Observational Study
Copyright ©The Author(s) 2020.
World J Orthop. Feb 18, 2020; 11(2): 90-106
Published online Feb 18, 2020. doi: 10.5312/wjo.v11.i2.90
Table 1 Incidence for postoperative delirium in specific orthopedic procedures from 2009 to 2014
ProcedureIncidence (%)
Primary THA0.8
Bilateral THA0.4
Primary TKA1.2
Bilateral TKA1.2
Spine fusion3.3
Other spine procedures1.9
Femur/pelvic fracture7.2
Other procedures1.0
Table 2 Patient demographics and study population
POD (Mean +/- SD or n, %), n = 959Non-POD (Mean +/- SD or n, %), n = 77533P value
Age, yr72.7+/-12.962.3+/-14.1< 0.001a
≥ 70610 (63.6)24038 (31.0)< 0.001a
Male389 (40.6)34777 (44.9)0.008a
BMI28.2+/-6.228.0+/-6.10.003a
Procedure type< 0.001a
THA161 (16.8)19753 (25.5)
TKA249 (26.0)20106 (25.9)
Bilateral THA3 (0.3)853 (1.1)
Bilateral TKA29 (3.0)2337 (3.0)
Spine fusions140 (14.6)4135 (5.3)
Other spine procedures126 (13.1)6587 (8.5)
Other procedures251 (26.2)23762 (30.7)
Trauma< 0.001a
Fracture of femur/pelvis57 (5.9)731 (0.9)
Other trauma30 (3.1)2607 (3.4)
No trauma872 (90.9)74195 (95.7)
Length of stay6.0+/-7.53.0+/-3.2< 0.001a
Latest creatinine before surgery< 0.001a
< 1.2 mg/dL825 (86.0)71048 (91.6)
1.2-2.0 mg/dL123 (12.8)6229 (8.0)
> 2.0 mg/d11 (1.2)256 (0.3)
Preoperative hyponatremia< 0.001a
Yes367 (38.3)21290 (27.5)
No591 (61.6)56190 (72.5)
Missing1 (0.1)53 (0.07)
Postoperative thiamine order< 0.001a
Yes119 (12.4)1390 (1.8)
No839 (87.5)76122 (98.2)
Missing1 (0.1)21 (0.03)
Atrial fibrillation (present on admission)130 (13.6)3815 (4.9)< 0.001a
Pressure ulcers (present on admission)23 (2.4)323 (0.42)< 0.001a
Opioid dependence or long-term use29 (6.2)1245 (1.6)< 0.001a
Psychiatric disease (present on admission)356 (37.1)16716 (21.6)< 0.001a
Anesthesia type< 0.001a
General344 (35.9)16356 (21.9)
Other578 (60.3)56067 (72.3)
Missing37 (3.9)4510 (5.8)
Patient-controlled analgesia< 0.001a
Epidural413 (43.1)40991 (52.9)
IV441 (46.0)22458 (29.0)
Peripheral nerve infusion11 (1.2)949 (1.2)
Missing94 (9.8)13135 (16.9)
Received diazepam< 0.001a
Yes98 (10.2)3135 (4.0)
No860 (89.7)74377 (95.9)
Missing1 (0.1)21 (0.03)
CT, MRI or both performed< 0.001a
Yes872 (90.9)64838 (83.6)
No86 (9.0)12674 (16.4)
Missing1 (0.1)21 (0.03)
ASA score< 0.001a
17 (0.73)4933 (6.4)
2477 (49.7)53801 (69.4)
≥ 3438 (45.7)14274 (18.4)
Missing37 (3.9)4525 (5.8)
Table 3 Total hip arthroplasty patient demographics and study population1
POD (Mean +/- SD or n, %), n = 140Non-POD (Mean +/- SD or n, %), n = 18232P value
Age, yr77.6+/-10.465.5+/-11.4< 0.001a
