main topic

Wien Med Wochenschr (2013) 163:448454

DOI 10.1007/s10354-013-0228-y

Treatment and prevention of postoperative

complications in hip fracture patients: infections and
delirium
PeterDovjak BernhardIglseder PeterMikosch MarkusGosch ErnstMller
GeorgPinter KatharinaPils IngeGerstofer HeinrichThaler MichaelaZmaritz
MoniqueWeissenberger-Leduc WalterMller
Received: 9 June 2013 / Accepted: 4 July 2013 / Published online: 15 August 2013
Springer-Verlag Wien 2013

Summary The course of older patients with hip fractures is often complicated by infections and delirium.
Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital
stay and nursing home placement, poorer mobility, and
functional decline. Because of immunosenescence and
higher infection rates, older patients need specific care,
immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline
the management of nosocomial infections, but there is a
need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have
first priority to reduce the rate of infections. Treatment
of geriatric syndromes like malnutrition, exsiccosis, gait
disorders, falls, delirium, urine incontinence, and organ
insufficiency are as important as immunization against

pneumococci and influenza. Advanced age, cognitive

impairment, hearing loss, peripheral vascular disease,
prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus,
older people with several chronic diseases are prone to
delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid
administration and augmented nutrition, monitoring of
vital signs, pain treatment, optimized medication, and
modification in perioperative management, significantly
reduces delirium incidence during hospitalization for
hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients needs.

Prim. Dr.P.Dovjak,MD()
Department of Acute Geriatrics, Hospital of Gmunden,
Miller von Aichholzstrae 49, 4810 Gmunden, Austria
e-mail: peter.dovjak@gespag.at

Prim. Dr.K.Pils,MD
Institute of Physics, Sophienspital, 1070 Vienna, Austria

Prim. Univ.-Prof. Dr.B.Iglseder

Department of Geriatric Medicine, Christian-Doppler-Klinik,
Paracelsus Medical University, 5020 Salzburg, Austria
Univ.-Doz. Dr.P.Mikosch
Department of Internal Medicine, Hanusch Krankenhaus,
1140Vienna, Austria

Keywords Orthogeriatrics Hip fracture Surgery Infection Delirium Risk factors

Dr.I.Gerstofer,MD
Department of Anaesthesia, AUVA-Unfallkrankenhaus Meidling,
1120 Vienna, Austria
Dr.H.Thaler,MD
Department of Internal Medicine,
AUVA-Unfallkrankenhaus Meidling, 1120 Vienna, Austria
M.Zmaritz
AUVA-Unfallkrankenhaus Meidling, 1120 Vienna, Austria

Mag. Dr.M.Gosch
Department of Internal Medicine, Hospital of Hochzirl,
6170 Zirl, Austria

Dr. Dr. Mag.M.Weissenberger-Leduc

Department of Philosophy, Universtity of Vienna, Vienna, Austria

Prim. Univ.-Prof. Dr.E.Mller

Department of Trauma Surgery, Klinikum-Klagenfurt,
9020 Klagenfurt am Wrthersee, Austria

Dr.W.Mller,MD
Department of Acute Geriatrics, Elisabethinen Spital,
9020 Klagenfurt, Austria

Prim. Dr.G.Pinter,MD
Department of Acute Geriatrics, Klinikum-Klagenfurt,
9020 Klagenfurt, Austria

448

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium

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main topic
Behandlung und Prvention von postoperativen
Komplikationen nach Schenkelhalsfraktur:
Infektionen und Delirium

