Preventing delirium in elderly hip surgery patients can seem like an elusive goal. Much has been written on it but little remains of value after careful analysis. Most sources revert to the now classic work by Marcantonio and colleagues (2001). In this study, a geriatric consult service was the experimental focus. Ten categories composed the “bundle” of care to be initiated. Among these were generic expectations such as ensuring fluid and electrolyte balance and adequate nutrition, but also geriatric concept-based interventions such as eliminating excessive medications and those medications especially problematic for elders such as benzodiazepines, and promoting early mobilization. An average of 9.5 interventions per patient were instituted. The incidence of delirium overall was high but was lower in the intervention group (32 vs. 50%, p=0.04). The intensity of delirium was assessed to be less in the intervention group as well, with severe delirium manifested only 12% of the time vs. 29% in the usual care group.
The most disappointing findings were that the length of days of delirium and the overall length of stay were not significantly different. Delirium at discharge was similar between groups as well. The study may have been underpowered with a total sample size of only 126 patients. Its strengths were that it was a randomized controlled trial with reasonably good adherence to protocol. On a practical level, we are left with a large “bundle” and we don’t know which interventions are the most important to emphasize in prioritizing care. Little different findings were found in examining the greater literature base on the topic.
A recent topic offering some hope for improvement in the area is the work on melatonin. Two studies have indicated that delirium is positively impacted by use of melatonin (Al-Aama, Brymer, Gutmanis, Woolmore-Goodwin, Esbaugh, & Dasgupta, 2010; Sultan, 2010). The former study in Canada demonstrated that melatonin was associated with a 12% delirium rate compared to a 31% rate when compared to placebo. DeJonge and colleagues (2011) expect to have additional data available on this subject in 2013. While two studies may not be sufficient to change practice, melatonin comes with few risks to patients, as it is a naturally occurring substance. The results of this third trial are a hopeful development in the face of little new to assist clinicians in delirium prevention and management.
Al-Aama, T., Brymer, C., Gutmanis, I., Woomore-Goodwin, S. M., Esbaugh, J., & Dasgupta, M. (2011). Melatonin decreasese delirium in elderly patients: A randomized, placebo-controlled trial. International Journal of Geriatric Psychiatry, 26, 687-694.
deJonghe, A, et al. (2011). The effects of melatonin versus placebo on delirium in hip fracture patients: study protocol of a randomized, placebo-controlled, double blind trial. BMC Geriatrics, 11, 34.
Marcantonio, E. R. , Flacker, J. M., Wright, R.J., & Resnick, N.M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 29, 516-522.
Sultan, S. S. (2010). Assessment of role of perioperative melatonin in prevention and treatment of postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly. Saudi Journal of Anesthesia, 4(3), 169-173.
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System