Main Article Content
delirium, femur, hip, fracture, cognitive status, hospitalization
Background and aim: The increase in the average-age and in the percentage of elderly people implies an exponential increase in fractures of the proximal femur. A common consequence of hip fracture in elderly patients is delirium, characterized by cognitive confusion or a lethargic-type condition. Predisposing factors have been identified, but risk factors assessment useful for managing clinical intervention, has not received unanimous consent. This work aims to identify the potential risk factors for delirium in the elderly operated for hip fracture.
Methods: In this prospective observational study, we included 83 patients aged ≥65 years. Patients undergoing osteosynthesis of the femur and hip replacement for fractures were included. Patients already delusional in the pre-operative period were excluded. At the time, deadlines T0 (pre-operative), and T1,T3,T7 post-operative day, delirium, hematic parameters, blood transfusions, were assessed.
Results: Level of delirium was assessed obtaining 80% not delusional and 20% delusional. Glycemia and hemoglobin were not found to be risk factors, although they are known to influence cognitive status; we hypothesize they should be considered predisposing factors. Comorbidities such as atrial fibrillation and Chronic Obstructive Pulmonary Disease were found associated with delirium. The most advanced age, anxiolytic drugs, the use of benzodiazepine as anaesthetic, the time surgical waiting, were found significantly associated with delirium.
Conclusions: Taken together, findings of this prospective observational study showed that environmental and metabolic risk factors might contribute to make elderly susceptible to develop postoperative delirium following hip surgery. Thus, these patients should be adequately assessed and monitored. (www.actabiomedica.it)
2. Fricchione GL, Nejad SH, Esses JA, et al. Postoperative delirium. Am J Psychiatry 2008; 165: 803–812.
3. Lee KH, Ha Y-C, Lee Y-K, Kang H, Koo K-H. Frequency, risk factors, and prognosis of prolonged delirium in elderly patients after hip fracture surgery. Clin Orthop Relat Res 2011; 469: 2612–2620.
4. Toro G, Calabrò G, Toro A, de Sire A, Iolascon G. Locking plate fixation of distal femoral fractures is a challenging technique: a retrospective review. Clin Cases Miner Bone Metab. 2015;12:55-8.
5. Bruce AJ, Ritchie CW, Blizard R, Lai R, Raven P. The incidence of delirium associated with orthopedic surgery: a meta-analytic review. Int Psychogeriatr 2007; 19: 197–214.
6. Fricchione GL, Nejad SH, Esses JA, et al. Postoperative delirium. Am J Psychiatry 2008; 165: 803–812.
7. Krogseth M, Watne LO, Juliebo V, et al. Delirium is a risk factor for further cognitive decline in cognitively impaired hip fracture patients. Arch Gerontol Geriatr 2016; 64: 38–44.
8. Zywiel MG, Hurley RT, Perruccio AV, Hancock-Howard RL, Coyte PC, Rampersaud YR. Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. J Bone Joint Surg Am 2015; 97: 829–836.
9. Gleason LJ, Schmitt EM, Kosar CM, et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg 2015; 150: 1134–1140.
10. Kat MG, de Jonghe JF, Vreeswijk R, et al. Mortality associated with delir¬ium after hip-surgery: a 2-year follow-up study. Age Ageing 2011; 40: 312–318.
11. Mosk CA, Mus M, Vroemen JPAM, van der Ploeg T, Vos DI, Elmans LHGJ, van der Laan L. Dementia and delirium, the outcomes in elderly hip fracture patients. Clin Interv Aging 2017: 12 421–430.
12. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet (London, England) 2014; 383: 911–922.
13. Guo Y, Jia P, Zhang J, Wang X, Jiang H, Jiang W. Prevalence and risk factors of postoperative delirium in elderly hip fracture patients. J Int Med Res 2016; 44: 317-327.
14. Shen Y, Shen H-L, Zhang W Fang X-T. Risk factors for delirium of elderly patients undergoing hip fracture operation. Natl Med J China 2013; 93: 3276–3279.
15. Moerman S, Tuinebreijer WE, de Boo M, Pilot P, Nelissen RGHH, Vochteloo AJH. Validation of the risk model for delirium in hip fracture patients. Gen Hosp Psychiatry 2012; 34: 153–159.
