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Andrijana Ćorić

Milena Mikić

Nemanja Gvozdenović

Anđela Opančina

Branimirka Aranđelović

Nursing undergraduate and master’s degree (BScN, MScN), PhD (Nursing) student. Third year Medical Student, Faculty of Medicine, University

of Novi Sad (Hajduk Veljkova 3, 21000 Novi Sad, Republic of Serbia).

BScN, MScN, PhD. Teaching Assistant, Faculty of Medicine, University of Novi Sad (Hajduk Veljkova 3, 21000 Novi Sad, Republic of Serbia);

University Clinical Center of Vojvodina, Clinic for Orthopedic Surgery and Traumatology (Hajduk Veljkova 1, 21000 Novi Sad, Republic of

Serbia).

MD, PhD. Associate Professor. Orthopedic surgeon, Faculty of Medicine, University of Novi Sad (Hajduk Veljkova 3, 21000 Novi Sad, Republic

of Serbia); University Clinical Center of Vojvodina, Clinic for Orthopedic Surgery and Traumatology (Hajduk Veljkova 1, 21000 Novi Sad,

Republic of Serbia).

MD. PhD student and Research Trainee. Faculty of Medicine, University of Novi Sad (Hajduk Veljkova 3, 21000 Novi Sad, Republic of Serbia).

BScN, MScN, PhD. Teaching Assistant. Faculty of Medicine, University of Novi Sad (Hajduk Veljkova 3, 21000 Novi Sad, Republic of Serbia).

R E S U M E N

Riesgo de caídas e incidencia de Riesgo de caídas e incidencia de

delirio en pacientes hospitalizados delirio en pacientes hospitalizados

en el servicio de ortopediaen el servicio de ortopedia

Fall risk and incidence of delirium in hospitalized Fall risk and incidence of delirium in hospitalized

orthopedic patientsorthopedic patients

Artículo de investigación

ISSN: 0121-7372 • ISSN electrónico: 2462-991X

de Medicina y Cirugía

Vol. 33

N°3 . 2024

INFORMACIÓN DEL ARTÍCULO

Historia del artículo:

Date received: october 17, 2023

Date accepted: april 30, 2024

Main and corresponding author email:

Andrijana Ćorić

912007d23@mf.uns.ac.rs / 015199@mf.uns.ac.rs

DOI

10.31260/RepertMedCir.01217372.1561

Introducción: el riesgo de caídas y de lesiones relacionadas, así como el de presentar delirio, representan un problema de

salud pública en constante aumento, en especial en sociedades con una población que envejece. Objetivo: el propósito de

este estudio fue evaluar el nivel de riesgo de caídas, previo a cirugía de cadera o rodilla, y la frecuencia de desarrollar delirio

después de las intervenciones quirúrgicas. Materiales y métodos: estudio observacional, analítico de corte transversal en el

que se encuestaron pacientes hospitalizados en la Clínica de Cirugía Ortopédica y Traumatología, Novi Sad, Serbia, entre el

inicio de diciembre de 2022 y n de enero de 2023. Resultados: del número total de pacientes (N = 106), la mayoría (61.3%)

tenían más de 70 años, de los cuales la mayor parte eran de sexo femenino (N = 80 (75.5%). El porcentaje más alto de los que

respondieron la encuesta fueron categorizados en nivel II de riesgo de caída (73.6%), mientras que se clasicó como nivel I

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Falls and fall-related injuries represent a growing

public health issue due to the increasing life expectancy

of individuals and the aging of the global population

A fall is dened as an unplanned event that leads to the

unintentional descent of a patient to the ground, oor, or

lower level in general, excluding intentional changes in

position with the purpose of relying on furniture, walls, or

objects in the immediate surroundings.

Falls and fall-related injuries are one of the most commonly

reported adverse events in hospital settings. According to

the Agency for Healthcare Research and Quality (AHRQ), in

the United States, there are 700.000 to 1,000,000 reported

patient falls annually during hospitalization.

NANDA

(North American Nursing Diagnosis Association) includes

the fall risk in nursing diagnosis, dened as “a state of

increased vulnerability to falling and the occurrence of

bodily harm”.

