Skip to main content

Advertisement

SpringerLink
Log in

Post-operative delirium in older hip fracture patients: a new onset or was it already there?

  • Research Paper
  • Published:
European Geriatric Medicine Aims and scope Submit manuscript

Key summary points

AbstractSection Aim

To investigate if and how the incidence of post-operative delirium is related to the existence of pre-operative delirium and other peri-operative risk factors in older patients undergoing hip fracture surgery.

AbstractSection Findings

Delirium was present more often pre- than post-operatively. The presence of pre- and post-operative delirium increased according to cognitive impairment severity.

AbstractSection Message

Identifying delirium onset is crucial to provide appropriate prevention and management by a multidisciplinary team.

Abstract

Purpose

Hip fractures are a worldwide health issue primarily for older patients, conditioning major morbidity and mortality. An experienced multidisciplinary team is essential to manage surgery and peri-operative implications, to enable rapid functional and cognitive recovery. Delirium is a recognizable problem associated with negative outcomes. Our study aims to determine the influence of pre-operative delirium in the incidence of post-operative delirium, and to evaluate the association between other known peri-operative risk factors with both conditions.

Methods

A single-center, retrospective cohort study, conducted at a Level II trauma center over a 14-month period, included 241 patients with 65 years of age or older submitted to hip fracture surgery. Peri-operative data were gathered regarding baseline characteristics (sociodemographic, functional and cognitive status), intra-operative events (anesthesia technique, surgery duration, blood loss) and post-operative outcomes (delirium occurrence).

Results

Statistical analysis evidenced a female (75.5%) and elderly population (83.9 ± 7.8 years old) with significant comorbidities (cognitive impairment in 51.9%, ASA ≥ III in 79.7%, mean CIRS-G 8.83 ± 4.69) that underwent surgical fracture repair, mostly under 4 h (96.3%) and under regional anesthesia (63.1%). Pre- and post-operative delirium incidence was 18.3% and 12.9%, respectively, displaying increased presence according to cognitive impairment severity.

Conclusion

Post-operative delirium was almost inexistent when it was absent pre-operatively. Moreover, pre-operative cognitive status was associated with the development of pre- and post-operative delirium. Careful cognitive assessment, implementation of preventive strategies and avoidance of peri-operative pro-delirium factors are crucial for comprehensive geriatric care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A et al (2017) European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 34:192–214

    Article  Google Scholar 

  2. Jong L, Rijckevorsel VAJIM, Raats JW, Klem TM, Kuijper TM, Roukema GR (2019) Delirium after hip hemiarthroplasty for proximal femoral fractures in elderly patients: risk factors and clinical outcomes. Clin Interv Aging 14:427–435

    Article  Google Scholar 

  3. Griffiths R, Alper J, Beckingsale A, Goldhill A, Heyburn G (2012) Management of proximal femoral fractures 2011—Guidelines of Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67:85–98

    Article  CAS  Google Scholar 

  4. Wang Y, Tang J, Zhou F, Yang L, Wu J (2017) Comprehensive geriatric care reduces acute perioperative delirium in elderly patients with hip fractures—a meta-analysis. Medicine 96(26):e7361

  5. Harrisa MJ, Brovmana EY, Urmana RD (2019) Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture. J Clin Anesth 58:61–71

    Article  Google Scholar 

  6. Yeung J, Patel V, Champaneria R, Dretzke J (2016) Regional versus general anaesthesia in elderly patients undergoing surgery for hip fracture: protocol for a systematic review. Syst Rev 5(66)

  7. Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA (2019) Association of duration of surgery with Postoperative Delirium among patients receiving Hip Fracture Repair. JAMA Netw Open 2(2):e190111

  8. Inouye SK, Westendorp RGJ, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922

    Article  Google Scholar 

  9. Johansson YA, Bergh I, Ericsson I, Sarenmalm EK (2018) Delirium in older hospitalized patients—signs and actions: a retrospective patient record review. BMC Geriatr 18(43)

  10. Hamilton GM, Wheeler K, Michele J, Lalu MM, McIsaac DI (2017) A systematic review and meta-analysis examining the impact of incident Postoperative Delirium on mortality. Anesthesiology 127(1):78–88