≥ 70112 (80.0)6499 (35.65)< 0.001a
Male57 (40.7)7891 (43.28)0.54
BMI26.7+/-5.228.4+/-5.8< 0.001a
Length of stay6.1+/-4.03.3+/-1.5< 0.001a
Latest creatinine before surgery< 0.001a
< 1.2 mg/dL107 (76.4)16376 (89.8)
1.2-2.0 mg/dL29 (20.7)1781 (9.8)
> 2.0 mg/dL4 (2.9)75 (0.4)
Preoperative hyponatremia< 0.001a
Yes40 (28.6)2525 (13.9)
No100 (71.4)15700 (86.1)
Missing0 (0)7 (0.04)
Postoperative thiamine order< 0.001a
Yes17 (12.1)387 (2.1)
No123 (87.9)17844 (97.9)
Missing0 (0)1 (0.01)
Atrial fibrillation (present on admission)5 (3.6)119 (0.7)< 0.001a
Pressure ulcers (present on admission)1 (0.7)47 (0.3)0.31
Opioid dependence or long-term use9 (6.4)199 (1.1)< 0.001a
Psychiatric disease (present on admission)47 (33.6)3584 (19.7)< 0.001a
Anesthesia type0.55
General4 (2.7)384 (2.1)
Other136 (97.1)17805 (97.7)
Missing0 (0)40 (0.2)
Patient-controlled analgesia< 0.001a
Epidural102 (72.9)14235 (78.1)
IV24 (17.1)1306 (7.2)
Missing14 (10)2691 (14.8)
Received diazepam0.03a
Yes8 (5.7)453 (2.5)
No132 (94.3)17778 (97.5)
Missing0 (0)1 (0.01)
CT, MRI or both performed0.009a
Yes127 (90.7)15616 (85.7)
No13 (9.3)2615 (14.3)
Missing0 (0)1 (0.01)
ASA score< 0.001a
273 (52.1)14667 (80.5)
≥ 367 (47.9)3519 (19.3)
Missing0 (0)46 (0.25)
Table 4 Total knee arthroplasty patient demographics and study population
POD (Mean +/- SD or n, %), n = 245non-POD (Mean +/- SD or n, %), n = 19864P value
Age, yr75.1+/-9.367.6+/-10< 0.001a
≥ 70171 (69.8)8304 (41.8)< 0.001a
Male89 (36.3)7364 (37.1)0.81
BMI30.0+/-6.130.6+/-6.30.13
Length of stay6.0+/-3.23.8+/-1.5< 0.001a
Latest creatinine before surgery< 0.001a
< 1.2 mg/dL203 (82.9)17828 (89.8)
1.2-2.0 mg/dL37 (15.1)1954 (9.8)
> 2.0 mg/dL5 (2.0)82 (0.4)
Preoperative hyponatremia0.07
Yes45 (18.4)2837 (14.3)
No200 (81.6)17019 (85.7)
Missing0 (0)8 (0.04)
Postoperative thiamine order< 0.001a
Yes28 (11.4)332 (1.7)
No217 (88.6)19530 (98.3)
Missing0 (0)2 (0.01)
Atrial fibrillation (present on admission)46 (18.8)1190 (6.0)< 0.001a
Pressure ulcers (present on admission)1 (0.4)29 (0.2)0.31
Opioid dependence or long-term use9 (3.7)198 (1.0)0.001a
Psychiatric disease (present on admission)77 (31.4)3915 (19.7)< 0.001a
Anesthesia type0.04a
General12 (4.9)545 (2.7)
Other233 (95.1)19252 (96.9)
Missing0 (0)67 (0.3)
Patient-controlled analgesia0.005a
Epidural179 (73.1)15151 (76.3)
IV38 (15.5)1801 (9.1)
Peripheral nerve infusion9 (3.7)711 (3.6)
Missing19 (7.8)2201 (11.1)
Received diazepam0.003a
Yes12 (4.9)381 (1.9)
No233 (95.1)19481 (98.1)
Missing0 (0)2 (0.01)
CT, MRI or both performed0.14
Yes226 (92.2)17733 (89.3)
