Age and Ageing 2005; 34: 387–409  The Author 2005.
2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
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Research Letters
Prediction of delirium in fractured neck
of femur as part of routine preoperative
nursing care
SIR—Delirium is a common complication of fractured
neck of femur occurring in 25–65% of patients [1].
Delirium on an orthopaedic ward is potentially catastrophic
as confused patients may require extra supervision, which
detracts from the care of other patients, and are at high risk
of suffering further falls, or of being over-sedated and suf-
fering complications of enforced immobility [2]. Delirium is
also a considerable source of distress to patients and family
and is likely to contribute to a poor functional recovery [3].
As delirium can be potentially prevented by multifactorial
nursing and medical interventions [4], there is a need for a
practical screening instrument that can be incorporated into
routine preoperative care by the nurses so that preventative
strategies can be focused on high-risk patients. The aim of
this study was to assess prospectively the value of routinely
collected nursing information combined as a simple risk
score in predicting the occurrence of delirium in fractured
neck of femur patients and thus potentially help in prevention
and treatment of delirium.
Methods
All patients over the age of 65 years admitted to hospital
with a fractured neck of femur over a 6 month period were
assessed for cognitive impairment using the standardised
Mini-Mental State Examination (MMSE) [5] and using a
simple delirium, elderly assessment of risk score (DEAR)
with one point respectively given for (i) cognitive impairment
defined as standard MMSE score of 23 or less; (ii) sensory
impairment defined as requiring a hearing aid or complaining
of poor vision—e.g. not being able to view a television
without spectacles; (iii) needing assistance with any activity
of daily living, including bathing, dressing, toileting, groom-
ing or feeding; (iv) substance abuse defined as more than
three drinks per week or use of a benzodiazepine more than
three times a week; (v) age over 80 years. The potential
score for the DEAR ranges from 0 (no risk factors) to 5 (all
risk factors present). Prior to the study the nurses were
instructed on the scoring of the standardised MMSE by a
consultant geriatrician with the help of a teaching video.
The inter-rater reliability of the DEAR score was also
checked on 20 patients (5 male, 15 female, mean age 81
years, range 68–90) and there was a high inter-rater reliabil-
ity of 0.97 between a doctor and a nurse. Patients were
assessed daily postoperatively for presence of delirium using
the Confusion Assessment Method (CAM) [5] by an inde-
pendent nurse observer. The CAM is a sensitive and specific,
reliable and valid instrument for identification of delirium
[6, 7]. The data were analysed using the SPSS statistical
package for Windows. The study was approved by the
hospital research ethics board.
Results
The results are summarised in Tables 1 and 2. One hundred
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patients were included in the study (80 females, 20 males,
age range 65–94 years, mean age 82.3±7.7 years). Twenty-four
patients (24%) had CAM-positive delirium. There were no
significant differences in age or gender in the patients with
delirium compared with those without. A DEAR score of 3
or more had a sensitivity of 71% with a specificity of 49%
(likelihood ratio positive 1.4). In comparison, a standardised
MMSE score of 23 or less had a sensitivity of 75% and a
specificity of 66% (likelihood ratio positive 2.2).
The receiver operating characteristic curves for the
DEAR score and the MMSE were calculated and the area
under the curve was 0.74 (95% CI 0.63–0.84) for the
MMSE and 0.61 (95% CI 0.47–0.73) for the DEAR score.
Logistic regression was used to explore the relationship
between preoperative factors and postoperative delirium
(Table 2). In the univariate analysis, cognitive impairment
(MMSE 23 or less) was most strongly associated with the
development of postoperative delirium (OR = 12.00, 95%
CI 3.26–44.13) and this association remains strong even
with adjustment for the other potential risk factors
(OR = 17.74, 95% CI 4.25–74.01).
Discussion
This study confirms that cognitive impairment is the most
significant factor associated with the development of delirium
following fractured neck of femur even when other possible
risk factors are taken into account. We have shown that the
standardised MMSE can be successfully taught and used by
orthopaedic nurses and this has implications for improving
the routine care and assessment of risk for these vulnerable
patients. A development of the MMSE, such as the DEAR
score, may have an added benefit in that the DEAR score
focuses care on more remediable factors such as sensory
impairment and drug use.
There are several limitations to our study. Firstly, we did
not attempt to estimate the type and severity of the delirium.
This would involve a much more elaborate study with a
more in-depth assessment, including delirium severity and
investigation of other multiple possible precipitating factors.
However, this type of study would have been difficult to
incorporate into the routine care on an orthopaedic ward
and may have introduced an observer effect. Also it could
be argued that any type of delirium, whatever its severity, is
important as it can result in a poorer outcome.
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Research letters

Table 1. Baseline risk factors and length of stay

Delirium patients Non-delirium patients
Baseline variable n = 24 n = 76 P value
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gender % female 80% 83% NS chi squared

