Postoperative delirium in geriatric patients with hip fractures

Abstract

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Recent advances in the identification of related factors and preventive strategies of hip fracture

“…The reasons for such a phenomenon remain poorly understood, but may include decreased physical activity, soil sealing, calcium and vitamin D deficiencies, less sun exposure, and changes in BMD ( 16 – 18 ).…”

Dementia and Hip Fractures

“…In the postoperative period, we strongly recommend using IV acetaminophen and limiting the use of narcotics. In a retrospective study of 123 geriatric hip fracture patients, use of IV acetaminophen reduced the incidence of POD from 32.8 to 15.4% 28 . While opioid administration can itself be a risk factor of POD 72 , pain is perhaps a stronger POD trigger in geriatric patients with hip fractures 73 .…”

“…Recent studies have evaluated the efficacy of an "orthogeriatric" care model for treating elderly patients with hip fractures. The care team primarily consists of orthopaedic surgeons, geriatricians, physical therapists, occupational therapists, and nurses 28 . With their expertise in navigating the substitute decision-making process, preoperative geriatric consultation ensures patients' wishes are heard and respected.…”

“…POD is a common issue within the geriatric population, with dementia being one of the most well-documented risk factors. Delirium after surgical management of hip fractures leads to increased complication rates, increased institutionalization rates, poorer cognitive outcomes, and increased mortality 23,28 . When present in those with preoperative dementia, POD has a compounding effect on mortality and complication rates 69 .…”

“…In a case-control study, elderly patients with preoperative exposure to antidepressants such as sertraline had significantly greater risk of POD after hip or knee surgery 70 . Similarly, appropriate analgesia decreases the risk of delirium after fracture fixation 28 . Before leaving the operating room, surgeons should consider giving a local cocktail injection consisting of bupivacaine, morphine, and ketorolac.…”