficial effect of the intervention over control was evidenced for patient health-related quality of life (HRQoL) based upon the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) by proxy: those in the intervention group had a mean EQ-5D utility score 0.071 units higher than control [95% confidence interval (95% CI) 0.018 to 0.124; p = 0.009], a relatively small effect of around one quarter of a standard deviation. A difference of 0.099 units, in favour of the intervention group, was also seen at the 6-month follow-up (95% CI 0.001 to 0.198; p = 0.047). Examination of the residuals from each of the models appeared to show violation of the normal distribution assumption for the length of stay, ‘Timed Up and Go’ and the Suitable Informant EQ-5D-5L models. Logarithmic transformation was applied to these data and the models refitted. None then showed any statistically significant difference except the model for length of stay. The individuals in the intervention group had significantly longer lengths of stay, on average 1.22 times longer (95% CI 1.02 to 1.45; p = 0.028). Over the trial’s duration, 57 participants (20.2%) died. A higher rate of all deaths was observed in the intervention group than in the control group (22.7% vs. 18.0%). Death in hospital was determined from the NHFD data and only available for participants in England, thus excluding 59 Scottish participants. Eleven participants (3.9%) died in hospital, with a higher rate in the control group (4.7% vs. 3.0%). Seventeen (8 intervention, 9 control) patients were known to have died within 30 days of surgery and 52 (28 intervention and 24 control) within 6 months. Process evaluation The process evaluation demonstrated that, under particular conditions, the PERFECT-ER intervention package can be implemented in diverse NHS contexts. General barriers to implementation including: staffing issues, low staff morale, staff sickness, staff movement between wards and lack of senior staff, impacted negatively on implementation. However, the protected SIL resource, PDSA processes, networking, and using key staff members and trust processes, along with the resourcefulness, determination, commitment and ingenuity of SILs, PPLs and others with whom they worked, were facilitators. We demonstrated that implementing an intervention encouraging more standardised practice and its documentation to improve patient, carer and staff outcomes via consistently amalgamating marginal gains was welcomed, necessary and seen as valuable. Health economics Data completeness was comparable between suitable informant-reported (SIR) and hospital records but slightly higher in the SIR data. Comparing agreement in the data, we found sources agreed on ‘non-use’, but suitable informant over- and under-reporting of ‘use’ compared with hospital records did not follow a consistent pattern. Comparing SIR ‘hospital use’ over the 3-month periods pre-baseline and pre-6-month follow-up were identical at both assessments. Data suggest that sources yielded inconsistent estimates for inpatient days and for emergency department visits but more consistent estimates for outpatient attendances. Total hospital costs yielded inconsistent estimates. Individual items of resource use were relatively well completed, with missing rates below 12%. However, the cumulative impact of missing data decreased the availability of complete costs at all-time points. A combination of missing resource use and unpaid care data from participants/suitable informants completing the trial and high attrition rates led to small or very small samples available for calculating 6-month costs. Low completion of self-reported HRQoL instruments (EQ-5D-5L and DEMQOL) and attrition led to small samples available for calculating 6-month participant-reported quality-adjusted life-year (QALY). There were 64 intervention participants and 79 controls at 6 months but on combinations of societal costs and self-completed HRQoL measures, only 25 cases were available for analysis. In line with the original proposal, cost-effectiveness estimates were produced. The evidence of these analyses points to substantial uncertainty as to the size of the incremental cost-effectiveness ratios produced. No assumptions were made as to the costs and QALY of participants that had died during the trial; instead, complete cases were analysed. The mechanisms underlying incomplete data were not necessarily observed or recorded and so no imputation strategy was possible. Conclusions The PERFECT-ER feasibility trial demonstrated mean recruitment of 1.87 participant per centre per month. Retention at 1 month was over 80% and at 6 months approximately 50%. In patients with CI and hip fracture, we estimated that 10–20% died within 30 days of sustaining a hip fracture. Our data suggest that short-term mortality could be reduced with implementation of PERFECT-ER from a culmination of increased good practice across a range of care domains. Thirty-day mortality is more commonly used as an outcome measure in the evaluation of enhanced recovery pathways; discussion with the patient and public involvement group indicated that this was an appropriate primary outcome in future trials. The process evaluation found patients and carers unable to comment on receiving the intervention, so did not assist in answering questions about PERFECT-ER implementation. Equipment costs contributed little to overall costs and these questions should be removed. Hospital records-extracted data were used to estimate costs for use in the cost-effectiveness analyses presented here. These are the ‘gold-standard’ source compared with SIR data. However, records did not include information on hospital stays outside the trusts providing the records, so use of other hospitals might have been omitted. The feasibility PERFECT-ER trial provided valuable information and evidence to future work. Thirty-day post-surgery mortality is appropriate primary outcome for future trials, but to compare longer-term survival, we recommend also measuring 3-month mortality. In a definitive PERFECT-ER trial, patient and carer interviews should not be undertaken. Community health use questions should be reduced, removing health care that might be routine and little affected by the intervention, such as dentistry. We consider that hospital records extraction proformas and trial database design in a definitive trial could address potential shortcomings. We would not recommend comparing SIR and hospital records sources in a larger study. Trial registration This trial is registered as Current Controlled Trials ISRCTN 99336264. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: DTC-RP-PG-0311-12004) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 1. See the NIHR Funding and Awards website for further award information.

