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GENERAL ARTICLES

Preoperative Factors Associated with Postoperative Change in Confusion Assessment Method Score in Hip Fracture Patients

Khwaja J. Zakriya, MD^*, Colleen Christmas, MD, James F. Wenz, Sr, MD, Shawn Franckowiak, BS, Ross Anderson, PhD, and Frederick E. Sieber, MD^*

*Department of Anesthesiology, School of Medicine, Division of Geriatrics and Gerontology, and Department of Orthopedics, Johns Hopkins Medical Institutions, Baltimore, Maryland

Address correspondence and reprint requests to Khwaja J. Zakriya, MD, Department of Anesthesiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Address e-mail to kzakriya{at}jhmi.edu

Postoperative delirium is a major problem in elderly patients undergoing surgical repair of hip fracture. It is imperative to identify potentially treatable preoperative factors associated with the onset of postoperative delirium to optimize outcome. We sought to determine what preoperative variables are associated with postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. In a prospective, IRB-approved study, patients admitted to the geriatric hip fracture service were examined daily in the hospital for the occurrence of postoperative delirium. All patients with a preoperative diagnosis of dementia or delirium were eliminated. A positive confusion assessment method score ([+]CAM) was used to determine the presence of postoperative delirium during the acute hospital stay. To determine the association between preoperative variables (demographics, laboratory values, and comorbidities) and postoperative (+)CAM scores, ² and logistic regression analysis were performed with calculation for the odds ratios (OR). One-hundred-sixty-eight patients (72% women) were included in the analysis. Twenty-eight percent (n = 47) of patients had a (+)CAM score. Three variables were significant predictors of a (+)CAM score: (a) normal white blood cell count (OR, 2.2), (b) abnormal serum sodium (OR, 2.4); and (c) ASA physical status >II (OR, 11.3). The results suggest that preoperative medical conditions (abnormal serum sodium and ASA physical status >II) and an inability to mount a stress response (normal white blood cell count) may influence the patient’s postoperative mental status. In particular, two of the risk factors we identified may be amenable to therapy and are abnormal serum sodium and lack of an increase in white blood cell count during the stress of trauma and surgery.

IMPLICATIONS: This prospective study investigated preoperative variables that are predictive of postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. The results suggest that the patient’s preoperative medical condition and inability to mount a stress response influence postoperative delirium.

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