Complications in hip fracture patients: infections

Zusammenfassung Infektionen und Delir komplizieren den Behandlungsverlauf von lteren Patienten mit
hftnahen Frakturen hufig. Eine rasche Behandlung
der Komplikationen und eine erhhte Aufmerksamkeit
dafr sind ntig, um die Mortalitt und Rate an verlngerten Krankenhausaufenthalten, sowie die Gefahr von
Funktionalittseinbuen zu senken. Eine besondere
Behandlung bentigen ltere wegen der mit dem Alter einhergehenden Immunoseneszenz und der damit
verbundenen hheren Infektionsrate. Viele Leitlinien
der Fachgesellschaften helfen bei der Versorgung von
Patienten mit nosokomialen Infektionen, aber spezielle
Daten fr Patienten mit Vielfacherkrankungen und Polypharmazie fehlen. Hygienemanahmen haben hchste
Behandlungsprioritt neben den therapeutischen Interventionen von geriatrischen Syndromen wie Exsiccose,
Mangelernhrung, Gangstrungen, Strzen, Delir, Inkontinenz und Organinsuffizienzen. Impfungen gegen
Influenza und Pneumokokken sind ebenfalls wichtig
fr dieses Klientel. Hheres Alter, kognitive Einschrnkungen, Hrverminderung, arterielle Durchblutungsstrungen, vorangegangene Delir-Episoden, Sehbehinderung und Polypharmazie sind auch Risikofaktoren fr
ein postoperatives Delir daher sind ltere Patienten
mit vielen chronischen Erkrankungen besonders gefhrdet. Ein multifaktorieller Zugang unter Anwendung
von standardisierten Screening Methoden, optimierter Sauerstoffversorgung, intravenser Flssigkeitsgabe
und Nahrungssupplementierung, sowie berwachung
der Vitalfunktionen, optimierter Schmerzbehandlung
und Medikation sowie Adaptierung der perioperativen Versorgung reduzieren die Hufigkeit eines Delirs
whrend des Spitalsaufenhaltes wegen einer hftnahen
Fraktur signifikant. Ein interdisziplinres Management
mit unfallchirugischer und geriatrischer Expertise kann
den Bedrfnissen von lteren Traumapatienten besser
begegnen.

Hip fractures are a major public health concern, which

even increase because of demographic change [1]. Postoperative complications and comorbidities determine
mortality and a poor outcome following the year after
hospitalization because of a hip fracture. Excess mortality is 20% in the first year after fracture repair and is even
higher in older men [2]. Postoperative complications
occur in 20% of patients in the course of a hip fracture, but
only in 14% of patients without comorbidities [3]. Infections are leading the list of postoperative complications.
In 2006, the rate of nosocomial infections in Germany
was estimated at 0.50.74% [4]. Although the spectrum of
infections jeopardizing older patients comprises hepatitis, surgical site infections, and multiorgan failure, only
the most frequent infections affecting patients with hip
fracture are subject of this overview [5].

Schlsselwrter Alterstraumatologie Hftnahe Fraktur Chirurgie Infektion Delir Risikofaktoren

Methods
The working group on orthogeriatrics was launched in
summer of 2012 by the Austrian Society of Geriatrics
and Gerontology (GGG). The group is made up of geriatricians working as specialists in orthopedic surgery,
internal medicine, anesthesiology, nursing sciences,
and social casework. A PubMed search was done using
the terms orthogeriatrics, hip fracture, infection, or
delirium. Data were collected, discussed, and balanced
by adjustment meetings in three attempts until summer
of 2013.

13

Introduction

Surgical site infections

One of the most frequent infections occurring after repair
of a hip fracture is surgical site infection. The rate in Germany is specified at 1.6%, whereas a single-center record
from Serbia specified an extraordinary rate of 22.7% [6, 7].
Postsurgical infections prolong hospital stay on average
for 28 days, provoke additional surgical procedures, and
result in significant morbidity [8]. The typical onset of a
surgical wound infection is between day 3 and 8 postsurgery and is reduced significantly by using surveillance program data and hygiene measures [9].
Whether a patient experiences a surgical site infection depends on susceptibility, virulence of the microorganism, and type of procedure. Risk factors on patient
side were indentified with diabetes, frailty, malnutrition,
organ failure, obesity, impaired immunocompetence,
ongoing chemotherapy, coagulopathy, and concurrent
medication with glucocorticoids and anticoagulants. On
the surgical side, experience, duration of the operation,
technical faults, prophylaxis with antibiotics, use of blood
transfusions, and hygiene measures are associated with
the rate of wound infections. Microorganisms isolated
from older patients with hip fractures were Staphylococcus in 35.5% of cases, followed by multiresistant Staphylococcus in 19.1%, coagulase-negative Staphylococcus in
16%, and Enterococcus in 12.8%. Gram-negative microorganisms like Escherichia coli and Enterobacter are isolated
in less than 5% of cases [8]. The spectrum of microorganisms varies widely and especially the multiresistant
microorganisms cause complex treatment courses [10].

