Abstract
Objective: To compare the effects of general anesthesia (GA) and spinal anesthesia (SA) on postoperative delirium (POD) in elderly patients undergoing hip fracture surgery and to identify associated risk factors. Methods: A retrospective study was conducted on 186 elderly patients who underwent hip fracture surgery at the Affiliated Hospital of Gansu University of Chinese Medicine from January 2021 to January 2023. Patients were categorized into GA and SA groups. The incidence of POD, postoperative pain control, and cognitive function changes were compared. Univariate and multivariate Logistic regression analyses were performed to identify independent risk factors for POD. The predictive value of significant factors was assessed using receiver operating characteristic (ROC) curve analysis. Results: The incidence of POD was significantly higher in the GA group than that in the SA group (27.4% vs. 9.9%, P=0.002). The visual analogue scale scores at 24 hours postoperatively and analgesic drug usage were significantly higher in the GA group (both P<0.001). Cognitive function scores postoperatively were significantly lower in the GA group (P<0.005). Multivariate analysis identified longer operation time (P<0.001, OR: 1.084, 95% CI: 1.047-1.123) and higher intraoperative blood loss (P=0.042, OR: 1.018, 95% CI: 1.001-1.035) as independent risk factors for POD. Conversely, higher preoperative hemoglobin (P=0.002, OR: 0.949, 95% CI: 0.919-0.981) and SA (P=0.021, OR: 0.174, 95% CI: 0.039-0.767) were protective factors. Conclusion: Compared to GA, SA significantly reduces POD incidence and improves postoperative analgesia in elderly hip fracture patients. Optimizing anesthetic strategies and preoperative assessments may enhance postoperative recovery in this population.
Keywords: Hip fracture, spinal anesthesia, postoperative delirium, risk factor analysis
Introduction
Hip fractures result from complete or partial breaks in the hip bone and are more prevalent in individuals over 65 years old [1]. With aging, bone density gradually decreases, weakening bone strength and reducing balance and reaction capabilities, making elderly individuals more prone to hip fractures due to falls [2,3]. Statistics indicate that osteoporotic fractures affect up to 50% of women and 20% of men over 50 years old [4]. As the population ages, the incidence of hip fractures in the elderly continues to rise.
Following a hip fracture, prolonged bed rest increases the risk of complications such as pulmonary infections, deep vein thrombosis, and pressure ulcers, which can significantly elevate mortality [5]. According to Sing et al. [6], the all-cause mortality rate after a hip fracture ranges from 14.4% to 28.3%.
Surgical treatment is the primary approach for elderly patients with hip fractures. However, due to age-related declines in organ function, anesthesia and surgery pose significantly higher risks in elderly patients than middle-aged individuals. Postoperative complications are more common, with postoperative delirium (POD) being one of the most prevalent complications [7]. POD is an acute neuropsychiatric syndrome occurring within a week after surgery and anesthesia, primarily characterized by cognitive dysfunction and impaired attention [8]. Selecting an optimal anesthetic approach is therefore crucial for ensuring surgical success and minimizing adverse outcomes in elderly patients.
For hip fracture surgery in the elderly, the main anesthesia options are regional anesthesia and general anesthesia [9]. General anesthesia (GA) induces unconsciousness through inhaled or intravenous anesthetic agents [10], whereas regional anesthesia involves injecting local anesthetics into the spinal cord or peripheral nerves to alleviate pain [11]. Spinal anesthesia (SA), a form of regional anesthesia, allows patients to remain conscious and maintain spontaneous breathing, potentially reducing central nervous system complications and lowering the risk of POD [12]. However, the specific impact of GA and SA on POD incidence in elderly hip fracture patients remains unclear.
This study aims to compare the effects of GA and SA on POD in elderly patients undergoing hip fracture surgery.
Materials and methods
Patient data
A retrospective study was conducted on 186 elderly patients who underwent hip fracture surgery at the Affiliated Hospital of Gansu University of Chinese Medicine between January 2021 and January 2023. This study was approved by the Medical Ethics Committee of the Affiliated Hospital of Gansu University of Chinese Medicine (ethics approval number: 20200416).
