Perioperative Delirium Prevention in Hip Fracture Surgery: An Orthopedic- Centered Review of Non-Pharmacologic Strategies

Abstract

Postoperative delirium is one of the most common complications following hip fracture surgery in older adults, affecting up to half of patients, and contributing to prolonged hospitalization, delayed functional recovery, institutionalization, increased healthcare costs, and increased mortality. Despite its clinical significance, delirium remains underrecognized, particularly in its hypoactive form, and no pharmacologic intervention has consistently demonstrated efficacy for prevention. Current evidence therefore supports multicomponent non-pharmacologic interventions as the cornerstone of delirium prevention. Orthopedic surgeons influence many perioperative decisions that affect delirium risk, including surgical timing, pain management, weight-bearing protocols, and coordination of multidisciplinary care, placing them in a central role for prevention. This review summarizes the pathophysiology and orthopedic-specific risk factors associated with perioperative delirium following hip fracture surgery and highlights evidence-based, non-pharmacologic strategies that can be incorporated into routine orthopedic practice. Key interventions include timely surgical fixation, multimodal opioid-sparing analgesia incorporating regional anesthesia techniques, early mobilization supported by weight-bearing as tolerated when construct stability permits, medication optimization, preservation of sleep and sensory function, and orthogeriatric co-management. Evidence from randomized trials, systematic reviews, and clinical practice guidelines demonstrates that these strategies reduce delirium incidence while improving mobility, functional recovery, discharge disposition, and other postoperative outcomes. Successful implementation requires coordinated multidisciplinary care involving orthopedic surgeons, anesthesiologists, geriatricians, nursing staff, rehabilitation specialists, patients, and caregivers. Integrating these evidence-based interventions into standardized hip fracture pathways provides a practical, orthopedic-centered approach to reducing delirium and optimizing outcomes for older adults undergoing hip fracture surgery.