Background Delirium and cognitive impairment are common in hip fracture populations and are associated with significant adverse patient outcomes. National hip fracture registries facilitate improvements in patient outcomes and care quality, such as reduced mortality and the development of specialist multidisciplinary services. However, there is substantial variation in the data collected and reported in relation to delirium and cognition, which impedes international comparison and may reduce quality of care. Objective This scoping review aims to identify delirium and cognition data items currently collected by hip fracture registries internationally, to identify associated registry guidance that exists for the administration of delirium and cognitive screening tools, and report outcomes of these data items across the most recently published annual reports of identified hip fracture registries. Methods This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR). We will search the following databases: Medline Ovid; Embase; CINAHL EBSCOHost. Relevant websites such as the Fragility Fracture Network (FFN) will also be searched. Study selection and review will be carried out independently by two research team members, with discrepancies resolved by a third member of the research team. Data extraction and synthesis will be conducted by one reviewer and checked for accuracy and omissions by another. The scoping review findings will be informed and validated through engagement with the FFN Hip Fracture Audit Special Interest Group, who will share their knowledge, expertise, and research to achieve consensus over core aspects of the scoping review findings. Conclusion By identifying existing heterogeneity in delirium and cognitive screening tool use and administration, it is hoped that administration and specific screening tool use will become standardised to optimise comparability across countries and ensure that high quality and reliable data are included across international registry reports.

Abstract Background Delirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible. Methods The study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants’ own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals. Discussion Findings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care. Trial registration The feasibility study was registered: ISRCTN15676570

Aims: Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analysed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods: This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results: A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion: Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. Cite this article: Bone Jt Open 2023;4(6):447–456.

Introduction Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care.Methods and analysis Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of −2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40–50 UK ICUs.Ethics and dissemination The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines.Trial registration number ClinicalTrials.gov NCT03653832.

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342–345.