Prevention of surgical site infections

General principles of prevention of surgical site infections are summarized as follows [11]:

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium

449

main topic

M
 odifying patients risk comprises optimizing blood
glucose level, electrolytes, cardiac function, adapting
analgesic drugs, avoiding nonsteroidal antirheumatic
drugs, and modifying immunosuppressive and anticoagulant medication.
Procedure-related prevention should minimize microbial inoculums and includes abridging the time
until operation, minimizing traffic in the operation
room, cleaning laminar air flow, environmental surfaces, preparation of the surgical field with chlorhexidinealcohol solution, and skin preparation and hand
hygiene measures.
Perioperative antimicrobial prophylaxis according to
the guidelines of the Paul Ehrlich Society 3060 min
before operation, using cefazolin and vancomycin or
clindamycin in case of known allergies and monitoring adverse drug effects like Clostridium difficile infections, allergies, and disturbances of liver function and
coagulation.
Analgesia and the choice of anesthetic procedure are
also important to reduce infection.

Chest infections
Older patients after hip fracture are typically compromised by immunoscenscence, a change in the immune
response associated with increased age, which causes
higher rates of infection and impaired wound healing.
Moreover, age-related changes of the lung epithelium
contribute to the higher susceptibility to chest infections,
since fibrillation frequency and clearance of the respiratory epithelium decrease with higher age [12]. Silent
aspiration of small volumes of oropharyngeal or gastric
secretions includes a high number of microorganisms
causing pneumonia in frail older patients. A number of
risk factors were identified, such as disorders of central
nervous system, treatment with dopamine antagonists,
and medication reducing alertness and gag reflex. If a
chest infection occurs, timely diagnostic and treatment
measures are required with a low threshold for the use
of systemic antibiotics and accurate monitoring. Hospital-acquired pneumonia is the second most frequent
nosocomial infection and is treated according to the recommendations of guidelines [13, 14].

Infection control measures to prevent

pneumonia [15]

 and washing
H
Avoiding mechanical ventilation, early weaning
Oral hygiene
Optimizing air moisture
Early remobilization, respiratory exercises
Control of gastroesophageal reflux, avoid proton
pump inhibitors
Monitoring alertness, avoiding sedative drugs

450

Urinary tract infections

Urinary tract infections are found in 38% of patients
admitted to the hospital with a hip fracture. They are the
leading cause of nosocomial infection and affect 1261%
of all patients with hip fractures [16]. Escherichia coli was
found in 33% and Enterococcus faecalis in 23.5% of the
urine specimens of fracture patients [17]. Placement of
urinary catheters is the single most important cause and
accounts for 80% of urinary tract infections that prolong
the hospital stay for another 2.5 days and cause delirium and even a higher mortality rate [18, 19]. Therefore,
indwelling catheters should be removed within 24h after
insertion as per the guideline of the American Association of Hospital Epidemiologists [20].

Prevention of urinary tract infections

R
 outine urine analysis on admission
Removal of indwelling catheters 24h after insertion
Systemic antibiotics in patients with or without symptoms and positive urinary culture

Value of C-reactive protein (CRP) analysis

after hip fracture
Quantifying CRP levels following the repair of a hip fracture is helpful for the monitoring of subliminal infections.
The level of CRP is about 8mg/dl on the second postoperative day in case of using pins for the hip fracture repair,
12 mg/dl in case of using a hip screw, and 16 mg/dl in
case of using a hip prosthesis. On average, the level of CRP
declines to 4mg/dl on the sixth postoperative day. Rising
levels above these values should alert doctors for underlining infections, thromboembolic events, or ischemia [21].

Conclusion and way forward

At present, there is no nationwide geriatric fracture
guideline in Austria, and barriers hampering the implementation of such a program will have to be overcome.
Such a model for caring older adults with fractures
provides surgical and geriatric comanagement, early
intervention, and functionality oriented patient care to
achieve an early discharge [22]. Several studies and pilot
projects indicate promising results in this field [23, 24].
Standardized procedures may help to reduce mortality
and morbidity of older adults with fragility fractures.

Complications in hip fracture patients: delirium

Epidemiology
Owing to increased expectation of life, the number of
older patients needing surgical care is snowballing. Prog-

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium

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ress in surgical techniques and anesthetic procedures

warrants surgical intervention even in frail patients.
Delirium on admission to the hospital or in the perioperative scenario is a frequent and often serious complication in older patients hospitalized for hip fracture;
incidence ratings from prospective cohorts vary between
10 and 65% [2527]. These rates are likely to be underestimated, since a high number remains unrecognized
because of the fluctuating nature of delirium, its overlap with dementia, and lack of formal assessment strategies. Experiencing delirium during hospitalization is
associated with poorer mobility and functional decline,
increased mortality, and nursing home placement within
1 month after dismissal [27]. Delirium upon hospitalization is associated with poorer cognitive and physical
status 6 months after the trauma [28]; up to one-third of
delirium episodes may persist after hospital discharge
[25, 27].