Inclusion and exclusion criteria
Inclusion criteria: Patients were diagnosed with hip fractures based on imaging findings [13], underwent hip fracture surgery, had an ASA classification of II or III, were aged 65 years or older, and had complete medical records.
Exclusion criteria: Patients had preoperative consciousness or cognitive disorders, medication allergies, fractures other than hip fractures, coagulation dysfunction, or acute infections.
Anesthesia protocols
Patients in the GA group fasted for 8 hours before surgery. One hour before surgery, they received 5-10 mg of diazepam (Shanxi Xinbaoyuan Pharmaceutical Co., Ltd., batch number: 20210108) orally, along with continuous ECG monitoring and nasal cannula oxygen supplementation. Upon entering the operating room, an intravenous line was established, and a continuous infusion of physiological saline or lactated Ringer’s solution was maintained. Anesthesia was induced with cisatracurium besylate (Zhejiang Xianjun Pharmaceutical Co., Ltd., batch number: 20200411) at 0.1 mg/kg, midazolam (Jiangsu Enhua Pharmaceutical Co., Ltd., batch number: MD202046) at 0.1 mg/kg, etomidate (Zhejiang Jiuxu Pharmaceutical Company, batch number: 2020712), and sufentanil (Yichang Renfu Pharmaceutical Company, batch number: 21A03261). After endotracheal intubation, remifentanil (Liaoning Haisike Pharmaceutical Company, batch number: 20A12061) was continuously administered via a micro-pump at 0.1-1.0 μg/(kg·min) with propofol (Sichuan Guorui Pharmaceutical Company, batch number: 2110261) at 0.1 mg/(kg·min). Additional anesthetic agents were administered as needed based on muscle relaxation and anesthesia depth.
The SA group underwent the same preoperative preparations as the GA group. Patients were positioned laterally on their right side, and a lumbar puncture was performed at the L2-3 or L3-4 interspace. A catheter was inserted 4-5 cm deep, and 2 mL of levobupivacaine (Shanghai Hefeng Company, batch number: H31021344) was injected to achieve an anesthetic level of T10.
Observation indicators
Primary outcomes
Postoperative pain management: The visual analogue scale (VAS) score at 24 hours postoperative [14] and the number of analgesic drug administrations were compared between the GA and SA groups.
Cognitive function changes: Cognitive function was assessed preoperatively and postoperatively using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) scales [15].
Incidence of POD: The incidence of POD was compared between the groups. Independent risk factors for POD were identified through univariate and multivariate logistic regression analyses.
Secondary outcomes
Surgical parameters: Surgery duration, intraoperative blood loss, and length of hospital stay were recorded for both groups.
Postoperative complications: The incidence of postoperative infections and postoperative hypotension was compared between the groups.
Statistical analysis
All statistical analyses were performed using SPSS software. Continuous variables were expressed as mean ± standard deviation (SD) and compared between groups using independent sample t-tests. Categorical variables were expressed as frequencies and analyzed using chi-square tests. POD, as a binary variable, was initially analyzed for potential risk factors through univariate analysis. Variables with significant differences were then included in a multivariate logistic regression model to identify independent predictors of POD. The predictive value of each independent risk factor was assessed using receiver operating characteristic (ROC) curve analysis, with the area under the curve (AUC) calculated. A P-value of <0.05 was considered statistically significant.
Results
Comparison of baseline data
A comparison of baseline characteristics between the two groups showed no statistically significant differences in body mass index, age, gender, American Society of Anesthesiologists classification, fracture site, education level, history of hypertension, history of diabetes, cause of fracture, preoperative waiting time, preoperative hemoglobin, or preoperative albumin (all P>0.05), as shown in Table 1.
Table 1.
