90岁以上髋部骨折患者术后发生谵妄的危险因素及预后分析

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摘要目的调查90岁以上髋部骨折患者术后谵妄发生率，分析发生谵妄的危险因素，研究谵妄对髋部骨折患者围手术期并发症、死亡率、行走能力的影响。方法回顾性观察研究，分析中国人民解放军总医院第七医学中心2012年1月至2018年12月90岁以上髋部骨折患者资料，157例患者根据术后是否发生谵妄，将患者分为谵妄组和无谵妄组，其中谵妄组41例，男15例，女26例；年龄90~104岁，平均(93.17±3.15)岁；非谵妄组116例，男43例，女73例，年龄90~102岁，平均年龄(92.07±2.44)岁，比较两组患者一般资料、围手术期并发症，术后30 d、1年和整体的死亡率及行走能力。结果 90岁以上髋部骨折患者术后41例(26.1%)发生谵妄，术后1~3 d是发生高峰，持续时间为1周以内。并存病数量≥4项(OR=5.205，95%CI：1.649~16.431；P＝0.005)、入院至手术时间(OR=1.540，95%CI：1.204~1.969；P＝0.001)和全身麻醉(OR=2.463，95%CI：1.852~7.117；P＝0.036)是术后发生谵妄的独立危险因素。谵妄组患者围手术期脑血管事件3例(7.3%)、心脏不良事件9例(22.0%)、肺部感染13例(31.7%)，概率高于无谵妄组(脑血管事件0例，0%；心脏不良事件10例，8.6%；肺部感染18例，15.5%)，差异有统计学意义(P＜0.05)。谵妄组患者平均住院时间(19.19±15.14)d，无谵妄组平均住院时间(14.77±10.53)d，差异有统计学意义(t＝2.049，P＝0.042)。谵妄组患者术后30 d、1年和整体的死亡率分别为17.1%(7例)、43.9%(18例)和56.1%(23例)，高于无谵妄组的死亡率(术后30 d 4.3%，5例；术后1年18.1%，21例；整体34.5%，40例)，差异有统计学意义(P＜0.05)。使用多因素Logistic回归分析，调整相关混淆因素后，谵妄是患者术后30 d(OR=7.825，95%CI：1.327~46.154；P＝0.023)和1年(OR=2.991，95%CI：1.162~1.696；P＝0.023)死亡的独立危险因素。术后1年谵妄组存活23例，其中仅6例(26.1%)可以独立行走，14例(60.9%)需要辅助装置行走，3例(13.0%)卧床；无谵妄组术后1年存活95例，34例(35.8%)可独立行走，52例(54.7%)需要辅助装置行走，9例(9.5%)需要卧床，两组比较差异无统计学意义(χ²=0.888，P＝0.641)。结论 90岁以上老年髋部骨折患者术后谵妄发生率高，术后1~3 d是其发生高峰，并存病数量≥4项、入院至手术时间和全身麻醉是术后发生谵妄的独立危险因素；谵妄患者围手术期并发症(脑血管时间、心脏不良事件和肺部感染)发生率高，谵妄是术后30 d和1年死亡的独立危险因素。

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	赵圣杰 1
	征华勇 2
	王晓伟 2*
	孙天胜 2
	张建政 2
	刘智 2

关键词 ：髋部骨折, 老年人, 谵妄

Abstract：Objective To investigate the incidence of postoperative delirium in hip fracture patients over 90，the risk factors of delirium，and study the influence of delirium on perioperative complications，mortality and walking ability.Methods A retrospective observation study was conducted to analyze the data of hip fracture patients over 90 in the seventh medical center of the General Hospital of the Chinese people's Liberation Army from January 2012 to December 2018.157 patients were divided into delirium group and non delirium group according to whether delirium occurred after operation.There were41 patients in delirium group，including 15 males，26 females，aged 90~104 years old，with an average of (93.17±3.15)years.And there were 116 patients in non delirium group，including 43 males and 73 females，aged 90~102 years old，with an average age of (92.07±2.44)years.The general data，perioperative complications，postoperative mortality and walking ability of the two groups were compared.Results Delirium occurred in 41 patients(26.1%) after operation in over 90 yearship fracture.Delirium mainly occurred within 1-3d after operation，and the duration was mostly within 1 week.The 4or morecomobidities (OR=5.205，95%CI：1.649~16.431；P＝0.005)，time of operation (OR=1.540，95%CI：1.204~1.969；P＝0.001)，general anesthesia (OR=2.463，95%CI：1.852~7.117；P＝0.036) were independent risk factors for delirium after operation.The incidence of cerebrovascular events 3 cases (7.3%)，cardiac adverse events 9 cases(22.0%)，pulmonary infection 13 cases(31.7%) in delirium group were higher than those in non-delirium group (cerebrovascular events，0 cases；10 cases(8.6%)；pulmonary infection，18 cases (15.5%).There werestatistical difference (P＜0.05).The mean lengths of stay in delirium group were (19.19±15.14)days，and those of non-delirium group were (14.77±10.53)d.The difference were statistically significant (t＝2.049，P＝0.042).The mortality of 30 days，1 year and overall mortality in delirium group were 17.1% (7 cases)，43.9%(18 cases) and 56.1%(23 cases)，respectively，which were higher than those of non-delirium group (30 days，4.3%，5 cases；1 year，18.1%，21 cases；overall，34.5%，40 cases)，respectively，which hadstatistical differences (P＜0.05).After adjusting the related confounding factors，delirium was an independent risk factor for 30 days mortality after operation (OR=7.825，95%CI：1.327~46.154；P＝0.023) and 1 year (OR=2.991，95%CI：1.162~1.696；P＝0.023).In the delirium group，23 patients survived at 1 year after operation，only 6(26.1%) could walk independently，14(60.9%) needed auxiliary device，3(13.0%) were in bed；95 patients survived at 1 year after operation，34(35.8%) could walk independently，52(54.7%) needed auxiliary device，9(9.5%) needed to stay in bed.There was no significant difference between the two groups (χ²=0.888，P＝0.641).Conclusion The incidence of postoperative delirium in very elderly patients with hip fracture is high，and the peak was 1-3 days after operation.The 4 or more comorbidities，timeof surgery and general anesthesia are independent risk factors for postoperative delirium.The incidence of perioperative complications (cerebrovascular time，adverse cardiac events and pulmonary infection) and postoperative mortality in delirium patients are high，which are independent risk factors for 30 days and 1 year after operation.

Key words： hip fracture elderly delirium

基金资助:首都卫生发展科研专项(2016-1-5092)

通讯作者: 王晓伟

作者简介: 赵圣杰(1983－ )，女，主治医师，首都医科大学附属康复医学院，中国康复研究中心，uu22vv33@126.com。

引用本文:

赵圣杰 1，征华勇 2，王晓伟 2*，孙天胜 2，张建政 2，刘智 2. 90岁以上髋部骨折患者术后发生谵妄的危险因素及预后分析[J]. 实用骨科杂志, 2022, 28(1): 20-24.
Zhao Shengjie 1，Zheng Huayong 2，Wang Xiaowei 2*，Sun Tiansheng 2，Zhang Jianzheng 2，Liu zhi 2. Risk Factors and Prognosis of Postoperative Delirium in Patients Over 90 with Hip Fracture. sygkzz, 2022, 28(1): 20-24.

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http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2022/V28/I1/20

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