Marcantonio 2001.

Methods	A randomised controlled trial comparing a geriatrician‐led recovery on a general orthopaedic ward compared to an orthopaedic surgeon‐led conventional rehabilitation and recovery intervention delivered on an orthopaedic ward for inpatients following hip fracture surgery in the USA. This paper presented data of a subgroup analysis of people with probable dementia as part of the larger randomised controlled trial.
Participants	Sample size: 126 participants were randomised to the 2 groups. Group allocation: 62 participants were randomised to receive the geriatrician‐led recovery intervention, whilst 64 participants received the orthopaedic surgeon‐led recovery intervention from the hospital ward. Diagnosis/cognitive status: From the subgroup of people with cognitive impairment, 21 participants were allocated to the geriatrician‐led recovery compared to 29 to the orthopaedic‐led recovery group. Cognitive function was assessed with the MMSE, delirium with the DSI, severity of delirium with the MDAS, and the ascertainment of delirium with the CAM. Proxy assessments were made using the Blessed Dementia Rating Scale. Pre‐fracture probable dementia was classified as a Blessed score of 4 or higher. 21 participants in the geriatrician‐led recovery group were thus classified as having probable dementia as opposed to 29 in the orthopaedic surgeon‐led recovery group. Age: The mean age of the geriatrician‐led recovery intervention group was 78 years (SD 8), as opposed to 80 years (SD 8) in the group that received the orthopaedic surgeon‐led recovery intervention in the hospital ward. Gender mix: The geriatrician‐led recovery intervention group consisted of 13 men and 49 women, whilst there were 14 men and 50 women in the orthopaedic surgeon‐led recovery intervention group from the hospital ward. Surgical management: Hip replacement surgery (unspecified if hemiarthroplasty or total hip arthroplasty) was performed in 20 participants in the geriatrician‐led recovery group and 22 participants in the orthopaedic‐led recovery group. Usual place of residence: Not stated. Comorbidites: Comorbidites were assessed using the Charlson Index. 24 participants in the geriatrician‐led recovery consultation review group and 21 participants in the orthopaedic‐led recovery group had a Charlson Index of 4 or greater. Eligibility: Inclusion: people aged 65 years and older admitted for primary surgical repair of hip fracture. Exclusion: presence of metastatic cancer or comorbid illnesses likely to reduce life expectancy to less than 6 months, or inability to obtain informed consent within 24 hours of surgery or 48 hours of admission. If patients demonstrated evidence of probable dementia or delirium at the time of enrolment, consent was also obtained from a designated healthcare proxy.
Interventions	Geriatrician‐led recovery intervention: Geriatric consultation preoperatively or within 24 hours postoperatively. A geriatrician performed daily visits to each participant randomised to this group and made targeted recommendations based on a protocol on aspects of care including: oxygen delivery; fluid and electrolyte balance; pain management; medication review to eliminate unnecessary medications; regulation of bowel and bladder function; nutritional intake; early mobilisation and rehabilitation; prevention, early detection, and treatment of major postoperative complications such as cardiac conditions, embolism, respiratory conditions, and urinary tract infections; optimising environmental stimuli through the provision of glasses and hearing aids, and the provision of clocks, calendars, radios, tape recorders, and soft lighting; and the treatment of agitated delirium. No more than 5 recommendations could be prioritised after the initial visit, and no more than 3 after follow‐up visits. Orthopaedic‐led recovery intervention: Pre‐ and postoperative management by the orthopaedic team with reactive internal medicine or geriatric consultation rather than on a proactive basis as per the geriatrician‐led recovery group.
Outcomes	Follow‐up intervals: Daily assessment of outcomes during acute hospital stay. Outcomes of interest to this review: MMSE; DSI; MDAS; CAM; incidence of severe delirium, defined as a CAM‐defined delirium when the MDAS score was 18 or higher on a least 1 hospital day; hospital length of stay; discharge disposition.
Notes	Funding sources: Older Americans Independence Center and Charles Farnsworth Trust. The sample size calculation was based on a target to observe a third reduction of delirium in the intervention groups compared to usual care with an 80% power.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: Participants randomised "by opening a sealed envelope containing the randomisation assignment derived from a random number table" (p 517). Comment: Done
Allocation concealment (selection bias)	Low risk	Quote: Participants randomised "by opening a sealed envelope containing the randomisation assignment derived from a random number table" (p 517). Comment: Done
Blinding of participants and personnel (performance bias) All outcomes	High risk	Comment: Due to the nature of the interventions, it was not possible to blind participants or personnel to the intervention received.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Quote: The researcher "conducted the assessments blinded to the intervention status of the subjects" (p 517). Comment: Done
Incomplete outcome data (attrition bias) All outcomes	Low risk	Quote: "follow‐up was completed on all randomise subjects" (p 518) Comment: Done
Selective reporting (reporting bias)	Unclear risk	Comment: MMSE, DSI, and MDAS were collected to inform the incidence of delirium, but were not reported as single outcomes. No trial protocol was presented to confirm full reporting of outcomes, therefore it was unclear whether this measure was prospectively defined.
Other bias	High risk	Comment: This was a subgroup analysis of a larger RCT. It was not possible to assess whether there was a difference in baseline characteristics between groups. Comment: High risk of contamination bias where intervention and control care pathways were delivered in the same hospital (p 517).