Elsevier

Archives of Gerontology and Geriatrics

Volume 36, Issue 1, January–February 2003, Pages 67-74
Archives of Gerontology and Geriatrics

The unfavorable nature of preoperative delirium in elderly hip fractured patients

https://doi.org/10.1016/S0167-4943(02)00058-4Get rights and content

Abstract

The onset of delirium is frequent in elderly patients who sustain hip fractures. The purpose of this study was to characterize different patterns of preoperative and postoperative delirium, to study factors associated with preoperative delirium and to evaluate the possible different outcome of these patients. This retrospective study comprised 281 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini mental state examination (MMSE), assessment of possible delirium by the confusion assessment method (CAM) and functional outcome assessed by functional independence measure (FIM). A database search was conducted to identify whether delirium onset occurred prior to or following surgery. About 31% of the total sample developed delirium. Delirious patients tended to be more disabled (P=0.03) and cognitively impaired (P=0.018), compared with non-delirious patients. Most delirious cases (53%) had their onset in the preoperative period. Patients with preoperative delirium were older (P=0.03), had a lower prefracture mobility (P<0.01), impaired cognition (P=0.04) and showed an adverse functional outcome in terms of FIM score. Regression analysis showed that prefracture dementia, prefracture mobility and low MMSE scores were strongly associated with higher probability of having preoperative delirium, with no additional effect of other variables. It is concluded that preoperative delirium should be viewed as a separate entity with unfavorable nature and adverse outcome. Careful preventive measures and better treating strategies should be employed to avoid this clinical condition.

Introduction

Delirium is an acute confusional state involving a disturbance of consciousness. This serious complication is common in many aged hip fracture patients (Gustafson et al., 1988). It is associated with lower functional outcome (Murray et al., 1993, O'Keeffe and Lavan, 1997, Marcantonio et al., 2000), increased length of stay (Pompei et al., 1994) and higher rates of institutionalization and mortality (Magaziner et al., 1989, Inouye et al., 1998). These problems prompted the development of many costly and complex strategies, aimed at reducing its incidence by taking preventive measures.

Many factors associated with or precipitating delirium are mentioned in the literature. However, delirium is traditionally considered as perioperative, and there is only a single recently published study considering the critical issue of time onset of delirium. The distinction between preoperative and postoperative delirium should assist in a better recognition of factors involved in delirium onset and, thereby, focusing on the proper intervention.

We undertook this retrospective study to determine the prevalence of preoperative and postoperative delirium, in elderly hip fracture patients, and to look for the factors which are independently associated with delirium onset, after controlling for some potential variables.

Section snippets

Design and setting

This study was designed as a retrospective cohort study, aimed at evaluating the relations between some clinically important factors and time onset of delirium, in patients undergoing surgical intervention for hip fractures. It was conducted in a geriatric-orthopedic ward, which is a 30-bed unit utilizing an interdisciplinary team approach. The nature and characteristics of this orthogeriatric facility has already been described in details (Adunsky et al., 2002). Briefly, this is

General characteristics

The analyses included the first 302 consecutive hip fracture patients, aged 60 years or older, who had been admitted to the ward during a 2 year period and had been treated by surgery. Data regarding the presence or absence of delirium, and the precise time onset of delirium were available for 281 patients (93%) who were included in the final analysis. The general characteristics of these patients are shown in Table 1. Mean MMSE score was 22.4±5.9. Since cognitive impairment is defined

Discussion

Preoperative delirium is insufficiently recognized. It is a common belief that delirium ‘typically presents early in the postoperative period’, but this seems to mislead. The present study specifically examines the important issue of preoperative versus postoperative delirium in elderly hip fractured patients, in a relatively large sample of patients, using strict criteria for assessing cognition, delirium and function. The results are important with regards to practical management, showing the

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