16. Lee HB, Mears SC, Rosenberg PB, Leoutsakos JM, Gottschalk A, Sieber FE. Predisposing factors for postoperative delirium after hip fracture repair in individuals with and without dementia. J Am GeriatrSoc 2011; 59: 2306-2313.
17. Gleason LJ, Schmitt EM, Kosar CM, et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg 2015; 150: 1134-1140.
18. Dolan MM, Hawkes WG, Zimmerman SI et al. Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol Ser A Biol Sci Med Sci 2000; 55: M527–M534.
19. Inouye S, Viscoli C, Horwitz R, Hurst L, Tinetti M. A predictive model for delirium in hospitalized elderly medical patient based on admission characteristic. Ann Intern Med 1993; 119: 474-480.
20. Inouye S, PA C. Precipitating factors for delirium in hospitalized elderly persons: a predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275: 852-857.
21. Schuurmans MJ, Duursma SA, Shortridge-Baggett LM, Clevers G-J, Pel-Littel R. Elderly patients with a hip fracture: the risk for delirium. Appl Nurs Res 2003; 16: 75–84.
22. Fick DM, Steis MR, Waller JL, Inouye SK. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med 2013; 8: 500–505.
23. Sieber FE, Neufeld KJ, Gottschalk A, et al. Effect of Depth of Sedation in Older Patients Undergoing Hip FractureRepair on Postoperative Delirium. The STRIDE Randomized Clinical Trial. JAMA Surg 2018; 153: 987–995.
24. Schrijver EJ, de Graaf K, de Vries OJ, Maier AB, Nanayakkara PW. Efficacy and safety of haloperidol for in-hospital delirium prevention and treatment: a systematic review of current evidence. Eur J Intern Med 2016; 27: 14–23.
25. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010; 304: 443–451.
26. Bilotta F, Lauretta MP, Borozdina A, Mizikov VM, Rosa G. Postopera¬tive delirium: risk factors, diagnosis and perioperative care. Minerva Anestesiol 2013; 79: 1066–1076.
27. de Sire A, Invernizzi M, Baricich A, et al. Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation. World J Orthop 2021; 12: 456-466.
28. Morrison RS, Magaziner J, Gilbert M et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol Ser Biol Sci Med Sci 2003; 58: 76–81.
29. Nie H, Zhao B, Zhang YQ, Jiang Y-H, Yang Y-X. Pain and cognitive dysfunction are the risk factors of delirium in elderly hip fracture Chinese patients. Arch Gerontol Geriatr 2012; 54: e172–e174.
30. Bruce A, Ritchie C, Blizard R. The incidence of delirium associated with orthopedic surgery: a meta-analytic review. Int Psycogeriatr 2007; 19: 197-214.
31. Trzepacz P, Baker R, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988; 23: 89-97.
32. Yang Y, Zhao X, Dong T, Yang Z, Zhang Q, Zhang Y. Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res 2017; 29:115–126.
33. Rawling AM, Sharret AR, Albert MS, et al. The Association of Late-Life Diabetes Status and Hyperglycemia With Incident Mild Cognitive Impairment and Dementia: The ARIC Study. Diabetes Care 2019; 42: 1248-1254.
34. Vochteloo AJ, Borger van der Burg BL, Mertens B, et al. Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskelet Disord 2011; 12: 262.
35. Leigheb M, Pogliacomi F, Bosetti M, et al., Postoperative blood salvage versus allogeneic blood transfusion in total knee and hip arthroplasty: a literature review. Acta Biomed 2016; 87(Suppl.1): 6-14.
36. Silverstein JH, Timberger M, Reich DL, Uysal S. Central nervous system dysfunction after noncardiac surgery and anesthesia in the elderly. Anesthesiology 2007; 106: 622–628.
37. Iolascon G, de Sire A, Calafiore D, et al. Multifactorial Assessment of Risk of Falling in 753 Post-Menopausal Women: A Multicenter Cross-Sectional Study by the Italian Group for the Study of Metabolic Bone Diseases. Clin Interv Aging. 2020; 15: 1077-1084.
38. Leigheb M. Intent and program of the new Minerva Orthopedics Editor in Chief. Minerva Orthop 2021;72:2-3.