Title: In elderly patients undergoing fractured neck of femur fixation, does the use of regional anaesthesia compared to general anaesthesia reduce incidence of post-operative delirium (GeRAFFE)? A programme of research
Funder: Department of Health and Social Care

Abstract: Background Delirium is defined as disturbance of attention, awareness and cognition which develops over a short period of time, represents a change from baseline and tends to fluctuate during course of the day1. It is estimated that delirium affects between 14-56% of hospitalised elderly patients and patients with hip fractures have the highest incidence of delirium of 32-53.3%2,3. Post-operative delirium is associated with higher mortality, poor long-term functional outcomes, increased institutionalisation, anxiety and depression4-12. Evidence suggests delirium can persist and increase the risk of developing dementia6,10,14,15. There is a lack of knowledge about patient delirium experience and more research is needed to investigate how delirium impact on both patients and family/carer and what provision of support is required.22 Hip fracture is a major growing public health problem. There are currently 70-75000 hip fractures per year, projected to increase by 2% every year27 and costing the NHS an estimated 1.5million bed days and cost of 2billion per year28. Patients with hip fractures require anaesthesia in order to receive surgery.30 Anaesthesia can be classified into general anaesthesia (GA, where patients are unconscious) or regional anaesthesia (RA, where nerves are numbed by local anaesthetic injection, negating the need of sedation or GA). The use of RA avoids GA drugs and opiates known to be linked to post-operative delirium33. Some studies have reported that the use of RA can significantly reduce the risk of early mortality, deep vein thrombosis and delirium. However such studies were small and dated, creating the need for an updated systematic review and a well-designed definitive study to provide best evidence for clinicians. Aims To perform a systematic review: In elderly patients undergoing fractured neck of femur fixation, does the use of regional anaesthesia (RA) compared to general anaesthesia (GA) reduce incidence of post-operative delirium? To assess the feasibility of carrying out a large randomised controlled trial comparing the effect of GA and RA on the incidence of post-operative delirium in patients undergoing hip fracture surgery in a pilot study. To conduct interviews to explore how delirium impact on patient and family/carer's quality of life. To conduct focus groups with anaesthetists to explore translation of research into clinical practice. Plan of investigation and Research questions Systematic review What is the evidence in the literature on the impact of anaesthetic techniques and the incidence of post-operative delirium? Pilot study What is patient recruitment rate? What is the effectiveness of patient identification and screening process? What are the reasons for failure to recruit patient? Are clinicians willing to participate? Is the randomisation process efficient? Are the planned procedures to blind researcher assessing delirium to treatment allocation adequate? Are the data collection processes robust? What is follow-up rate of patients at 6 and 12 months? What are the reasons for loss of follow-up? Qualitative study - patients What is the impact of delirium on the patient and family/carer's quality of life What support (NHS/social services/financial) was provided What additional support should be providedQualitative study - anaesthetists What type of research data is needed to change practice? How should research results be communicated? What factors influence the implementation of research findings? Potential benefits to NHS and patients Delirium remains under-researched despite its clinical importance, marked health costs and high incidence. NHS Costs associated include longer in-hospital stay, increased demands on primary care, rehabilitation, social services and sheltered accommodation. The lack of any known effective treatment meant that prevention of acute delirium is key to improving patient outcomes. The results of our pilot study will lead to a substantive trial aimed to find the best anaesthetic technique to prevent delirium in this vulnerable population.

Lay abstract: Acute confusion (or delirium) is a serious and under-recognised complication in patients with hip fractures. Delirium increases complication rates, mortality and can develop into long-term memory problems. There is evidence that using regional anaesthesia (patient receives injection to numb part of the body) instead of general anaesthesia (patient is unconscious) may reduce the incidence of delirium. A research programme includes: Literature review Pilot study comparing the effect of regional anaesthesia and general anaesthesia on the incidence of delirium in patients with hip fractures Qualitative study 1 - how delirium affect patients and carers Qualitative study 2 - research translation strategy

Research activity codes: 6.4 SURGERY
Health categories: MUSCULOSKELETAL