Abstract Background Delirium is a heterogeneous syndrome with inattention as the core feature. There is considerable variation in the presence and degree of other symptom domains such as altered arousal, psychotic features and global cognitive dysfunction. Delirium is independently associated with increased mortality, but it is unclear whether individual symptom domains of delirium have prognostic importance. We conducted a systematic review and meta-analysis of studies in hospitalised adults in general settings to identify the relationship between symptom domains of delirium and outcomes. (PROSPERO: CRD42018093935). Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials from inception to November 2019. We included studies of hospitalised adults that reported associations between symptom domains of delirium and 30-day mortality (primary outcome), and other outcomes including mortality at other time points, length of stay, and dementia. Reviewer pairs independently screened articles, extracted data, and assessed risk of bias (Risk of Bias Assessment tool for Non-randomized Studies) and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework. We performed random-effects meta-analyses stratified by delirium domain where possible. Results From 7092 citations we included 6 studies (6002 patients, 1112 with delirium). Higher mortality (ranging from in-hospital to follow-up beyond 12 months) was associated with altered arousal (pooled Odds Ratio (OR) 2.80, 95% Confidence Interval (CI) 2.33–3.37; moderate-quality evidence), inattention (pooled OR 2.57, 95% CI 1.74–3.80; low-quality evidence), and in single studies with disorientation, memory deficits and disorganised thoughts. Risk of bias varied across studies but was moderate-to-high overall, mainly due to selection bias, lack of blinding of assessments and unclear risk of selective outcome reporting. We found no studies on the association between psychotic features, visuospatial deficits or affective disturbances in delirium and outcomes, or studies reporting non-mortality outcomes. Conclusions Few studies have related symptom domains of delirium to outcomes, but the available evidence suggests that altered arousal and inattention in delirium are associated with higher mortality than normal arousal and attention in people with or without delirium. Measurable symptom domains of delirium may have value in predicting survival and stratifying patients for treatment. We recommend that future delirium studies report outcomes by symptom domain.

Abstract Background Risk prediction after myocardial infarction is often complex in older patients. The Global Registry of Acute Coronary Events (GRACE) model includes clinical parameters and age, but not frailty. We hypothesised that frailty would enhance the prognostic properties of GRACE. Methods We performed a prospective observational cohort study in two independent cardiology units: the Royal Infirmary of Edinburgh, UK (primary cohort) and the South Yorkshire Cardiothoracic Centre, Sheffield, UK (external validation). The study sample included 198 patients ≥65 years old hospitalised with type 1 myocardial infarction (primary cohort) and 96 patients ≥65 years old undergoing cardiac catheterisation for myocardial infarction (external validation). Frailty was assessed using the Clinical Frailty Scale (CFS). The GRACE 2.0 estimated risk of 12-month mortality, Charlson comorbidity index and Karnofsky disability scale were also determined for each patient. Results Forty (20%) patients were frail (CFS ≥5). These individuals had greater comorbidity, functional impairment and a higher risk of death at 12 months (49% vs. 9% in non-frail patients, p

Abstract Background Hip fracture represents a substantial acute inflammatory trauma, which may constitute a significant insult to the degenerating brain. Research suggests that an injury of this kind can affect memory and thinking in the future but it is unclear whether, and how, inflammatory trauma injures the brain. The impact of Acute SystematiC inflammation upon cerebRospinal fluId and blood BiomarkErs of brain inflammation and injury in Dementia: a study in acute hip fracture patients (ASCRIBED) explores this relationship, to understand the effect of inflammation on the progression of dementia. Methods This protocol describes a multi-centre sample collection observational study. The study utilises the unique opportunity provided by hip fracture operations undertaken via spinal anaesthesia to collect cerebrospinal fluid (CSF) and blood, to investigate the impact of acute brain inflammation caused by hip fracture on the exacerbation of dementia. We will recruit 200 hip fracture patients with a diagnosis or evidence of dementia; and 200 hip fracture patients without dementia. We will also recruit ‘Suitable informants’, individuals in regular contact with the patient, to provide further proxy evidence of a patient’s potential cognitive decline. We will compare these 400 samples with existing CSF and blood samples from a cohort of dementia patients who had not experienced a systemic inflammatory response due to injury. This will provide a comparison between patients with and without dementia who are suffering a systemic inflammatory response; with stable patients living with dementia. Discussion We will test the hypothesis that hip fracture patients living with dementia show elevated markers of brain inflammation, as well as neuronal injury and Alzheimer-related plaque pathology, in comparison to (1) stable patients living with dementia and (2) hip fracture patients without dementia, as measured by biomarkers in CSF and blood. The findings will address the hypothesis that systemic inflammatory events can exacerbate underlying dementia and inform the search for new treatments targeting inflammation in dementia. Trial registration ISRCTN43803769. Registered 11 May 2017.

