HSS Journal ®

, Volume 7, Issue 2, pp 151–156 | Cite as

Postoperative Delirium in Elderly Patients After Elective Hip or Knee Arthroplasty Performed Under Regional Anesthesia

  • Matthew C. Rade
  • Jacques T. YaDeauEmail author
  • Carey Ford
  • M. C. Reid
Original Article


Delirium is a major adverse postoperative event in elderly patients. Incidence rates of postoperative delirium are difficult to determine. Because of the accuracy, brevity, and ease of use by clinical interviewers, the Confusion Assessment Method (CAM) has become widely used. This study used the CAM to determine the rate of postoperative delirium in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures under regional anesthesia. Following Institutional Review Board approval, a prospective study of 20 patients per group ages 70 and above undergoing unilateral THA or TKA was initiated. Both groups received a combined spinal–epidural, postoperative patient-controlled epidural anesthesia, and postoperative oral opioids. Patient interviews occurred five times: once preoperatively and two times each on postoperative days 1 and 2. Only two patients were assessed as delirious according to the CAM method (one in each group; 5%). Patient assessment by other clinicians indicated that five additional patients experienced acute change in mental status; however, these patients were not delirious at the times of the study interviews. The rate of delirium in the elderly after arthroplasty performed under regional anesthesia is very low. Reasons for this include patient selection criteria and anesthesia type. The study excluded patients with several proposed risk factors for postoperative delirium: prior history of dementia, history of mental illness, and use of benzodiazepines. The use of regional anesthesia may have also reduced the occurrence of postoperative delirium.


postoperative delirium delirium confusion assessment method elderly total knee arthroplasty total hip arthroplasty regional anesthesia 



Adapted from Inouye et al. [5] and Inouye [4].

We would also like to acknowledge Ruchi Pancholy’s contributions as a patient assessor.


  1. 1.
    Bruera E, Bush SH, Willey J, Paraskevopoulos T, Li Z, Palmer JL, Cohen MZ, Sivesind D, Elsayem A. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 2009;115:2004–12CrossRefGoogle Scholar
  2. 2.
    Ely EW. Delirium in mechanically ventilated patients; validity and reliability of the Confusion Assessment Method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703–10CrossRefGoogle Scholar
  3. 3.
    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(3):189–98CrossRefGoogle Scholar
  4. 4.
    Inouye SK. The Confusion Assessment Method (CAM): Training Manual and Coding Guide. 2003; New Haven: Yale University School of Medicine.Google Scholar
  5. 5.
    Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A New method for detection of delirium. Ann Intern Med 1990:113:941–8CrossRefGoogle Scholar
  6. 6.
    Kalisvaart KJ, Vreeswijk R, de Jonghe JFM, van der Ploeg T, van Gool WA, Eikelenboom P. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model. J Am Geriat Soc 2006;54:817–22CrossRefGoogle Scholar
  7. 7.
    Kudoh A, Takse H, Takahira Y, Takazawa T. Postoperative confusion increases in elderly long-term benzodiazepine users. Anesth Anal 2004;99:1674–8CrossRefGoogle Scholar
  8. 8.
    Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. AM J Emerg Med. 1995;13:142–5CrossRefGoogle Scholar
  9. 9.
    Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998;86:781–5CrossRefGoogle Scholar
  10. 10.
    Marcantonio ER, Michaels M, Resnick NM. Diagnosing delirium by telephone. J Gen Intern Med. 1998;13:621–3CrossRefGoogle Scholar
  11. 11.
    Mason SE, Noel-Storr A, Ritchie CW. The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium: a systematic review with meta-analysis. J Alzheimers Dis 2010;22 Suppl 3:67–79CrossRefGoogle Scholar
  12. 12.
    Morrison RS, Chassin MR, Siu AL. The medical consultant’s role in caring for patients with hip fracture. Ann Intern Med 1998;128:1010–20CrossRefGoogle Scholar
  13. 13.
    Ramaiah R, Lam AR. Postoperative Cognitive Dysfunction in the Elderly. Anesthesiology Clin 2009;27:485–96CrossRefGoogle Scholar
  14. 14.
    Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc 1992;40(9):922–35CrossRefGoogle Scholar
  15. 15.
    Williams-Russo P, Urquhart B, Sharrock N, Charlson M. Postoperative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc 1992;40:759–67CrossRefGoogle Scholar
  16. 16.
    YaDeau JT, Cahill JB, Zawadsky MW, Sharrock NE, Bottner F, Morelli CM, Kahn RL, Sculco TP. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg 2005;101:891–5CrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2011

Authors and Affiliations

  • Matthew C. Rade
    • 1
  • Jacques T. YaDeau
    • 1
    • 2
    Email author
  • Carey Ford
    • 1
  • M. C. Reid
    • 3
  1. 1.Department of AnesthesiologyHospital for Special SurgeryNew YorkUSA
  2. 2.Weill College of Medicine of Cornell UniversityNew YorkUSA
  3. 3.Department of MedicineWeill College of Medicine of Cornell UniversityNYUSA

Personalised recommendations