About 15–20% of falls result in serious injuries, with or

without fractures. Falls without injury are also associated

INTRODUCTION

with negative health impacts, such as loss of function,

anxiety, depression, fear of falling, and social withdrawal.

Many countries with developed healthcare systems have

established fall prevention services.

Categories of falls in hospital settings

There are three categories of falls in hospital settings:

anticipated physiological factors/anticipated physiological

falls (unsteady gait, history of falls, and current fall

risk); unanticipated physiological factors/unanticipated

physiological falls (syncope, seizures, pathological fractures);

and environmental factors/accidental falls (external hazards

or equipment malfunctions). Additionally, organizational

units within healthcare institutions dier in terms of

patients, sta, healthcare delivery model, environment, and

equipment accessibility, all of which signicantly impact

patient fall rates.

Age-related physiological changes are

associated with an increased fall risk. Unaddressed sensory

impairments hinder obstacle detection and/or avoidance,

ABSTRACT

Introduction: The fall risk and fall-related injuries, as well as the risk of developing delirium, represent a constantly

increasing public health problem, especially in societies with an aging population. Objective: This study aimed to assess the

level of risk for falls in patients before hip or knee surgery and the frequency of delirium after hip or knee surgery. Materials

& Methods: The study was conducted as an observational, analytical cross-sectional study by surveying hospitalized patients

at the Clinic for Orthopedic Surgery and Traumatology, Novi-Sad, Serbia, between the beginning of December 2022 and

the end of January 2023. Results: From the total number of patients (N = 106), the majority (61.3%) were over 70 years of

age, of which the largest number were female (female = 80 (75.5%)). The highest percentage of respondents had a level II

fall risk (73.6%), while level I and level III risks had 14 respondents each (13.2%). The results of the 4AT score showed that

the largest number of patients, N = 50 (47.2%), had delirium or cognitive impairment with low probability, with possible

cognitive impairment in 40 patients (37.7%), while delirium was possible in 16 patients (15.1%). Conclusion: Orthopedic

patients hospitalized at the University Clinical Center of Vojvodina had level II fall risk, and the largest number of these

patients had a low probability of cognitive impairment or postoperative delirium.

Key words: fall risk, delirium, nursing, orthopedic patients.

This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

y III a 14 pacientes en cada uno de dichos niveles (13.2%). Los resultados del puntaje 4AT evidenciaron que en la mayoría

de los pacientes (N = 50 47.2%) la probabilidad de presentar delirio o deterioro cognitivo fue baja, con posibles deterioro

cognitivo en 40 (37.7%) y delirio en 16 (15.1%). Conclusión: los pacientes hospitalizados en el servicio de ortopedia de la

Clínica de Cirugía Ortopédica y Traumatología del Centro Clínico Universitario de Vojvodina tenían riesgo de caída nivel II,

con baja probabilidad de presentar deterioro cognitivo o delirio en el postoperatorio.

Palabras clave: riesgo de caídas, delirio, enfermería, pacientes de ortopedia.

Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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The study was conducted as an observational, analytical

cross-sectional study by surveying hospitalized patients

at the Clinic for Orthopedic Surgery and Traumatology of

the University Clinical Center of Vojvodina between the

beginning of December 2022 and the end of January 2023.

The clinic has a capacity of 70 beds and provides care for

patients with degenerative musculoskeletal conditions, as

well as traumatized patients. A total of 106 patients, with

diagnoses of Gonarthrosis and Coxarthrosis, both male and

female, 50 to 94 years old, participated in the research.

The fall risk assessment was performed upon admission to

the Clinic for Orthopedic Surgery and Traumatology, while

MATERIALS AND METHODS

while decreased muscle strength and weakened reexes

have a negative impact on reactivity.

In older people, falls

are recognized as the leading cause of injuries and hospital

admissions worldwide, most commonly due to fall-related

injuries.

Annually, one-third of older people (65 years and

older) experience a fall at least once, with 20% of these

falls resulting in injuries. The high prevalence of injuries

imposes an additional nancial burden on the entire

healthcare system.

