Is the CRP-Albumin-Lymphocyte (CALLY) Index Effective in Predicting Postoperative Delirium in Geriatric Patients Undergoing Hip Fracture Surgery

Introduction: Postoperative delirium (POD) is a common complication in elderly surgical patients and is significantly associated with prolonged hospital stays, cognitive impairment, functional decline, and increased mortality rates within 6 to 12 months. Its incidence has been reported to range between 10% and 70%, depending on the diagnostic criteria used, the population studied, and the type of surgical procedure performed. The incidence is particularly higher following vascular, cardiac, and hip fracture surgeries.

According to the 2024 updated guidelines by the European Society of Anaesthesiology and Intensive Care (ESAIC), POD should be screened at least once daily for a minimum of three days, beginning in the post-anesthesia recovery unit, based on the DSM-5 criteria. POD is a complex syndrome associated with various phenotypes and is likely the result of a combination of neuroinflammatory and oxidative stress processes.

Candidate biomarkers for POD include inflammatory parameters (such as interleukins, C-reactive protein [CRP], erythrocyte sedimentation rate, and CD68), dopamine receptors, norepinephrine levels, cortisol levels, genetic biomarkers (e.g., apolipoprotein E4), acetylcholinesterase levels, and albumin levels. However, systemic stress can lead to nonspecific activation of the immune system, resulting in a decrease in lymphocyte count.

Although the relationships between CRP, albumin, and lymphocyte count with POD have been individually investigated in the literature, no study has examined the combined effect of these three parameters. Based on this, we aimed to investigate whether the CRP-Albumin-Lymphocyte (CALLY) Index, a novel index not previously reported in the literature, is effective in predicting POD in geriatric patients with hip fractures. The CALLY Index is calculated using the formula: (Albumin × Lymphocyte) / (CRP × 10⁴).

Aim/Hypothesis:

H₀: The CALLY Index cannot predict the risk of postoperative delirium in geriatric patients undergoing hip fracture surgery.

H₁: The CALLY Index can predict the risk of postoperative delirium in geriatric patients undergoing hip fracture surgery.

Material-Methods:

The following data will be recorded for each patient:

• Demographic variables: age, sex, height, weight, and body mass index (BMI)
• American Society of Anesthesiologists (ASA) physical status classification
• Comorbidities and medication use
• Smoking and alcohol consumption history
• Preoperative laboratory parameters: obtained from the hospital information system for CALLY Index calculation
• Perioperative variables: type and duration of anesthesia, duration of surgery, type of surgical procedure, estimated blood loss, blood product transfusion status, and occurrence of intraoperative adverse events
• Postoperative data:
• Ward of admission after surgery (orthopedic ward/intensive care unit)
• Presence of delirium, assessed twice daily (morning and evening) for three days using DSM-5 criteria, starting in the post-anesthesia recovery unit
• Occurrence of postoperative complications
• Length of stay in the intensive care unit
• Total hospital length of stay
• Mortality status

Patients aged 65 years and older who undergo surgery for femoral neck or intertrochanteric fractures will be included in the study. Patients with preoperative delirium, preoperative dementia, pathological or open fractures, systemic or localized infections in the fracture region during the preoperative period, or multiple trauma will be excluded. Additionally, those with a BMI <18.5 or ≥35 chronic organ failure, or advanced-stage cancer will be excluded from the study.

Study Overview

• Status: Recruiting
• Conditions: Hip Fracture; Postoperative Delirium (POD); CRP; Lymphocyte; Albumin
• Intervention / Treatment: Diagnostic test: The Diagnostic and Statistical Manual of Mental Disorders (DSM) - 5 criteria for delirium diagnosis

• Study Type: Observational
• Enrollment (Estimated): 100

Contacts and Locations

• Study Contact: Name: Erbil Türksal, Specialist; Phone Number: +90 530 228 1319; Email: drerbilturksal@hotmail.com

Study Locations

• Turkey
  • Keçiören
    • Ankara, Keçiören, Turkey, 06290
      • Recruiting
      • University of Health Sciences, Ankara Atatürk Sanatorium Training and Research Hospital
      • Contact: Erbil Türksal, Specialist; Phone Number: +90 530 228 1319; Email: drerbilturksal@hotmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

In the literature, the preoperative CRP/albumin ratio has been found to have a sensitivity of 94.1% and a specificity of 43.9% (AUC: 3.69) in detecting postoperative delirium. The incidence of postoperative delirium varies between 10% and 70%, depending on the diagnostic criteria used, the population studied, and the type of surgical procedure. Its incidence is higher following vascular, cardiac, and hip fracture surgeries.

In our study, which investigates the predictive value of the CRP-Albumin-Lymphocyte (CALLY) Index in detecting delirium after hip fracture in the geriatric patient population, these literature findings were taken into account. Based on the Sample Size Estimation in Diagnostic Accuracy Studies, with a power of 0.85, a Type I error of 5%, a specificity of 43.9%, and a prevalence of 50%, the required sample size was calculated as 84 patients. Considering a 20% margin of error, it was decided to include 100 patients in the study.

Description

Inclusion Criteria:

• Patients aged 65 years and older who undergo surgery for femoral neck or intertrochanteric fractures

Exclusion Criteria:

• Patients with preoperative delirium
• Patients with preoperative dementia
• Patients with pathological fractures
• Patients with open fractures
• Patients with systemic or localized infections in the fracture region during the preoperative period
• Patients with multiple trauma
• Patients with a BMI <18.5 or ≥35
• Patients with chronic organ failure
• Patients with advanced-stage cancer

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Geriatric patients undergoing hip fracture surgery; Patients aged >65 years undergoing hip fracture surgery during the study period	Diagnostic test: The Diagnostic and Statistical Manual of Mental Disorders (DSM) - 5 criteria for delirium diagnosis; Delirium presence will be assessed using DSM-5 criteria twice daily (morning and evening) for three days, after surgery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative delirium	Delirium presence will be assessed using DSM-5 criteria	Twice daily (morning and evening) for three days

Collaborators and Investigators

• Sponsor: Ankara Ataturk Sanatorium Training and Research Hospital
• Investigators: Principal Investigator: Erbil Türksal, Specialist, University of Health Sciences, Ankara Atatürk Sanatorium Training and Research Hospital

Study record dates

Study Major Dates

• Study Start (Actual): February 6, 2025
• Primary Completion (Estimated): August 6, 2025
• Study Completion (Estimated): December 31, 2025

Study Registration Dates

• First Submitted: February 5, 2025
• First Submitted That Met QC Criteria: February 7, 2025
• First Posted (Actual): March 25, 2025

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 12, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neurologic Manifestations; Nervous System Diseases; Mental Disorders; Wounds and Injuries; Postoperative Complications; Pathologic Processes; Leg Injuries; Confusion; Neurobehavioral Manifestations; Neurocognitive Disorders; Femoral Fractures; Hip Injuries; Emergence Delirium; Delirium; Fractures, Bone; Hip Fractures
• Other Study ID Numbers: 2024-BÇEK/195

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No