# Enhancing Cognitive Impairment Assessment and Management in Hip Fracture Patients: A Two-Cycle Clinical Audit

## TL;DR

This study shows how implementing targeted changes can improve cognitive assessments in elderly hip fracture patients, but sustaining these improvements requires ongoing effort.

## Contribution

The paper introduces a two-cycle audit framework with electronic alerts and training to improve cognitive assessment compliance in hip fracture care.

## Key findings

- AMTS documentation improved from 46.7% to 72% after interventions.
- Postoperative day 1 assessments increased from 0% to 36%.
- Day 4 orthogeriatric assessments declined from 63.3% to 52%, indicating intervention fatigue.

## Abstract

Background: Cognitive impairment significantly affects elderly hip fracture patients, dramatically worsening their outcomes, yet healthcare teams consistently fail to screen for it. Despite national guidelines mandating routine cognitive assessment, compliance remains alarmingly low. This audit confronted this critical gap between evidence and practice in fragility hip fracture care.

Methods: We conducted a prospective two-cycle audit at Northwick Park Hospital in Harrow, England, to transform cognitive assessment practices. Cycle 1 (July-November 2023) exposed baseline failures in 30 patients aged ≥65 with fragility hip fractures. With these insights, we deployed a multifaceted intervention: electronic alerts that could not be ignored, intensive staff training, and strategic visual reminders throughout the unit. Cycle 2 (November 2023-January 2024) tested whether these changes could continue in 25 similar patients. We tracked Abbreviated Mental Test Score (AMTS) documentation at four critical junctures: admission, postoperative days 1 and 2, and the day 4 orthogeriatric review.

Results: The change occurred in a noticeable way, but it was not brought to completion. Initial AMTS documentation improved from 14 (46.7%) to 18 (72%) between cycles. Most dramatically, postoperative day 1 assessments, completely absent at baseline, reached nine (36%) completions, while day 2 assessments climbed from zero to four (16%). However, orthogeriatric day 4 assessments actually declined from 19 (63.3%) to 13 (52%), suggesting intervention fatigue. The shift to electronic records proved double-edged-boosting admission assessments while paradoxically disrupting established day 4 documentation routines.

Conclusions: Strategic interventions can revolutionize cognitive assessment practices, particularly for initial screening, but sustaining these gains demands more than one-time fixes. While education and visual cues successfully embedded new behaviors, the persistent gaps in postoperative reassessment reveal the challenge of truly transforming clinical culture. Success requires not just implementing change but hardwiring it through workflow integration, electronic health record (EHR) optimization, and relentless performance monitoring.