Non-pharmacological Perioperative Interventions for the Prevention of Postoperative Delirium in Elderly Patients Undergoing Hip and Knee Arthroplasty Surgery: A Systematic Review

Postoperative delirium is common in elderly patients after orthopedic surgery. While pharmacological interventions often prove ineffective and are associated with significant adverse effects, non-pharmacological strategies targeting modifiable risk factors show promise. This systematic review evaluates perioperative non-pharmacological interventions for preventing postoperative delirium in elderly adults undergoing total knee or hip arthroplasty. This systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five electronic databases were searched for randomized controlled trials and observational studies examining non-pharmacological interventions to prevent postoperative delirium in patients aged 60 years or older undergoing total knee or hip arthroplasty. Two independent reviewers performed study selection, data extraction, and quality assessment using the Cochrane Risk of Bias tool (RoB 2) for randomized trials and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for non-randomized studies. Eleven studies comprising 15,761 patients were included. Postoperative delirium incidence ranged from 0% to 34% across interventions. The fast-track methodology achieved the lowest incidence at 0%, while maintaining 10-20% below baseline showed the highest incidence at 34%. Tourniquet use was associated with higher delirium rates (19.1% vs 9.6%; 15.22% vs 5.43%) and increased pain scores. Comprehensive care protocols reduced delirium incidence (15.9% vs 30.8%) and duration (2.06 vs 3.42 days) compared to conventional care. Fresh frozen plasma transfusion demonstrated a 5.96-fold increased delirium risk. Transcranial direct current stimulation reduced the incidence of delirium from 19.7% to 4.9%. Hospital length of stay ranged from 2.6 days with fast-track methodology to 15 days with suboptimal blood pressure management. Multimodal non-pharmacological interventions can significantly reduce postoperative delirium in elderly orthopedic surgery patients. Evidence-based strategies include maintaining adequate intraoperative blood pressure, implementing fast-track care pathways, avoiding unnecessary fresh frozen plasma transfusions, and adopting comprehensive care bundles. Standardized delirium prevention protocols should be prioritized in clinical practice to improve outcomes in this vulnerable population.