Aging Clinical and Experimental Research

, Volume 19, Issue 3, pp 178–186 | Cite as

Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study

  • Maria LundströmEmail author
  • Birgitta Olofsson
  • Michael Stenvall
  • Stig Karlsson
  • Lars Nyberg
  • Undis Englund
  • Bengt Borssén
  • Olle Svensson
  • Yngve Gustafson
Original Articles


Background and aims: Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. Methods: One hundred and ninety-nine patients, aged 70 years and over (mean age±SD, 82±6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. Results: The number of days of postoperative delirium among intervention patients was fewer (5.0±7.1 days vs 10.2±13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0±17.9 days vs 38.0±40.6 days, p=0.028). Conclusions: Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.


Delirium femoral neck fracture geriatric team intervention RCT 


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  1. 1.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, American Psychiatric Association, 1994.Google Scholar
  2. 2.
    Berggren D, Gustafson Y, Eriksson B, et al. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesth Analg 1987; 66: 497–504.PubMedCrossRefGoogle Scholar
  3. 3.
    Gustafson Y, Berggren D, Brännström B, et al. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc 1988; 36: 525–30.PubMedGoogle Scholar
  4. 4.
    Lundström M, Edlund A, Bucht G, Karlsson S, Gustafson Y. Dementia after delirium in patients with femoral neck fractures. J Am Geriatr Soc 2003; 51: 1002–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc 2000; 48: 618–24.PubMedGoogle Scholar
  6. 6.
    Kallin K, Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Why the elderly fall in residential care facilities, and suggested remedies. J Fam Pract 2004; 53: 41–52.PubMedGoogle Scholar
  7. 7.
    Gustafson Y, Brännström B, Berggren D, et al. A geriatricanesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc 1991; 39: 655–62.PubMedGoogle Scholar
  8. 8.
    Lundström M, Edlund A, Lundström G, Gustafson Y. Reorganization of nursing and medical care to reduce the incidence of post-operative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 1999; 13: 193–200.PubMedGoogle Scholar
  9. 9.
    Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001; 49: 516–22.PubMedCrossRefGoogle Scholar
  10. 10.
    Mcintosh TK, Bush HL, Yeston NS, et al. Beta-endorphin, cortisol and postoperative delirium: a preliminary report. Psychoneuroendocrinology 1985; 10: 303–13.PubMedCrossRefGoogle Scholar
  11. 11.
    Flacker JM, Lipsitz LA. Neural mechanisms of delirium: current hypotheses and evolving concepts. J Gerontol A Biol Sci Med Sci 1999; 54: B239–46.PubMedCrossRefGoogle Scholar
  12. 12.
    Olsson T. Activity in the hypothalamic-pituitary-adrenal axis and delirium. Dement Geriatr Cogn Disord 1999; 10: 345–9.PubMedCrossRefGoogle Scholar
  13. 13.
    O’Keeffe ST, Devlin JG. Delirium and the dexamethasone suppression test in the elderly. Neuropsychobiology 1994; 30: 153–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Sapolsky RM, Pulsinelli WA. Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications. Science 1985; 229: 1397–400.PubMedCrossRefGoogle Scholar
  15. 15.
    Milisen K, Foreman MD, Abraham IL, et al. A nurse-led inter-disciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001; 49: 523–32.PubMedCrossRefGoogle Scholar
  16. 16.
    Vidan M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc 2005; 53: 1476–82.PubMedCrossRefGoogle Scholar
  17. 17.
    Williams MA, Campbell EB, Raynor WJ, Mlynarczyk SM, Ward SE. Reducing acute confusional states in elderly patients with hip fractures. Res Nurs Health 1985; 8: 329–37.PubMedCrossRefGoogle Scholar
  18. 18.
    Inouye SK, Bogardus ST, Jr., Charpentier PA, et al. A multi-component intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76.PubMedCrossRefGoogle Scholar
  19. 19.
    Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg 1961; 43: B647–63.Google Scholar
  20. 20.
    Sletvold O, Tilvis R, Jonsson A, et al. Geriatric work-up in the Nordic countries. The Nordic approach to comprehensive geriatric assessment. Dan Med Bull 1996; 43: 350–9.Google Scholar
  21. 21.
    Jonsson A, Gustafson Y, Schroll M, et al. Geriatric rehabilitation as an integral part of geriatric medicine in the Nordic countries. Dan Med Bull 2003; 50: 439–45.PubMedGoogle Scholar
  22. 22.
    Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–98.Google Scholar
  23. 23.
    Jensen E, Dehlin O, Gustafson L. A comparison between three psychogeriatric rating scales. Int J Geriatr Psychiatry 1993; 8: 215–29.CrossRefGoogle Scholar
  24. 24.
    Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982; 17: 37–49.PubMedCrossRefGoogle Scholar
  25. 25.
    Sheikh J, Yesavage JA. A Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986; 5: 165–72.CrossRefGoogle Scholar
  26. 26.
    de Craen AJ, Heeren TJ, Gussekloo J. Accuracy of the 15- item geriatric depression scale (GDS-15) in a community sample of the oldest old. Int J Geriatr Psychiatry 2003; 18: 63–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Björkelund KB, Larsson S, Gustafson L, Andersson E. The Organic Brain Syndrome (OBS) scale: a systematic review. Int J Geriatr Psychiatry 2006; 21: 210–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Eriksson M, Samuelsson E, Gustafson Y, Åberg T, Engström KG. Delirium after coronary bypass surgery evaluated by the organic brain syndrome protocol. Scand Cardiovasc J 2002; 36: 250–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in aged: the Index of ADL: a standardized measure of biological and psychosocial function. J Am Med Ass 1963; 185: 914–9.CrossRefGoogle Scholar
  30. 30.
    Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005; 53: 622–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2006; 61: 176–81.PubMedCrossRefGoogle Scholar
  32. 32.
    Gustafson Y, Brännström B, Norberg A, Bucht G, Winblad B. Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc 1991; 39: 760–5.PubMedGoogle Scholar
  33. 33.
    Sörensen Duppils G, Wikblad K. Acute confusional states in patients undergoing hip surgery: a prospective observation study. Gerontology 2000; 46: 36–43.CrossRefGoogle Scholar

Copyright information

© Springer Internal Publishing Switzerland 2007

Authors and Affiliations

  • Maria Lundström
    • 1
    Email author
  • Birgitta Olofsson
    • 1
    • 2
  • Michael Stenvall
    • 1
  • Stig Karlsson
    • 1
  • Lars Nyberg
    • 3
  • Undis Englund
    • 1
  • Bengt Borssén
    • 4
  • Olle Svensson
    • 2
  • Yngve Gustafson
    • 1
  1. 1.Department of Community Medicine and Rehabilitation, Geriatric MedicineUmeå UniversityUmeå
  2. 2.Department of Surgical and Perioperative Science, OrthopedicsUmeå UniversityUmeå
  3. 3.Department of Health SciencesLuleå University of TechnologyLuleå
  4. 4.Department of OrthopedicsUmeå University HospitalUmeåSweden

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