Fall risk factors in older people

Fall risk factors in older people can be divided into two

groups: intrinsic factors and environmental factors. Among

intrinsic factors, in addition to older age and gender, many

diseases and physical dysfunctions have a signicant

impact, such as muscle weakness, gait and balance problems,

visual impairments, postural hypotension, and a signicant

number of chronic conditions (osteoporosis, hypertension,

diabetes, stroke, cognitive impairment, epilepsy, dementia

etc). The use of medications for the treatment of mental

disorders, diabetes, and cardiovascular diseases, as well as

non-steroidal anti-inammatory drugs, is also associated

with an increased fall risk. Environmental factors most

commonly relate to living in an unsafe environment.

Orthopedic patients are at a signicantly increased fall risk

due to musculoskeletal disorders, mobility impairments, and

prolonged immobility

9,10

and delirium is not uncommon

among these patients during hospitalization.

11,12

Fall risk factors and the onset of delirium in older

people

Delirium is characterized by an acute and uctuating

impairment of consciousness, accompanied by disturbances

in attention, cognition, and perception. Postoperative

delirium is a serious complication for older patients as

it is associated with functional impairment, prolonged

hospitalization, and institutionalization. Early recognition,

diagnosis, and treatment of delirium can reduce the length of

hospital stays, in-hospital morbidity, and healthcare costs.

The prevalence of delirium during hospitalization in these

patients is as high as 60%. Older orthopedic patients are at

an increased risk of developing delirium, especially after

a surgical procedure. Several predisposing factors for the

development of delirium in hospitalized patients have been

identied. These factors commonly include the patient’s age,

cognitive impairment, depression, severe illness, conrmed

infection, sedative use, sleep disturbances, hospitalization-

related fractures, signicant physical function impairment,

and preadmission institutionalization.

A number of risk

factors that signicantly increase the likelihood of delirium

following orthopedic interventions have been identied.

They include preoperative aective dysfunction, general

anesthesia, intraoperative hypercapnia and hypotension,

a surgery duration longer than 3 hours, postoperative

pain, postoperative sleep disturbances, and the length of

hospitalization itself. Notably, orthopedic pathology related

to the hip joint has the highest incidence of postoperative

delirium.

In patients who have undergone hip joint replacement,

impaired joint function and muscle weakness can increase

the fall risk. These patients may also experience a fear of

falling during activities of daily living (ADL).

Fear of falling

The fear of falling is dened as a persistent concern

about falling and can lead to self-restriction in performing

daily activities. Fear is a predominant risk factor for falls in

older individuals, regardless of their history or frequency

of falls.

Recurrent falls, along with fear, can result in

serious psychological trauma known as post-fall syndrome,

where older adults refuse to move due to the fear of further

falls and injuries.

Even 65% of older patients who have

not experienced a fall and 92% of those who have report

experiencing a fear of falling. Fear of falling after a surgical

procedure diminishes self-ecacy and one’s perception of

one’s own abilities.

In hospital settings, various guidelines

are used for fall prevention, which involve systematic

identication of patients at high fall risk and a clinical

assessment to select an appropriate fall prevention strategy.

However, there are signicant dierences among guidelines,

which create confusion regarding the correct approach

to fall prevention. Unclear fall prevention guidelines can

burden healthcare delivery and potentially increase the risk

for patients.

Aim of the study

Based on everything stated, we have concluded that there

is a need to assess the fall risk in hospitalized orthopedic

patients upon admission to the hospital, as well as the

frequency of delirium in patients after surgical procedures.

Our aims were to: (i) Assess the fall risk level among

hospitalized patients prior to hip or knee surgery; and (ii)

Evaluate the incidence of postoperative delirium among

patients undergoing hip or knee surgery.

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the evaluation of potential delirium was conducted 24

hours after the surgical procedure. The study was organized

as individual interviews with each patient conducted by

the researchers. Medical documentation was used for

data related to the ASA status (ASA - American Society

of Anesthesiologists) and the type of anesthesia used

during the surgical procedure. The American Society of

Anesthesiologists (ASA) adopted a classication of patient

risk prior to anesthesia in 1963. This classication allows

for a numerical assessment of the patient’s health (ranging

from I to VI) and an evaluation of potential anesthesia-

related risk factors.

