Hip fractures can be disastrous for older persons. It is unfortunately very common for frail older people to experience acute confusion, called delirium, after surgery for hip fracture. This occurs in up to 60% of older people undergoing this surgery. This is not only distressing at the time, but the confusion may never completely clear. In addition, having an episode of postoperative delirium is associated with an increased risk of complications like falls during the hospital stay, nursing home placement, and death.
Risk factors for developing delirium include older age, deficits in vision and hearing, using sleeping pills or alcohol, needing help with self-care before the hip fracture, and pre-existing memory problems. If these risk factors are recorded before the operation, it is possible to pinpoint who will have trouble with delirium after the operation. These “high-risk” patients can then be targeted with special post-operative orders designed specifically to prevent delirium.
Interventions in “high-risk” people include avoiding drugs that can cause confusion, including ones that are commonly used postoperatively like Gravol, sleeping pills, and higher doses of opioid analgesics. In addition, extra attention to non-narcotic analgesia, bowel, and bladder issues can help keep frail older people from developing postoperative delirium.
We have developed a set of “delirium-friendly” postoperative orders, which we believe will help prevent delirium in frail, older, “high-risk” hip fracture patients. Through this study, we hope to generate a new model of care that is easy to incorporate into routine practice and that will significantly reduce the risk of postoperative delirium in this population. Improved cognitive outcomes after surgery may equate to a more rapid return to pre-fracture functioning, improved quality of life, and reduced healthcare costs.
Ongoing Clinical Trial
Our study seeks to answer two important questions:
- Whether “delirium-friendly” standing orders can be implemented successfully in postoperative hip fracture patients.
- Whether the use of “delirium-friendly” standing orders can significantly reduce the incidence or severity of delirium in hip fracture patients at highest risk for postoperative delirium.
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Predicting post-operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Freter SH, Dunbar MJ, MacLeod H, Morrison M, MacKnight C, Rockwood K. Age Ageing. 2005 Mar;34(2):169-71.