Clinical presentation
International Classification of Diseases (ICD-10) criteria
outline the clinical features of delirium as follows [29].
For a definite diagnosis, symptoms, mild or severe,
should be present in each one of the following areas:
1.
Impairment of consciousness and attention (on a
continuum from clouding to coma; reduced ability to
direct, focus, sustain, and shift attention)
2.Global disturbance of cognition (perceptual distortions, illusions, and hallucinations, most often visual;
impairment of abstract thinking and comprehension,
with or without transient delusions, but typically with
some degree of incoherence; impairment of immediate recall and of recent memory, but with relatively
intact remote memory; disorientation for time as well
as, in more severe cases, for place and person)
3.
Psychomotor disturbances (hypo- or hyperactivity
and unpredictable shifts from one to the other; increased reaction time; increased or decreased flow of
speech; enhanced startle reaction)
4.Disturbance of the sleepwake cycle (insomnia or, in
severe cases, total sleep loss or reversal of the sleepwake cycle; daytime drowsiness; nocturnal worsening
of symptoms; disturbing dreams or nightmares, which
may continue as hallucinations after awakening)
5.
Emotional disturbances, e.g., depression, anxiety
or fear, irritability, euphoria, apathy, or wondering
perplexity.
The onset is usually rapid (hours to days), the course is
diurnally fluctuating, and the total duration of the condition is less than 6 months. The clinical picture is so
characteristic that a fairly reliable diagnosis of delirium
can be made even if the underlying cause is not definitely
established.
Depending on the predominant psychomotoric symptoms, there are three different clinical subtypes of delir-

13

ium [30]: (a) hyperactivehyperalert patients are restless

and agitated because of overactivity of the sympathetic
nervous system; (b) hypoactivehypoalert patients are
lethargic, dulled and confused, respond tardily to questions, and do not initiate voluntarily movements, thus
they often misleadingly receive a diagnosis of depression; and (c) mixed variants of hyperactive and hypoactive delirium (develop in up to 70% of older patients).
Difficulties in thinking clearly and concentration and
alterations in the sleepwake cycle with restlessness
and vivid dreams during the night and day time sleepiness may precede full-blown delirium. Disorientation at
awakening and hallucinations are further symptoms in
the prodromal stage.

Pathophysiology and risk factors

Advanced age, cognitive impairment, hearing loss,
peripheral vascular disease, prior delirium episodes,
sight disorders, and polypharmacy, particularly involving
anticholinergic and psychoactive drugs, are established
risk factors for delirium. The concept of patient vulnerability as defined by the aforementioned risk factors in
relation to provoking triggers is widely accepted. According to this concept, a severe condition, such as trauma
or serious infection, is required to provoke delirium in a
previously fit person, but even a negligible cause, such as
hospitalization, may result in delirium in people at high
risk; thus, older people with several chronic diseases are
prone to delirium [31].
A recent study demonstrated that the Charlson comorbidity score may predict complication risk after hip fracture, with an odds ratio of 1.12 for each point increase,
and that delirium was the most common postoperative
complication [32].
Hitherto, the pathophysiology of delirium associated with hip fracture is poorly understood. Generally accepted hypotheses focus on the involvement of
neurotransmitters, inflammation, and chronic stress. A
number of provoking events affect patients with hip fracture: fall, transport to the hospital, admission, diagnostic
procedures, anesthesia, surgical treatment, pain, medications, urinary catheters, sleep deprivation, and unfamiliar surroundings. All these factors may contribute to
the development of delirium.
Numerous biological markers have been investigated
in delirium of older patients. Several proinflammatory
cytokines may play a role in the development of delirium,
but for the most investigated cytokines, interleukin (IL)-6
and IL-8, only inconsistent correlations were demonstrated. Proinflammatory cytokines and stress hormones
have been demonstrated to affect attention, perception,
memory, and mood. Higher levels of cortisol and IL-8
were found in hip fracture patients before developing
delirium, whereas higher levels of IL-6 and S100B were
determined during delirium [33].
A body of evidence supports the role of acetylcholine
deficiency: administration of anticholinergic medica-