Research instruments

The Fall Risk Assessment Score Sheet

, was used as

the primary research instrument. Permission to use the

instrument was obtained through written correspondence

with the author. This instrument was specically designed

to identify the fall risk level in hospitalized patients

upon admission to a hospital facility. It consists of 16

items distributed across two domains. The rst domain

relates to patient characteristics, including age, history of

falls, environmental changes, and personality traits. The

second domain focuses on assessing the patient’s physical

condition, including physical tness, cognitive functions,

physical activity, and medication use. Based on the number

of identied elements, the fall risk level is assessed, ranging

from the lowest (Level I) to the highest risk level (Level III).

Level I indicates a score of 0-3, Level II indicates a score of

4-9, and Level III indicates a score of 10 or higher.

Another instrument used in this research was the 4AT -

Rapid Clinical Test for Delirium Detection.

It was used in

the postoperative period, 24 hours after hip/knee surgery.

The 4AT has the strongest evidence base for diagnostic

accuracy compared to all instruments designed for

delirium assessment. The 4AT evaluates the patient’s level

of consciousness and accuracy of responses to questions

about their date of birth, current location, and current

Study participants: Out of the total number of patients,

N=106, the majority of participants (61.3%) were above

the age of 70. There were 80 female patients (75.5%) and

26 male patients (24.5%).

Table 1 presents general data on the surgical procedure

of the participants N=106. Fall risk Level I was present in

14 participants (13.2%), fall risk Level II in 78 participants

(73.6%), and fall risk Level III in 14 participants (13.2%)

(gure 1).

Considering the total 4AT score, the largest number

of patients, N = 50 (47.2%), had a low probability of

delirium or cognitive impairment; 40 patients (37.7%) had

possible cognitive impairment; and delirium was possible

in 16 patients (15.1%) (gure 2). Out of the total number

of patients with possible delirium, 11 patients (10.38%)

developed postoperative delirium after hip surgery, of

whom 9 were female (81.82%), while 2 were male (18.18%).

RESULTS

Source: the authors.

Table 1. Data on the surgical procedure (N=106)

year, indicating orientation to self, others, time, and place.

It also assesses attention and any signicant changes or

uctuations in wakefulness, cognitive functions, and other

mental functions (present in the past two weeks and still

evident within the last 24 hours). A score of 0 indicates a

low probability of delirium or cognitive impairment (but

without exclusion), scores of 1-3 suggest possible cognitive

impairment, and a score of 4 or higher indicates possible

delirium with or without cognitive impairment. The

instrument is freely available for use at www.the4at.com.

Statistical data analysis

Data analysis was performed using IBM SPSS Statistics 25

software. Within descriptive statistics, absolute and relative

frequencies were calculated. For computing dierences, the

chi-square test was used for qualitative variables. A p value

<0.05 was considered statistically signicant.

Surgical procedure

Hip

Knee

Type of anesthesia

Regional

General

ASA status

III

% n

44.3

55.7

69.8

30.2

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Figure 2. Total 4AT score. Source: the authors.

Low probability

of delirium or

cognitive

impairment

Possible

cognitive

impairment

Possible

delirium +/-

cognitive

impairment

15 (30%)

35 (70%)

20 (40%)

30 (60%)

23 (46%)

27 (54%)

45 (90%)

5 (10%)

32 (64%)

18 (36%)

8 (20%)

32 (80%)

31 (77.5%)

9 (22.5%)

10 (25%)

30 (75%)

26 (65%)

14 (35%)

15 (37.5%)

25 (62.8%)

3 (18%)

13 (82%)

14 (87.5%)

2 (12.5%)

3 (18.7%)

13 (81.3%)

3 (18.8%)

13 (81.3%)

0 (0%)

16 (100%)

1.54

18.62

6.31

29.90

21.33

0.463

<0.0001*

0.043*

<0.0001*

Sex

Male

Female

Age (years)

>70

<70

Surgical procedure

Hip

Knee

ASA status

III

Anesthesia

Regional

General

Source: the authors.

Note: Statistically signiﬁcant differences*

Table 2. Differences between groups based on 4AT score results

Figure 1. Fall risk level. Source: the authors.