No19 (7.8)2129 (10.7)
Missing0 (0)2 (0.01)
ASA score< 0.001a
12 (0.8)489 (2.46)
2130 (53.1)14933 (75.2)
≥ 3113 (46.1)4327 (22.0)
Missing0 (0)70 (0.4)
Table 5 Spine fusion patient demographics and study population
POD (Mean +/- SD or n, %), n = 137non-POD (Mean +/- SD or n, %), n = 4107P value
Age, yr67.5+/-12.560.1+/-15.6< 0.001a
≥ 6591 (66.4)1765 (43.0)< 0.001a
Male54 (39.4)1810 (44.1)0.28
BMI28.5+/-6.528.1+/-5.90.40
Length of stay9.0+/-5.15.6+/-3.6< 0.001a
Latest creatinine before surgery0.01a
< 1.2 mg/dL116 (84.7)3754 (91.4)
1.2-2.0 mg/dL20 (14.6)346 (8.4)
> 2.0 mg/dL1 (0.7)7 (0.2)
Preoperative hyponatremia0.16
Yes43 (31.4)1070 (26.1)
No94 (68.6)3033 (73.9)
Missing0 (0)4 (0.1)
Postoperative thiamine order< 0.001a
Yes20 (14.6)93 (2.3)
No117 (85.4)4013 (97.7)
Missing0 (0)1 (0.02)
Atrial fibrillation (present on admission)12 (8.8)135 (3.3)0.003a
Pressure ulcers (present on admission)3 (2.2)13 (0.32)< 0.001a
Opioid dependence or long-term use11 (8.0)124 (3.0)0.004a
Psychiatric disease (present on admission)65 (47.5)1185 (28.9)< 0.001a
Anesthesia type1
General136 (99.3)4052 (98.7)
Other0 (0)8 (0.2)
Missing1 (0.7)47 (1.1)
Patient-controlled analgesia1
Epidural0 (0)18 (0.4)
IV136 (99.3)3968 (96.6)
Missing1 (0.7)121 (3.0)
Received diazepam< 0.001a
Yes34 (24.8)476 (11.6)
No103 (75.2)3630 (88.4)
Missing0 (0)1 (0.02)
CT, MRI or both performed0.26
Yes136 (99.3)3999 (97.4)
No1 (0.7)107 (2.6)
Missing0 (0)1 (0.02)
ASA score< 0.001a
11 (0.7)214 (5.2)
278 (56.9)2974 (72.4)
≥ 357 (41.6)871 (21.2)
Missing1 (0.7)48 (1.2)
Table 6 Perioperative risk factors and adjusted association with postoperative delirium by procedure
THAOR (95%CI), n = 18276THA P valueTKAOR (95%CI), n = 19987TKA P valueSFOR (95%CI), n = 4183SF P value
Age, yr
≥ 70 vs < 704.9 (3.0, 7.9)< 0.001a2.16 (1.58, 2.94)< 0.001a--
≥ 65 vs < 65----2.76 (1.79, 4.25)< 0.001a
Male0.90 (0.60, 1.35)0.620.82 (0.60, 1.12)0.210.73 (0.48, 1.10)0.13
BMI0.94 (0.90, 0.98)0.004a0.99 (0.96, 1.02)0.370.99 (0.95, 1.02)0.46
Latest creatinine value before surgery
1.2-2.0 mg/dL vs < 1.2 mg/dL1.77 (1.05, 3.00)0.03a0.79 (0.49, 1.27)0.321.40 (0.73, 2.68)0.31
> 2.0 mg/dL vs < 1.2 mg/dL4.08 (1.06, 15.66)0.04a1.39 (0.46, 4.20)0.562.26 (0.20, 26.24)0.51
Preoperative hyponatremia2.36 (1.54, 3.64)< 0.001a1.25 (0.87, 1.79)0.231.24 (0.82, 1.88)0.31
PCA route
IV vs Epidural1.98 (1.19, 3.28)0.008a1.26 (0.83, 1.92)0.27--
Peripheral nerve infusion vs Epidural--0.93 (0.47, 1.86)0.85--
Postoperative thiamine order5.05 (2.72, 9.37)< 0.001a6.40 (4.00, 10.26)<0.001a6.64 (3.72, 11.85)<0.001a