Comparison of baseline data
| General anesthesia group (n=95) | Spinal anesthesia group (n=91) | χ2/t | P | |
|---|---|---|---|---|
| BMI (kg/m2) | 21.87±2.77 | 22.28±2.72 | 1.015 | 0.311 |
| Age | 0.566 | 0.452 | ||
| <75 years | 63 | 65 | ||
| ≥75 years | 32 | 26 | ||
| Gender | 0.264 | 0.607 | ||
| Male | 28 | 30 | ||
| Female | 67 | 61 | ||
| ASA Classification | 0.689 | 0.407 | ||
| Level II | 65 | 57 | ||
| Level III | 30 | 34 | ||
| Fracture Site | 0.123 | 0.726 | ||
| Femoral Neck | 68 | 63 | ||
| Intertrochanteric | 27 | 28 | ||
| Educational Level | 0.265 | 0.606 | ||
| Junior High School and below | 39 | 34 | ||
| High School and above | 56 | 57 | ||
| History of Hypertension | 0.262 | 0.609 | ||
| Yes | 25 | 21 | ||
| No | 70 | 70 | ||
| History of Diabetes | 0.273 | 0.601 | ||
| Yes | 15 | 17 | ||
| No | 80 | 74 | ||
| Cause of Fracture | 1.226 | 0.268 | ||
| Fall | 78 | 80 | ||
| Traffic Accident | 17 | 11 | ||
| Preoperative Waiting Time (d) | 3.69±1.31 | 3.38±1.40 | 1.563 | 0.120 |
| Preoperative Hemoglobin (g/L) | 119.47±17.53 | 118.02±15.82 | 0.594 | 0.553 |
| Preoperative Albumin (g/L) | 39.25±4.21 | 38.78±4.24 | 0.748 | 0.456 |
Note: BMI, body mass index; ASA, American Society of Anesthesiologists.
Comparison of surgical conditions
No significant differences were observed between the two groups in terms of surgery duration or hospital stay. However, intraoperative blood loss was significantly higher in the GA group than that in the SA group (P<0.05), as shown in Figure 1.
Figure 1.
Comparison of surgical conditions. Note: ns means P>0.05 for comparison between the two groups, *** means P<0.05 for comparison between the two groups.
Comparison of postoperative analgesic effects
The GA group had significantly higher VAS scores at 24 hours postoperatively and a greater number of analgesic drug administrations compared to the SA group (both P<0.05), as shown in Figure 2.
Figure 2.
Postoperative analgesic effects. Note: *** indicates P<0.001 compared between the two groups. VAS, visual analogue scale.
Comparison of cognitive function changes
There were no significant differences in preoperative MMSE and MoCA scores between the two groups (both P>0.05). However, postoperative MMSE and MoCA scores were significantly lower in the GA group than those in the SA group (both P<0.05) (Figure 3).
Figure 3.
Comparison of cognitive function changes. Note: ns means P>0.05 for comparison between the two groups, *** means P<0.05 for comparison between the two groups. MMSE, mini-mental state examination; MoCA, Montreal cognitive assessment.
Comparison of POD and adverse reaction rates
POD occurred in 26 cases in the GA group and 9 cases in the SA group. The incidence of POD was significantly higher in the GA group than that in the SA group (P<0.05).
Regarding postoperative complications, the GA group had 5 cases of postoperative infection and 9 cases of postoperative hypotension, while the SA group had 7 cases of postoperative infection and 4 cases of postoperative hypotension. No significant differences were observed in the incidence of postoperative infection, hypotension, or nausea and vomiting between the two groups (all P>0.05), as shown in Table 2.
Table 2.
Postoperative delirium and adverse reaction rates
| Comparison | Postoperative delirium | Postoperative infection | Postoperative hypotension | Postoperative nausea and vomiting |
|---|---|---|---|---|
| General anesthesia group (n=95) | 26 | 5 | 9 | 16 |
| Spinal anesthesia group (n=91) | 9 | 7 | 4 | 9 |
| χ2 | 9.295 | 0.454 | 1.844 | 1.931 |
| P | 0.002 | 0.500 | 0.175 | 0.165 |
Univariate analysis of POD showed that age, preoperative hemoglobin, operation time, intraoperative blood loss, 24-hour postoperative VAS score, preoperative MMSE score, preoperative MoCA score, and anesthesia type were significantly associated with the occurrence of POD (P<0.05, Table 3).