Comparison of patients based on their 4AT score

Subjects whose total 4AT score indicates possible delirium

have signicantly higher values of the ASA score compared

to other subjects (χ

= 23.33, p 0.0001). Additionally,

in this group of patients, there were signicantly more

individuals who underwent general anesthesia (χ

= 14.98,

p 0.0001). They also have a signicantly higher fall risk

compared to others (χ

= 22.28, p 0.0001) (table 2, gures

3-5

Among the statistically signicant dierences among

subjects with dierent 4AT scores, it stands out that

patients with a low probability of delirium or cognitive

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Figure 3. Difference in anesthesia type between groups

based on 4AT score results. Source: the authors.

Figure 4. Difference in ASA status between groups based

on 4AT score results. Source: the authors.

Source: the authors.

Note: Statistically signiﬁcant differences*

Table 3. Comparison of 4AT score results in relation to fall risk

impairment are signicantly younger than others (χ

18.15, p 0.0001), more frequently undergo knee surgery

(χ

= 6.10, p = 0.04), have a lower ASA score (χ

= 18.32,

p 0.0001), more frequently undergo regional anesthesia (χ

= 14.82, p 0.0001), and have a lower fall risk (χ

= 22.28,

p 0.0001). Patients with possible cognitive impairment are

statistically signicantly older than others (χ

= 7.08, p =

0.04) (table 2).

The majority of patients with fall risk Level II had a

low probability of developing delirium or cognitive

impairment (table 3).

Out of the total number of patients who developed

delirium 24 hours after the surgical procedure (N = 11),

1 patient had ASA status II (9.09%), and 10 patients had

ASA status III (90.91%), of which 9 patients were operated

under general anesthesia (90.91%).

Low probability

of delirium or

cognitive

impairment

Possible

cognitive

impairment

Possible

delirium +/-

cognitive

impairment

12 (24%)

37 (74%)

1 (2%)

2 (5%)

33 (82.5%)

5 (12.5%)

0 (0%)

8 (50%)

31.37

<0.0001*

4AT score

Fall risk

Risk level I

Risk level II

Risk level III

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Figure 5. Difference in fall risk between groups based on

4AT score results. Source: the authors.

On stationary orthopedic wards, risk assessment is

conducted multiple times during hospitalization. A

structured risk assessment for falls is performed upon

admission to the hospital, as needed multiple times during

hospitalization, and after surgery. The most important

aspect is enabling patients to safely perform daily activities.

Qualied medical nurses, nurse technicians, occupational

therapists, physicians, and physiotherapists play a

signicant role in the clinical fall risk assessment.

Frail and older patients, often with cognitive impairment

following major joint surgery, have been considered

burdensome for orthopedic and hospital services. The

development of national registries in highly developed

European countries, as well as Australia and New Zealand,

has changed these attitudes, as reports indicate improved

treatment outcomes.

The majority of our participants

were over 70 years old and predominantly female, which

is consistent with literature regarding the age threshold

for the occurrence of degenerative joint pathologies.

25,26

Considering that there have been no studies in the available

literature that assessed the fall risk in orthopedic patients

using the Fall Risk Assessment Score Sheet, developed

by Hagino et al.

, we are obliged to interpret our own

results, which relate to the assessment of fall risk, to the

greatest extent possible. In the aforementioned study, the

sample consisted of 5,219 patients admitted to the General

National Hospital in Kofu from April 2016 to March 2019.

The majority of patients in our study had a total score

corresponding to level II risk for falls, which is twice as

high compared to the study conducted by the authors

DISCUSSION

of the Fall Risk Assessment Score Sheet. The reason for

this may lie in the fact that the authors of the utilized

instrument did not exclusively have orthopedic patients in

their sample. When it comes to the possibility of delirium

occurring in hospitalized orthopedic patients, 15.1% of

patients were assessed as having the potential for delirium,

which is signicantly lower compared to the study, which

used data from the National Hip Fracture Database (NHFD)

and internal hospital computer systems (Medway, ICE,

and Clinic letters).

The researchers found that 29.3% of

orthopedic patients had possible delirium, with 68 patients

(38.9%) developing delirium and having an ASA IV score.