ASA Score
2 vs 1--1.91 (0.26, 13.88)0.521.90 (0.25, 14.19)0.53
> 3 vs 1--3.63 (0.49, 26.74)0.212.38 (0.31, 18.46)0.41
≥ 3 vs 22.01 (1.33, 3.05)< 0.001a----
Anesthesia type
Other vs general2.92 (0.66, 12.85)0.160.89 (0.43, 1.82)0.74--
Surgery length1.00 (1.00, 1.01)0.101.00 (0.99, 1.01)0.551.00 (1.00, 1.00)<0.001a
Atrial fibrillation, present on admission0.97 (0.53, 1.77)0.911.93 (1.32, 2.81)<0.001a2.19 (1.09, 4.41)0.03a
Pressure ulcers, present on admission0.65 (0.08, 5.05)0.68--7.56 (1.89, 30.24)0.004a
Opioid dependence or long-term use7.11 (3.26, 15.51)< 0.001a2.98 (1.38, 6.41)0.005a1.88 (0.91, 3.90)0.09
Parenteral diazepam5.05 (1.5, 16.97)0.009a4.40 (1.52, 12.75)0.007a2.17 (1.19, 3.97)0.01a
Elixhauser comorbidity
Deficiency anemias1.64 (0.74, 3.63)0.221.10 (0.57, 2.11)0.781.11 (0.42, 2.93)0.83
Congestive heart failure2.35 (0.93, 5.96)0.071.59 (0.74, 3.38)0.231.54 (0.39, 6.11)0.54
Rheumatoid arthritis/collagen vascular diseases1.06 (0.45, 2.51)0.9000.35 (0.13, 0.94)0.04a1.02 (0.49, 2.13)0.95
Chronic pulmonary disease1.13 (0.67, 1.92)0.640.84 (0.55, 1.28)0.411.06 (0.65, 1.73)0.82
Coagulopathy1.32 (0.39, 4.53)0.661.60 (0.70, 3.62)0.262.80 (1.05, 7.50)0.04a
Depression1.70 (1.05, 2.75)0.03a1.47 (1.02, 2.11)0.04a2.61 (1.73, 3.92)<0.001a
Diabetes w/o chronic complications1.54 (0.90, 2.64)0.121.90 (1.36, 2.66)< 0.001a1.54 (0.92, 2.58)0.10
Diabetes w chronic complications2.05 (0.45, 9.23)0.351.77 (0.68, 4.58)0.243.34 (1.02, 10.91)0.046a
Hypertension1.62 (1.06, 2.48)0.03a1.21 (0.59, 1.64)0.231.00 (0.66, 1.51)0.99
Hypothyroidism1.01 (0.61, 1.66)0.981.46 (1.06, 2.02)0.02a1.07 (0.65, 1.76)0.80
Liver disease0.41 (0.05, 3.22)0.400.70 (0.16, 3.07)0.630.71 (0.15, 3.30)0.66
Lymphoma1.33 (0.25, 7.20)0.74----
Fluid and electrolyte disorders0.31 (0.04, 2.43)0.261.41 (0.44, 4.56)0.571.14 (0.36, 3.63)0.82
Other neurological disorders2.04 (0.98. 4.27)0.062.79 (1.69, 4.60)< 0.001a2.14 (1.10, 4.14)0.02a
Obesity1.06 (0.53, 2.12)0.880.79 (0.53, 1.19)0.271.56 (0.90, 2.69)0.11
Peripheral vascular disorders1.20 (0.47, 3.10)0.701.40 (0.62, 3.16)0.421.68 (0.64, 4.42)0.30
Psychoses2.52 (0.81, 7.90)0.116.39 (3.51, 11.62)< 0.001a4.95 (2.38, 10.28)<0.001a
Pulmonary circulation disorders1.20 (0.47, 3.10)0.701.69 (0.89, 3.23)0.111.57 (0.51, 4.88)0.44
Renal failure0.94 (0.41, 2.15)0.882.32 (1.31, 4.11)0.004a0.97 (0.39, 2.45)0.95
Solid tumor w/o metastasis--1.42 (0.31, 6.45)0.65--
Valvular disease1.08 (0.59, 1.97)0.801.23 (0.79, 1.92)0.371.17 (0.61, 2.26)0.63
Weight loss0.61 (0.05, 7.46)0.707.14 (0.62, 82.11)0.11--