Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Abstract

Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

Factors predicting incidence of post‐operative delirium in older people following hip fracture surgery: a systematic review and meta‐analysis

“…Delirium (sometimes called 'acute confusional state') is characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. The incidence of post-operative delirium following hip fracture surgery has been estimated to be between 4% and 53%, and is the most common surgical complication for older people following surgery (Rizk et al, 2016). The consequences of experiencing delirium include higher mortality rates, hospital-acquired complications, persistent cognitive impairments, poor functional recovery after surgery and increased healthcare costs (Martocchia et al, 2015).…”

Approaches to acute pain management in older people

“…Older people report less pain than their younger counterparts because of a variety of physiological, social and cultural reasons or language barriers (Keen et al 2017). Delirium is one reason which can have a profound effect on pain assessment and management (Rizk et al 2016). The BPS (2013) found that people over the age of 85 with poor cognitive performance were the most likely group to receive inadequate pain control in hospital.…”

“…Under-treatment of acute pain is more likely to occur in cognitively impaired older people (Rizk et al 2016, Swart et al 2017. Although acute pain assessment and management in older people with cognitive impairment presents specific challenges, nurses can dramatically improve care through the use of observational and behavioural pain assessment tools and timely administration of appropriate treatments.…”

Association of postoperative delirium with markers of neurodegeneration and brain amyloidosis: a pilot study

“…Elective surgery is an ideal approach to investigate the brain vulnerabilities predisposing to POD, since it allows neuroimaging examinations to be performed before surgery. However, individuals after nonelective surgery were a more frail population with increased risk of delirium and adverse long-term outcomes compared to the elective surgery ones, deserving further investigations (Rizk et al, 2016).…”