94 patients (22.3%) were without delirium (p 0.05). In

our study, the majority of patients had possible cognitive

impairment (37.7%) or delirium or cognitive impairment

with low probability (47.2%). The fact that we did not have

patients with an ASA IV score may be the reason for the

lower incidence of delirium in our results. Patients identied

with higher 4AT scores, indicating possible delirium, had

higher ASA scores compared to other patients, indicating

that these patients had other serious systemic illnesses.

Additionally, the results show that a higher percentage

of patients underwent surgery under general anesthesia.

Similar results were published in the study by Rajeev et

al.

The reason for signicant variations in the range of

postoperative delirium incidence may lie in inconsistent

criteria for diagnosing delirium.

In the study conducted in University Malaya Medical

Centre on a sample of 447 patients

, 11.2% of patients

with postoperative delirium were recoreded, slightly

lower compared to our sample. The study on a sample of

223 patients (154 in the control group and 69 in the study

group—those undergoing hip or knee surgery) undergoing

hip or knee surgery at Ramathibodi Hospital in Bangkok

reported a signicantly lower number of patients (1%)

in whom the total 4AT score indicated postoperative

delirium.

Interestingly, due to this result, the researchers

sought the opinion of a psychiatrist specialist to conrm the

low rate of delirium in the control group. Also, the majority

of participants in their study were female, as was the case

in our study.

In the study conducted at Brunico-Bruneck Hospital in

Northern Italy

, out of 202 orthopedic patients comprising

the sample, 7.5% had postoperative delirium, with 73.3%

developing delirium within the rst 48 hours after surgery.

Our results are similar, considering that 11 patients

developed delirium 24 hours after the surgical procedure

(10.38%). In study conducted on a sample of 61 hospitalized

orthopedic patients at Port of Spain General Hospital

, 42

underwent surgical procedures and 18 patients (42.8%)

exhibited cognitive impairment after surgery, while 9

(21.4%) had delirium. They emphasize that delirium occurs

more frequently after general anesthesia (26.7%) compared

to regional anesthesia (8.4%). Our results identied slightly

fewer participants with possible cognitive impairment and

delirium. Additionally, we found that our patients with a

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low probability of delirium or cognitive impairment were

signicantly more likely to undergo surgery under regional

anesthesia (χ

= 14.82, p 0.0001).

Limitations, strengths of the study and future

research

Our study has certain limitations. Firstly, we had access to

only one study for comparison regarding the risk assessment

tool for falls, namely the study by Hagino et al.

, and we

did not perform a reassessment of fall risk. Secondly, the

limitation relates to the time of delirium onset monitoring,

as only a 24-hour period after surgery was considered,

during which delirium manifested in 11 patients, but

subsequent evaluation of other patients was not conducted.

Considering that the highest percentage of our participants

is over 70 years old, it is important to highlight that the

comprehensive goal of the United Nations Decade of

Healthy Ageing (2021–2030) is to improve the quality of

life for older individuals on a global level. Healthy aging

entails “the functional ability of an individual to be and do

what they love and value.” Reducing the incidence of falls

and fall-related injuries, preserving functional mobility,

and eliminating the fear of falling, along with the design of

specic guidelines for fall prevention.

Falls have a signicant impact on quality of life, which is

a key treatment outcome, especially in older individuals.

Additionally, a high percentage of potential delirium

among hospitalized patients can be prevented, leading

to improved postoperative recovery and the overall

quality of healthcare services provided. The results of the

research have shown that orthopedic patients hospitalized

at the University Clinical Center of Vojvodina have a fall

risk level II.

Most hospitalized orthopedic patients had a low

probability of cognitive impairment or postoperative

delirium, indicating the high quality of healthcare services

provided and a signicant indicator of patient safety in

healthcare institutions performing inpatient care.

None perceived.

The research has been approved by the Ethics Committee

of the University Clinical Center of Vojvodina.

The authors declare no conict of interest.

The datasets generated during and/or analyzed during

the current study are not publicly available due to privacy

CONCLUSION

FUNDING INFORMATION

ETHICAL APPROVAL

CONFLICT OF INTEREST STATEMENT

DATA AVAILABILITY STATEMENT

and ethical considerations. The data that support the

ndings of the study are available from the corresponding

author on reasonable request.

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