Table 3.
Single factor results
| Postoperative delirium (n=35) | Non-Postoperative delirium (n=151) | OR (95% CI) | P | |
|---|---|---|---|---|
| BMI (kg/m2) | 21.71+3.09 | 22.15+2.66 | 0.943 (0.824-1.079) | 0.392 |
| Age | 0.042 | |||
| <75 years | 19 | 109 | 2.185 (1.020-4.654) | |
| 75 years | 16 | 42 | 0.458 (0.215-0.973) | |
| Gender | 0.972 | |||
| Male | 11 | 47 | 0.986 (0.455-2.247) | |
| Female | 24 | 104 | 1.014 (0.459-2.240) | |
| ASA Classification | 0.706 | |||
| Level II | 22 | 100 | 1.159 (0.529-2.463) | |
| Level III | 13 | 51 | 0.863 (0.402-1.853) | |
| Fracture Site | 0.498 | |||
| Femoral Neck | 23 | 108 | 1.310 (0.585-2.828) | |
| Intertrochanteric | 12 | 43 | 0.763 (0.349-1.669) | |
| Educational Level | 0.777 | |||
| Junior High School and below | 13 | 60 | 1.116 (0.528-2.436) | |
| High School and above | 22 | 91 | 0.896 (0.419-1.915) | |
| History of Hypertension | 0.149 | |||
| Yes | 12 | 34 | 0.557 (0.254-1.263) | |
| No | 23 | 117 | 1.795 (0.810-3.978) | |
| History of Diabetes | 0.991 | |||
| Yes | 6 | 26 | 1.005 (0.399-2.896) | |
| No | 29 | 125 | 0.995 (0.375-2.638) | |
| Cause of Fracture | 0.367 | |||
| Fall | 28 | 130 | 1.548 (0.565-3.855) | |
| Traffic Accident | 7 | 21 | 0.646 (0.250-1.667) | |
| Preoperative Waiting Time (d) | 3.54+1.34 | 3.54+1.36 | 1.000 (0.759-1.311) | 0.999 |
| Preoperative Hemoglobin (g/L) | 108.69+16.10 | 121.10+15.99 | 0.954 (0.930-0.977) | <0.001 |
| Preoperative Albumin (g/L) | 38.81+4.24 | 39.07+4.22 | 0.986 (0.903-1.076) | 0.749 |
| Surgery Duration (min) | 145.20+16.77 | 115.98+21.83 | 1.076 (1.048-1.105) | <0.001 |
| Blood Loss (mL) | 188.60+33.05 | 152.39+34.64 | 1.030 (1.018-1.143) | <0.001 |
| Hospital Stay (d) | 17.91+4.44 | 17.44+3.86 | 1.031 (0.940-1.131) | 0.521 |
| VAS Score at 24 hours Postoperatively | 2.91+0.85 | 2.40+0.95 | 1.821 (1.197-2.770) | 0.005 |
| Number of Analgesic Drug Usages | 1.46+0.85 | 1.42+0.84 | 1.113 (0.353-4.258) | 0.863 |
| Preoperative MMSE Score | 27.14+4.88 | 27.21+4.04 | 0.996 (0.912-1.087) | 0.93 |
| Preoperative MoCA Score | 23.31+3.40 | 24.87+3.67 | 0.892 (0.807-0.986) | 0.026 |
| Anesthesia Method | 0.003 | |||
| General Anesthesia | 26 | 69 | 3.433 (1.557-8.209) | |
| Spinal Anesthesia | 9 | 82 | 0.291 (0.128-0.663) |
Note: BMI, body mass index; ASA, American Society of Anesthesiologists; MMSE, mini-mental state examination; MoCA, Montreal cognitive assessment; VAS, visual analogue scale.