    Article  Google Scholar 

  11. Jin Z, Hu J, Ma D (2020) Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth 125(4):492–504

    Article  Google Scholar 

  12. Wilson JE, Mart MF, Cunningham C et al (2020) Delirium. Nat Rev Dis Primers 6(90)

  13. Mosk CA, Mus M, Vroemen JP, van der Ploeg T, Vos DI, Elmans LHGJ et al (2017) Dementia and delirium, the outcomes in elderly hip fracture patients. Clin Interv Aging 12:421–430

    Article  Google Scholar 

  14. Freter S, Dunbar M, Koller K, MacKnight C (2016) Prevalence and characteristics of pre-operative delirium in hip fracture patients. Gerontology 62:396–400

    Article  Google Scholar 

  15. Wu J, Yin Y, Jin M, Li B (2021) The risk factors for postoperative delirium in adult patients after hip fracture surgery: a systematic review and meta-analysis. Int J Geriatr Psychiatry 36(1):3–14

    Article  Google Scholar 

  16. Li T, Yeung J, Li J, Zhang Y, Melody T, Gao Y et al (2017) Comparison of regional with general anaesthesia on postoperative delirium (RAGA-delirium) in the older patients undergoing hip fracture surgery: study protocol for a multicentre randomised controlled trial. BMJ Open 7:e016937

    Article  Google Scholar 

  17. Daiello LA, Racine AM (2019) Postoperative delirium and postoperative cognitive dysfunction—overlap and divergence. Anesthesiology 131(3):477–491

    Article  Google Scholar 

  18. Freter S, Dunbar M, Koller K, MacKnight C, Rockwood K (2015) Risk of Pre- and Post-Operative Delirium and the Delirium Elderly at Risk (DEAR) tool in hip fracture patients. Can Geriatr J 18(4):212–216

    Article  Google Scholar 

  19. Sieber F, Neufeld KJ, Gottschalk A, Bigelow GE, Oh ES, Rosenberg PB et al (2019) Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial. Br J Anaesth 122(4):480–489

    Article  Google Scholar 

  20. Gruber-Baldini AL, Zimmerman S, Morrison RS, Grattan LM, Hebel JR, Dolan MM et al (2003) cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up. J Am Geriatr Soc 51:1227–1236

    Article  Google Scholar 

  21. Juliebø V, Bjøro K, Krogseth M, Skovlund E, Ranhoff AH, Wyller TB (2009) Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc 57(8):1354–1361

    Article  Google Scholar 

  22. Reisberg B, Ferris SH, de Leon MJ, Crook T (1982) The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 139:1136–1139

    Article  CAS  Google Scholar 

  23. Salvi F, Miller MD, Grilli A, Giorgi R, Towers AL, Morichi V et al (2008) A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients. J Am Geriatr Soc 56(10):1926–1931

    Article  Google Scholar 

  24. Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel Index. Md State Med J 14:61–65

    CAS  PubMed  Google Scholar 

  25. Mayhew D, Mendonca V, Murthy BVS (2019) A review of ASA physical status—historical perspectives and modern developments. Anaesthesia 74:373–379

    Article  CAS  Google Scholar 

  26. Holden M, Gill K, Magliozzi M, Nathan J, Piehl-Baker L (1984) Clinical gait assessment in the neurologically impaired: reliability and meaningfulness. Phys Ther 64:35–40

    Article  CAS  Google Scholar 

  27. Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T et al (2009) Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 13(9):782–788

    Article  CAS  Google Scholar 

  28. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (Dsm-5®), 5th edn. Amer Psychiatric Pub Inc, Washington, DC

    Book  Google Scholar 

  29. European Delirium Association; American Delirium Society (2014) The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Med 12:141

    Article  Google Scholar 

  30. Liu X, Yu Y, Zhu S (2018) Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): a meta-analysis of observational studies. PLoS One 13(4)

  31. Mathews SB, Arnold SE, Epperson NC (2014) Hospitalization and cognitive decline: can the nature of the relationship be deciphered? Am J Geriatr Psychiatry 22(5):465–480

    Article  Google Scholar 

  32. Morandi A, Davis D, Fick DM, Turco R, Boustani M, Lucchi E et al (2014) Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc 15(5):349–354