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tions may trigger delirium and serum anticholinergic

activity is increased during delirium episodes. Dopaminergic excess is another factor contributing to the
occurrence of delirium, as known from treatment with
dopaminergic drugs or bupropion, whereas antipsychotic agents, which act as dopamine antagonists, effectively attenuate symptoms. Perturbations of nearly all
neurotransmitters (serotonin, gamma-aminobutyric
acid (GABA), norepinephrine, glutamate, melatonin)
may be involved in the pathogenesis of delirium, either
by direct effects or by interaction with cholinergic or
dopaminergic transmissions.

Prevention and diagnosis of delirium

Clinicians looking for the underlying cause of delirium
need to be aware of the eventuality of atypical presentations of many diseases in older patients, including
myocardial infarction, infection, and respiratory failure.
Neuroimaging studies are reserved for patients presenting with new focal neurologic signs, a history or signs of
head trauma, or an obscure history. Electroencephalography may be useful for identifying subtle status epilepticus or postictal delirium. Laboratory workup addresses
signs of electrolyte imbalance, renal or liver impairment,
and infections.
Prevention is the most effective strategy to reduce incidence, severity, and complications of delirium. Two randomized controlled trials (RCTs) have demonstrated that
targeted geriatric intervention can significantly reduce
the number of delirium episodes. In one trial, forceful
geriatric consultation including directed recommendations such as pain management, fluid and electrolyte
balance, stopping of unneeded prescriptions, removal of
urinary catheters in time, and early mobilization lowered
the incidence of delirium from 50 to 28% [34]. The other
RCT compared a specialized geriatric ward staff implementing comprehensive geriatric assessment and management with usual care. The geriatric approach resulted
in a 20% absolute risk reduction for delirium incidence
and 5-day reduction of duration of delirium episodes
[26].
A multifactorial intervention program comprising
oxygen support, intravenous fluid administration and
augmented nutrition, monitoring of vital signs, consequent pain treatment and delirium screening, optimized
medication, and modification in perioperative management resulted in a 35% reduction of delirium incidence
during hospitalization for hip fracture, compared with a
historical control group [35]. In detail, the multifactorial
intervention program implies the following suggestions:
1.Supplemental oxygen 34 l/min: In the ambulance
and continually till day 2 postsurgery, during patient
mobilization, or when patients oxygen saturation is
not 95% without oxygen.
2.Intravenous fluid administration and extra nutrition:
Glucose/saline 5001,000ml in the ambulance or im-

452

mediately after admittance; in addition, i.v. supplementation in case of increased fasting and extra oral
multinutrient drinks daily after surgery.
3.
Accurate monitoring of vital parameters: oxygen
saturation starting at the place of injury until postoperative day 5. Systolic blood pressure should be maintained 90100 mmHg. Red blood cell transfusion
should be considered if hemoglobin <10 g/dl. Avoid
hypo- or hyperthermia.
4.Pain relief: Immediately after admittance with opiates
and paracetamol i.v.
5.Avoid delay in transfer logistics: Nurse assessment of
patient immediately (5 min) after admittance; assessment by the surgeon (30min) before referral to
the x-ray department; after x-ray directly to the traumatic surgery/orthopedic ward.
6.Screen for delirium through daily testing. All staff is
educated and instructed to pay increased attention to
symptoms of delirium.
7.Avoid polypharmacy: Sedatives/hypnotics and drugs
with anticholinergic properties should be administered with restriction.
8.Perioperative/anesthetic period: For premedication,
paracetamol is recommended as a first choice. Propofol and/or alfentanil i.v. is recommended at arrival
at the operating department before transfer to the operation table. Spinal anesthesia is recommended as
first choice. Systolic blood pressure should be maintained at <2/3 of baseline or >90 mmHg. Red blood
cell transfusion should be administered if there is
a tendency toward increased blood loss (>0.3 l) or
hemoglobin <10 g/dl. For sedation, propofol is recommended. Adequate postoperative analgesia with
paracetamol as first choice or combined with an opiate is recommended.
Another innovative approach is the implementation of a
geriatric companion nurse, who acts as the patients constant attendant for the pre- and postoperative time. The
authors report an incidence of delirium of only 5.75%,
which is lower than that in previously published studies
[36].
Several screening tools and assessment instruments
for making the diagnosis of delirium are established in
clinical practice. Widely used are the Confusion Assessment Method (CAM), the Organic Brain Syndrome (OBS)
scale, and the Delirium Observation Screening Scale
(DOSS). The CAM is based on structured observation
of the essential clinical features of delirium: (1) acute
change in mental status with fluctuating course, (2) inattention, (3) disorganized thinking, and (4) altered level
of consciousness. To make the diagnosis of delirium,
presence of both symptoms 1 and 2 and at least one of
the other two is required. This instrument allows distinguishing delirium from dementia and depression with
100% sensitivity and 94% specificity [37, 38]. The CAM
for the Intensive Care Unit (CAM-ICU) is a validated tool
allowing every patient to get checked for delirium usu-