Multivariate analysis of POD
Multivariate logistic regression analysis of the significant factors from the univariate analysis revealed the following:
Age (P=0.161, OR: 2.245, 95% CI: 0.725-6.952), 24-hour postoperative VAS score (P=0.717, OR: 1.121, 95% CI: 0.605-2.074) and preoperative MoCA score (P=0.136, OR: 0.877, 95% CI: 0.757-1.039) were not independent risk factors for POD.
Longer operation time (P<0.001, OR: 1.084, 95% CI: 1.047-1.123) and greater blood loss (P=0.042, OR: 1.018, 95% CI: 1.001-1.035) were identified as independent risk factors for postoperative delirium.
Higher preoperative hemoglobin (P=0.002, OR: 0.949, 95% CI: 0.919-0.981) and SA (P=0.021, OR: 0.174, 95% CI: 0.039-0.767) were identified as independent protective factors.
These findings are summarized in Table 4.
Table 4.
Multivariate results
| Postoperative delirium (n=35) | Non-Postoperative delirium (n=151) | OR (95% CI) | P | |
|---|---|---|---|---|
| Age | 0.161 | |||
| <75 years | 19 | 109 | 2.245 (0.725-6.952) | |
| 75 years | 16 | 42 | 0.445 (0.144-1.380) | |
| Preoperative Hemoglobin (g/L) | 108.69+16.10 | 121.10+15.99 | 0.949 (0.919-0.981) | 0.002 |
| Surgery Duration (min) | 145.20+16.77 | 115.98+21.83 | 1.084 (1.047-1.123) | <0.001 |
| Blood Loss (mL) | 188.60+33.05 | 152.39+34.64 | 1.018 (1.001-1.035) | 0.042 |
| VAS Score at 24 hours Postoperatively | 2.91+0.85 | 2.40+0.95 | 1.121 (0.605-2.074) | 0.717 |
| Preoperative MoCA Score | 23.31+3.40 | 24.87+3.67 | 0.877 (0.757-1.039) | 0.136 |
| Anesthesia Method | 0.021 | |||
| General anesthesia | 26 | 69 | 5.762 (1.303-25.474) | |
| Spinal anesthesia | 9 | 82 | 0.174 (0.039-0.767) |
Note: VAS, visual analogue scale; MoCA, Montreal cognitive assessment.
Predictive value of independent risk factors for POD
ROC curve analysis was performed to assess the predictive value of preoperative hemoglobin, operation time, blood loss, and anesthesia type for POD. The AUC values for these factors were 0.699, 0.865, 0.774, and 0.643, respectively, indicating that these independent risk factors have good predictive value for POD (Figure 4).
Figure 4.
ROC curve of independent influencing factors for predicting postoperative delirium. ROC, receiver operating characteristic.
Discussion
Hip fractures are a common and severe condition in elderly patients, with surgery being the primary treatment. However, due to age-related declines in physiological function, elderly patients face higher anesthesia and surgical risks, with POD being one of the most prevalent complications [16]. This study aimed to compare the effects of GA and SA on POD incidence in elderly hip fracture patients and to analyze associated risk factors.
This study found no significant difference in surgery duration or hospital stay between the GA and SA groups. However, intraoperative blood loss was significantly higher in the GA group than that in the SA group. A possible explanation is that GA induces vasodilation, leading to increased intraoperative bleeding [17]. In contrast, SA blocks sympathetic nerve activity, reducing blood flow in the surgical area and thereby decreasing intraoperative blood loss [18]. These findings are consistent with a study by Zorrilla-Vaca et al. [19], which reported that regional anesthesia in lumbar spine surgery is associated with lower rates of nausea and vomiting, shorter hospital stays, and reduced intraoperative blood loss compared to GA.
Postoperative VAS scores at 24 hours and analgesic drug usage were significantly higher in the GA group than those in the SA group. This suggests that GA may heighten postoperative pain sensitivity, leading to an increased need for analgesics. In contrast, SA provides more effective regional pain control, reducing postoperative pain and improving patient comfort. The improved pain control associated with SA may also help lower the risk of POD by minimizing physiological stress responses.