    Article  Google Scholar 

  33. Richardson S, Teodorczuk A, Bellelli G, Davis DH, Neufeld KJ, Kamholz BA et al (2016) Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies. Int Psychogeriatr 28(5):853–861

    Article  Google Scholar 

  34. Avelino-Silva TJ, Campora F, Curiati JA, Jacob-Filho W (2017) Association between delirium superimposed on dementia and mortality in hospitalized older adults: a prospective cohort study. PLoS Med 14(3):e1002264

  35. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA (2010) Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 304:443–451

    Article  CAS  Google Scholar 

  36. Morandi A, McCurley J, Vasilevskis EE, Fick DM, Bellelli G, Lee P et al (2012) Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 60(11):2005–2013

    Article  Google Scholar 

  37. Neuman MD, Ellenberg SS, Sieber FE (2016) Regional versus General Anesthesia for Promoting Independence after Hip Fracture (REGAIN): protocol for a pragmatic, international multicentre trial. BMJ Open 6

  38. Abbott TEF, Pearse RM (2019) Depth of anesthesia and postoperative delirium. JAMA 321(5):459–460

    Article  Google Scholar 

  39. Kowark A, Adam C, Ahrens J, Bajbouj M, Bollheimer C, Borowski M et al (2018) Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia. BMJ Open 8:e023609

  40. Miller D, Lewis SR, Pritchard MW, Schofield-Robinson OJ, Shelton CL, Alderson P et al (2018) Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery. Cochrane Database Syst Rev 8:CD012317

  41. Punjasawadwong Y, Chau-in W, Laopaiboon M, Punjasawadwong S, Pin-on P (2018) Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults. Cochrane Database Syst Rev 5:CD011283

  42. Pluta MP, Dziech M, Czempik PF, Szczepańska AJ, Krzych ŁJ (2020) Antipsychotic drugs in prevention of postoperative delirium-what is known in 2020? Int J Environ Res Public Health 17(17):6069

    Article  Google Scholar 

  43. Hip fracture overview [Internet] (2020) Hip fracture—NICE Pathways. http://pathways.nice.org.uk/pathways/hip-fracture. Accessed on 11 Sep 2020

Download references

Author information

Authors and Affiliations

  1. Anaesthesiology Department, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal

    Isabel Costa-Martins, Joana Carreteiro, Vanessa Artilheiro & Manuel Chedas

  2. Internal Medicine Department, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal

    Ana Santos & Luís Campos

  3. Clinical Psychologist, Rua Major Neutel de Abreu, nr 13, 10° A, 1500-409, Lisbon, Portugal

    Mariana Costa-Martins

  4. Orthogeriatric Unit, Internal Medicine Department, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal

    Sofia Duque

Authors
  1. Isabel Costa-Martins
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joana Carreteiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ana Santos
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mariana Costa-Martins
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vanessa Artilheiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sofia Duque
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Luís Campos
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Manuel Chedas
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

ICM: conceptualization, methodology, investigation, resources, data curation, writing—original draft, review and editing, visualization, and project administration. JC: conceptualization, methodology, investigation, resources, data curation, writing—original draft, review, and editing. AS: resources, writing—original draft, review, and editing. MCM: formal analysis, resources, writing—original draft, review, and editing. VA: formal analysis, writing—original draft, review, and editing. SD: conceptualization, resources, data curation, writing—review, and editing. LC: writing—review and editing. MC: conceptualization and supervision.

Corresponding author

Correspondence to Isabel Costa-Martins.

Ethics declarations

Conflict of interest

There is no financial arrangement or other relationship that could be construed as a conflict of interest.

Ethics approval

The study complied with the ethical standards of the Human Research Committee and Declaration of Helsinki. The Centro Hospitalar Lisboa Ocidental Research and Ethics Committee approved the study design and waived the requirement for written informed consent due to the observational and retrospective nature of the study.

Consent to participate

For this type of study, informed consent is not required.

Consent for publication

For this type of study, informed consent is not required.

Availability of data and material

Data transparency under request.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Costa-Martins, I., Carreteiro, J., Santos, A. et al. Post-operative delirium in older hip fracture patients: a new onset or was it already there?. Eur Geriatr Med 12, 777–785 (2021). https://doi.org/10.1007/s41999-021-00456-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s41999-021-00456-w

Keywords

Search

Navigation