Abstract Background Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. Main body The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). Short conclusion In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.

Abstract Background Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 ‘A’s Test (4AT, www.the4AT.com) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). Methods This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0–12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. Results Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84–0.96). The 4AT had a sensitivity of 76% (95% CI 61–87%) and a specificity of 94% (95% CI 92–97%). The CAM had a sensitivity of 40% (95% CI 26–57%) and a specificity of 100% (95% CI 98–100%). Conclusions The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. Trial registration International standard randomised controlled trial number (ISRCTN) 53388093. Date applied 30/05/2014; date assigned 02/06/2014.

Background: Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 ‘A’s Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. Methods: 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. Discussion: The findings will inform clinical practice regarding delirium assessment in palliative care settings. Trial registration: ISRCTN ISRCTN97417474 (21/02/2020).

Abstract Background Delirium is a common and serious clinical syndrome which is often missed in routine clinical care. The core cognitive feature is inattention. We developed a novel bedside neuropsychological test for assessing inattention in delirium implemented on a smartphone platform (DelApp). We aim to evaluate the diagnostic performance of the DelApp in a representative cohort of older hospitalised patients. Methods This is a prospective study of older non-scheduled hospitalised patients (target n = 500, age ≥ 65), recruited from elderly care and acute orthopaedic wards. Exclusion criteria are: non-English speakers; severe vision or hearing impairment; photosensitive epilepsy. A structured reference standard delirium assessment based on DSM-5 criteria will be used, which includes a cognitive test battery administered by a trained assessor (Orientation-Memory-Concentration Test, Abbreviated Mental Test-10, Delirium Rating Severity Scale-Revised-98, digit span, months and days backwards, Vigilance A’ test) and assessment of arousal (Observational Scale of Level of Arousal, Richmond Agitation Sedation Scale). Prior change in cognition will be documented using the Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be categorized as delirium (with/without dementia), possible delirium, dementia, no cognitive impairment, or undetermined. A separate assessor (blinded to diagnosis and assessments) will administer the DelApp index test within 3 h of the reference standard assessment. The DelApp comprises assessment of arousal (score 0-4) and sustained attention (score 0-6), yielding a total score between 0 and 10 (higher score = better performance). Outcomes (length of stay, mortality and discharge location) will be collected at 12 weeks. We will evaluate a priori cutpoints derived from a previous case-control study. Measures of the accuracy of DelApp will include sensitivity, specificity, positive and negative predictive values, and area under the ROC curve. We plan repeat assessments on up to 4 occasions in a purposive subsample of 30 patients (15 delirium, 15 no delirium) to examine changes over time. Discussion This study evaluates the diagnostic test accuracy of a novel smartphone test for delirium in a representative cohort of older hospitalised patients, including those with dementia. DelApp has the potential to be a convenient, objective method of improving delirium assessment for older people in acute care. Trial registration Clinical trials.gov, NCT02590796. Registered on 29 Oct 2015. Protocol version 5, dated 25 July 2016.

Abstract Background The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is an RCT investigating the effect of clonidine in medical patients > 65 years with delirium. To assess the dosage regimen and safety measures of this study protocol, we measured the plasma concentrations and hemodynamic effects of clonidine in the first 20 patients. Methods Patients were randomised to clonidine (n = 10) or placebo (n = 10). The treatment group was given a loading dose (75μg every 3rd hour up to a maximum of 4 doses) to reach steady state, and further 75μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days. Blood pressure (BP) and heart rate (HR) were measured just before every dose. If the systolic BP was