The incidence of POD was 26% in the GA group and 9% in the SA group, demonstrating a statistically significant difference. These results suggest that SA may significantly reduce the risk of POD in elderly patients undergoing hip fracture surgery. A possible explanation is that SA maintains patient consciousness and reduces central nervous system depression, thereby lowering the risk of cognitive impairment. Additionally, SA has been associated with reduced intraoperative blood loss and a lower stress response, both of which may contribute to a decreased risk of delirium.
Previous studies have also suggested that certain local anesthetics may better control surgical stress responses, further supporting the potential protective effects of SA against POD [20].
The results of the multivariate logistic regression analysis identified preoperative hemoglobin levels, surgery duration, blood loss, and anesthesia method as independent risk factors for POD. ROC curve analysis showed that the AUC values for predicting POD were 0.699 (preoperative hemoglobin), 0.865 (operation time), 0.774 (blood loss), and 0.643 (anesthesia method), indicating that these factors have good predictive value.
A lower preoperative hemoglobin level may indicate poor nutritional status or chronic disease, which increases the risk of postoperative complications [21]. Additionally, longer surgery duration and greater blood loss may lead to prolonged postoperative recovery, elevating the risk of POD. A study by Sui et al. [22] found that prolonged surgery in elderly patients increases the likelihood of POD, severely impacting cognitive function, extending hospital stays, and increasing medical costs. Therefore, optimizing preoperative assessment and perioperative management may help reduce the incidence of POD.
The anesthesia method was also identified as an independent risk factor for POD, reflecting the significant impact of anesthesia techniques on neurocognitive function in elderly patients. GA may increase the risk of cognitive dysfunction by depressing central nervous system activity, whereas SA preserves consciousness and minimizes neurological impairment. Belrose et al. [23] reported that GA is associated with delayed neurocognitive recovery in certain patients. These findings suggest that in clinical practice, choosing the appropriate anesthesia method can improve postoperative pain management and reduce the risk of POD.
However, some studies have reported no significant difference in cognitive dysfunction incidence between GA and regional anesthesia in elderly hip fracture patients [24]. This highlights the need to individualize anesthesia selection based on patient-specific factors and the nature of the surgery to optimize recovery outcomes.
Additionally, a study by Zhang et al. [25], which retrospectively analyzed 566 cases of spinal surgery in elderly patients, also identified blood loss as an independent risk factor for POD. Other factors such as preoperative anxiety, elevated C-reactive protein, and hyponatremia were also associated with increased POD risk, emphasizing the need for comprehensive perioperative monitoring.
This study provides a detailed comparative analysis of GA and SA in elderly patients undergoing hip fracture surgery, offering new insights into postoperative delirium and associated risk factors.
Unlike previous studies, this research conducted detailed comparisons across multiple dimensions, including POD incidence, postoperative pain control, cognitive function changes, surgical conditions, and adverse event rates.
This study employed both univariate and multivariate logistic regression analyses to accurately identify independent risk factors and protective factors for POD.
It confirmed that longer operation time and higher blood loss were independent risk factors, while higher preoperative hemoglobin and SA were independent protective factors.
By calculating AUC values from ROC curves, this study quantified the predictive value of key risk factors, aiding in early clinical intervention and perioperative management optimization.
This provides more precise and actionable insights than previous studies.
This study has several limitations. First, as a retrospective study, there is a potential for selection bias, which may affect the accuracy of the findings. Second, the study only compared GA and SA, without considering other anesthesia techniques that may also influence POD risk. In addition, this study did not assess long-term cognitive outcomes, making it unclear how different anesthesia methods affect long-term prognosis.
Future studies should adopt prospective designs and include long-term follow-up assessments to provide more robust conclusions.
In conclusion, SA demonstrates favorable anesthetic effects in elderly patients undergoing hip fracture surgery, offering comparable pain control to GA while reducing POD incidence.
A comprehensive preoperative assessment, including cognitive function, age, and perioperative risk factors, is essential for optimizing anesthesia strategies. Tailoring anesthesia choices to individual patients can effectively lower POD risk and enhance postoperative recovery.
Disclosure of conflict of interest
None.
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