Clinical Orthopaedics and Related Research®

, Volume 469, Issue 9, pp 2612–2620 | Cite as

Frequency, Risk Factors, and Prognosis of Prolonged Delirium in Elderly Patients After Hip Fracture Surgery

  • Kyung-Hag Lee
  • Yong-Chan Ha
  • Young-Kyun Lee
  • Hyun Kang
  • Kyung-Hoi Koo
Clinical Research

Abstract

Background

Delirium in elderly patients after hip fracture surgery is believed to be a transient event, although it frequently lasts for more than 4 weeks.

Questions/purposes

We determined the incidence, risk factors, morbidity, and mortality of prolonged delirium in elderly patients after hip fracture surgery.

Patients and Methods

We evaluated 232 elderly patients (older than 65 years) (232 hips) who underwent hip fracture surgery for the development and duration of delirium and categorized them into three groups; nondelirium group, transient (≤ 4 weeks) delirium group, and prolonged (> 4 weeks) delirium group. Patients underwent a global geriatric evaluation, which included postoperative complications, mortality, and functional and mental status evaluations. The three groups were compared with respect to these variables.

Results

Seventy patients (30.2%) had delirium develop, and among these, 14 (20%) had prolonged delirium with a total incidence of 6%. Multivariate analysis showed preinjury dementia was a risk factor of prolonged delirium. At the final followup, five (62.5%) of the eight patients who were ambulatory outdoors in the prolonged delirium group became housebound, whereas only 18 (16.4%) of the 110 patients who were ambulatory outdoors in the nondelirium group became housebound. Survival at 40 months was 81.0% (95% confidence interval, 72.6%–89.3%) in the nondelirium group and 63.6% (95% confidence interval, 35.2%–92.1%) in the prolonged delirium group.

Conclusions

Prolonged delirium was found to be associated with a poor functional outcome and increased mortality.

Level of Evidence

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Notes

Acknowledgments

We thank Byung-Gun Chang MD, Hyun-Jeong Oh RN, and Sere Noh RN, for their efforts in enrolling and interviewing patients for this study.