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ally twice a day during ICU treatment. The CAM has been
translated and validated for use in several languages.
The OBS scale consists of two subscales: the first
explores signs of confusion such as disturbances of
awareness and orientation, whereas the second comprises a range of symptoms such as emotional reactions,
time-related variations and fluctuations in the clinical
presentation, suspiciousness and delusions, neurological symptoms such as language and speech problems,
spatial disorientation and impaired recognition, physical
and practical disabilities, and impairment of social interaction skills [39].
The Delirium Observation Screening Scale (DOSS),
originally a 25-item instrument, was developed to warrant early identification of delirium on the basis of nurses
observations during regular care [40]. The DOSS consists
of 13 items recording early symptoms of delirium; each
item is rated as present or absent and given a score of 1 or
0, respectively. A total score of 3 or more points is indicative for delirium.

Treatment
The essential steps in management of delirium are to
identify and address underlying conditions, facilitate
supportive care, handle behavioral symptoms, and prevent complications. In general, nonpharmacological
approaches suggest a calm environment with use of orienting influences, such as clocks and calendars in the
field of vision, restricted change of rooms and staff members, reorienting communication, warranting an uninterrupted period of night sleep, and early and consequent
mobilization during daytime. Pharmacological treatment
should be limited to those patients who threaten their
own safety or the safety of other patients [41].
The antipsychotic haloperidol is widely used as treatment of choice in doses of 0.51.0mg twice daily orally,
with additional doses every 4 h as needed (peak effect,
46 h). If parenteral application is needed, 0.51.0 mg
i.m. may be adequate (peak effect, 2040 min). Haloperidol was tested in RCTs. Intravenous administration
is not recommended because of short duration of action.
Extrapyramidal symptoms are seen frequently, especially
in doses >3mg daily.
The atypical antipsychotics risperidone (0.51 mg
twice daily), olanzapine (2.55mg once daily), and quetiapine (2550mg twice daily) are widely used, but they
are tested only in small uncontrolled studies. Extrapyramidal side effects may be less pronounced than with haloperidol. With all antipsychotics, increased mortality in
older demented patients was reported; thus, a prolonged
corrected QT interval on electrocardiogram requires particular attention.
The benzodiazepine lorazepam (0.51mg orally, with
additional doses every 4h as needed) is predominantly
used in cases caused by alcohol and sedative withdrawal,
in patients with Parkinsons disease, and in those with
malignant neuroleptic syndrome. Side effects include

13

sedation and therefore a risk of masking and prolongation of delirium episodes, paradoxical excitation, and
respiratory depression. Intravenous use is restricted to
emergencies.
The antidepressant trazodone (2550 mg orally at
bedtime) was tested in uncontrolled studies; side effects
include oversedation and hypotension. Since cholinergic deficit plays a major role in the pathophysiology of
delirium, the use of cholinesterase inhibitors appears
self-evident, but up to now, clinical studies have failed
to demonstrate robust benefits. The same holds true for
melatonin, normalizing sleepwake cycle, and gabapentin, which may act by an improved pain control. New
prospects for treatment of delirium include strategies
targeting inflammation and cerebral blood flow.

Conclusion
Mortality and functional outcome in older patients with
hip fracture are significantly related to the incidence of
delirium. Early detection of this disorder can improve
survival and level of functional recovery. Recent research
supports the introduction of routinely screening and
assessment of this frequent complication in order to initiate an adequate treatment without loss of time.
Conflict of interest
The authors declared no potential conflict of interest with
respect to the research, authorship, and/or publication
of this article.

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