Preoperative MMSE mean (SD) 20.6 (4.6) 24.2 (5.3) 0.02 t-test
Age >80 (%) 75 64.5 NS chi squared
Sensory impairment (%) 66.7 73.7 NS chi squared
Dependence in ≥1 ADL (%) 37.5 34.2 NS chi squared
Cognitive impairment (%) 87.5 36.8 0.01 chi squared
Substance abuse (%) 25 43.4 NS chi squared
Length of stay mean (SD) 12.2 (8–14) 15.8 (8–10) NS t-test

Table 2. Multiple logistic regression analysis of DEAR risk factors for postoperative delirium

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Borderline variable Crude OR (95% CI) Adjusted OR (95% CI)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
Cognitive impairment 12.00 (3.26–44.13) 17.74 (4.25–74.01)
Sensory impairment 0.71 (0.26–1.93) 0.59 (0.18–1.91)
Age >80 1.65 (0.58–4.69) 1.20 (0.32–4.54)
Dependence in ≥1 ADL 1.15 (0.44–3.01) 0.49 (0.15–1.61)
Substance abuse 0.43 (0.15–1.22) 0.33 (0.10–1.07)
a
The −2 log likelihood improved from 89.7 to 83.5 with the additional variables.

A second criticism is that we relied on a single instrument S. H. FRETER1, J. GEORGE2*, M. J. DUNBAR1, M. MORRISON1,
(the CAM) to identify delirium and it may be that we missed C. MACKNIGHT1, K. ROCKWOOD1
1
cases of hypoactive delirium. Indeed, our incidence of delir- Division of Geriatric Medicine and Surgery, Dalhousie University,
ium was in the lower range compared with previous studies Halifax, Nova Scotia, Canada B3H 2EI
2
[1]. Nevertheless, despite these reservations, this study is Department of Geriatric Medicine, Cumberland Infirmary,
encouraging in that we have demonstrated that it is possible Carlisle CA2 7HY, UK
to anticipate the development of delirium postoperatively by *To whom correspondence should be addressed
identifying high-risk patients as part of everyday routine pre- Email: jim.george@ncumbria-acute.nhs.uk
operative nursing care. Using the MMSE and DEAR preop-
eratively seems to be useful and practical for identifying
high-risk fracture patients, as has also been shown for the 1. Inouye SK. Delirium after hip fracture: to be or not to be.
elective arthroplasty population [8]. Our results emphasise J Am Geriatr Soc 2001; 49: 678–9.
the importance of cognitive impairment in predisposing eld- 2. Williams-Russo P, Urquhart RN, Sharrock NE, Charlson MF.
erly fractured neck of femur patients to delirium. Further Post-operative delirium: predictors and prognosis in elderly
research is needed to evaluate the role of the standardised orthopaedic patients. J Am Geriatr Soc 1992; 40: 759–67.
MMSE and DEAR scores in other patient populations and 3. Marcantonio ER, Flacker JM, Michaels M, Resnick NM.
Delirium is independently associated with poor functional
to ascertain whether they can be used to target interventions recovery after hip fracture. J Am Geriatr Soc 2000; 48:
in the prevention and treatment of delirium. 618–24.
4. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reduc-
ing delirium after hip fracture: a randomised trial. J Am Geriatr
Soc 2001; 49: 516–22.
Key points 5. Molloy DW, Alemayehu E, Roberts R. Reliability of the
• Delirium is a common and potentially preventable com- standardised mini-mental status examination compared
plication in fractured neck of femur patients. with the traditional examination. Am J Psychiatry 1991;
• Pre-existing cognitive impairment is the most important 148: 102–5.
risk factor for the development of delirium in fractured 6. Inouye SK, van Dyck CH, Alessi CA et al. Clarifying
neck of femur patients. confusion. The confusion assessment method. Ann Intern
• Orthopaedic nurses can be trained to identify risk factors Med 1991; 119: 474–81.
for the development of delirium using a simple risk score 7. Zou Y, Cole MG, Primeau FJ et al. Detection and diagnosis of
delirium in the elderly: psychiatric diagnosis, confusion assess-
and the Mini-Mental State Examination. ment method or consensus diagnosis? Int Psychogeriatr 1998;
10: 303–8.
Acknowledgements 8. Freter SH, Dunbar MJ, MacLeod H, Morrison M, Macknight C,
Rockwood K. Predicting post-operative delirium in elective
This study was completed during J.G.’s sabbatical in Halifax orthopaedic patients: the Delirium Elderly At-Risk (DEAR)
funded by the BUPA Foundation. C.M. and K.R. are both instrument. Age Ageing 2005; 34: 169–71.
supported by investigator awards from the Canadian Insti-
tute of Health Research. doi:10.1093/ageing/afi099

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