References

  1. 1.
    Blass JP, Gibson GE. Cerebrometabolic aspects of delirium in relationship to dementia. Dement Geriatr Cogn Disord. 1999;10:335–338.PubMedCrossRefGoogle Scholar
  2. 2.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.PubMedCrossRefGoogle Scholar
  3. 3.
    Chiam PC, Ng TP, Tan LL, Ong PS, Ang A, Kua EH. Prevalence of dementia in Singapore: results of the National Mental Health Survey of the Elderly 2003. Ann Acad Med Singapore. 2004;33(5 suppl):S14–S15.PubMedGoogle Scholar
  4. 4.
    Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing. 2009;38:19–26.PubMedCrossRefGoogle Scholar
  5. 5.
    Cole MG, McCusker J, Dendukuri N, Han L. Symptoms of delirium among elderly medical inpatients with or without dementia. J Neuropsychiatry Clin Neurosci. 2002;14:167–175.PubMedCrossRefGoogle Scholar
  6. 6.
    Edlund A, Lundstrom M, Lundstrom G, Hedqvist B, Gustafson Y. Clinical profile of delirium in patients treated for femoral neck fractures. Dement Geriatr Cogn Disord. 1999;10:325–329.PubMedCrossRefGoogle Scholar
  7. 7.
    Evans DA, Funkenstein HH, Albert MS, Scherr PA, Cook NR, Chown MJ, Hebert LE, Hennekens CH, Taylor JO. Prevalence of Alzheimer’s disease in a community population of older persons: higher than previously reported. JAMA. 1989;262:2551–2556.PubMedCrossRefGoogle Scholar
  8. 8.
    Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59:175–179.PubMedCrossRefGoogle Scholar
  9. 9.
    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;12:189–198.PubMedCrossRefGoogle Scholar
  10. 10.
    Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc. 1992;40:601–606.PubMedGoogle Scholar
  11. 11.
    Freeman GB, Mykytyn V, Gibson GE. Differential alteration of dopamine, acetylcholine, and glutamate release during anoxia and/or 3,4-diaminopyridine treatment. Neurochem Res. 1987;12:1019–1027.PubMedCrossRefGoogle Scholar
  12. 12.
    Gustafson Y, Berggren D, Brannstrom B, Bucht G, Norberg A, Hansson LI, Winblad B. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc. 1988;36:525–530.PubMedGoogle Scholar
  13. 13.
    Hofman A, Rocca WA, Brayne C, Breteler MM, Clarke M, Cooper B, Copeland JR, Dartigues JF, da Silva Droux A, Hagnell O, et al. The prevalence of dementia in Europe: a collaborative study of 1980–1990 findings. Eurodem Prevalence Research Group. Int J Epidemiol. 1991;20:736–748.PubMedCrossRefGoogle Scholar
  14. 14.
    Horikawa N, Yamazaki T, Miyamoto K, Kurosawa A, Oiso H, Matsumoto F, Nishimura K, Karasawa K, Takamatsu K. Treatment for delirium with risperidone: results of a prospective open trial with 10 patients. Gen Hosp Psychiatry. 2003;25:289–292.PubMedCrossRefGoogle Scholar
  15. 15.
    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;113:941–948.PubMedGoogle Scholar
  16. 16.
    Inouye SK, Zhang Y, Jones RN, Kiely DK, Yang F, Marcantonio ER. Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med. 2007;167:1406–1413.PubMedCrossRefGoogle Scholar
  17. 17.
    Jitapunkul S, Pillay I, Ebrahim S. Delirium in newly admitted elderly patients: a prospective study. Q J Med. 1992;83:307–314.PubMedGoogle Scholar
  18. 18.
    Jorm AF, Korten AE, Henderson AS. The prevalence of dementia: a quantitative integration of the literature. Acta Psychiatr Scand. 1987;76:465–479.PubMedCrossRefGoogle Scholar
  19. 19.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457–481.CrossRefGoogle Scholar
  20. 20.
    Kelly KG, Zisselman M, Cutillo-Schmitter T, Reichard R, Payne D, Denman SJ. Severity and course of delirium in medically hospitalized nursing facility residents. Am J Geriatr Psychiatry. 2001;9:72–77.PubMedGoogle Scholar
  21. 21.
    Kiely DK, Bergmann MA, Jones RN, Murphy KM, Orav EJ, Marcantonio ER. Characteristics associated with delirium persistence among newly admitted post-acute facility patients. J Gerontol A Biol Sci Med Sci. 2004;59:344–349.PubMedCrossRefGoogle Scholar
  22. 22.
    Kiely DK, Marcantonio ER, Inouye SK, Shaffer ML, Bergmann MA, Yang FM, Fearing MA, Jones RN. Persistent delirium predicts greater mortality. J Am Geriatr Soc. 2009;57:55–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Kim J, Jeong I, Chun JH, Lee S. The prevalence of dementia in a metropolitan city of South Korea. Int J Geriatr Psychiatry. 2003;18:617–622.PubMedCrossRefGoogle Scholar
  24. 24.
    Koizumi J, Shiraishi H, Ofuku K, Suzuki T. Duration of delirium shortened by the correction of electrolyte imbalance. Jpn J Psychiatry Neurol. 1988;42:81–88.PubMedGoogle Scholar
  25. 25.
    Kolbeinsson H, Jonsson A. Delirium and dementia in acute medical admissions of elderly patients in Iceland. Acta Psychiatr Scand. 1993;87:123–127.PubMedCrossRefGoogle Scholar
  26. 26.
    Koponen H, Stenback U, Mattila E, Soininen H, Reinikainen K, Riekkinen PJ. Delirium among elderly persons admitted to a psychiatric hospital: clinical course during the acute stage and one-year follow-up. Acta Psychiatr Scand. 1989;79:579–585.PubMedCrossRefGoogle Scholar
  27. 27.
    Kua EH. The prevalence of dementia in elderly Chinese. Acta Psychiatr Scand. 1991;83:350–352.PubMedCrossRefGoogle Scholar
  28. 28.
    Kua EH, Ko SM. Prevalence of dementia among elderly Chinese and Malay residents of Singapore. Int Psychogeriatr. 1995;7:439–446.PubMedCrossRefGoogle Scholar
  29. 29.
    Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989;320:578–582.PubMedCrossRefGoogle Scholar
  30. 30.
    Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48:618–624.PubMedGoogle Scholar
  31. 31.
    McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS, Inouye SK. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc. 2006;54:1245–1250.PubMedCrossRefGoogle Scholar
  32. 32.
    McCusker J, Cole M, Dendukuri N, Han L, Belzile E. The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med. 2003;18:696–704.PubMedCrossRefGoogle Scholar
  33. 33.
    Mullen JO, Mullen NL. Hip fracture mortality: a prospective, multifactorial study to predict and minimize death risk. Clin Orthop Relat Res. 1992;280:214–222.PubMedGoogle Scholar
  34. 34.
    Mungas D. In-office mental status testing: a practical guide. Geriatrics. 1991;46:54–58, 63, 66.Google Scholar
  35. 35.
    Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology. 1978;49:239–243.PubMedCrossRefGoogle Scholar
  36. 36.
    Plum F. Dementia: an approaching epidemic. Nature. 1979;279:372–373.PubMedCrossRefGoogle Scholar
  37. 37.
    Robertson BD, Robertson TJ. Postoperative delirium after hip fracture. J Bone Joint Surg Am. 2006;88:2060–2068.PubMedCrossRefGoogle Scholar
  38. 38.
    Rockwood K. Acute confusion in elderly medical patients. J Am Geriatr Soc. 1989;37:150–154.PubMedGoogle Scholar
  39. 39.
    Rockwood K. The occurrence and duration of symptoms in elderly patients with delirium. J Gerontol. 1993;48:M162–M166.PubMedGoogle Scholar
  40. 40.
    Rudberg MA, Pompei P, Foreman MD, Ross RE, Cassel CK. The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity. Age Ageing. 1997;26:169–174.PubMedCrossRefGoogle Scholar
  41. 41.
    Sahadevan S, Saw SM, Gao W, Tan LC, Chin JJ, Hong CY, Venketasubramanian N. Ethnic differences in Singapore’s dementia prevalence: the stroke, Parkinson’s disease, epilepsy, and dementia in Singapore study. J Am Geriatr Soc. 2008;56:2061–2068.PubMedCrossRefGoogle Scholar
  42. 42.
    Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics. 2002;43:171–174.PubMedCrossRefGoogle Scholar
  43. 43.
    Sirois F. Delirium: 100 cases. Can J Psychiatry. 1988;33:375–378.PubMedGoogle Scholar
  44. 44.
    Winawer N. Postoperative delirium. Med Clin North Am. 2001;85:1229–1239.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Kyung-Hag Lee
    • 1
  • Yong-Chan Ha
    • 2
  • Young-Kyun Lee
    • 1
  • Hyun Kang
    • 3
  • Kyung-Hoi Koo
    • 1
  1. 1.Department of Orthopaedic SurgerySeoul National University Bundang HospitalSeongnamSouth Korea
  2. 2.Department of Orthopaedic SurgeryChung-Ang University College of MedicineSeoulSouth Korea
  3. 3.Department of AnesthesiologyChung-Ang University College of MedicineSeoulSouth Korea

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