The Effectiveness of Nursing Interventions for Preventing Postoperative Delirium in Older Adults Undergoing Major Orthopedic Surgery: A Systematic Review

The Effectiveness of Nursing Interventions for Preventing Postoperative Delirium in Older Adults Undergoing Major Orthopedic Surgery: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Effectiveness of Nursing Interventions for Preventing Postoperative Delirium in Older Adults Undergoing Major Orthopedic Surgery: A Systematic Review Sunee Kraonual², Wichayaporn Thongpeth¹, Thaworn Thongpet³ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8624240/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Postoperative delirium (POD) is a common adverse event in elderly patients following major orthopedic surgery. Non-pharmacological interventions delivered by nurse are at the heart of prevention, however, the evidence is mixed. We conducted this systematic review to provide an overview of the evidence on effective nursing interventions aimed at reducing POD in this vulnerable population. Methods In agreement with PRISMA 2020 pattern, we performed a systematic search in five databases for studies published between 2010 and 2025. We enrolled studies investigating nursing-led delirium prevention interventions in patients aged ≥ 65 years after major orthopedic surgery. Two reviewers independently screened 529 records, full-text appraised articles and extracted information about study design, population, intervention and outcomes. Quality assessment Quality was assessed using design-specific tools. Results Seventeen studies (N = 4945 participants) met the inclusion criteria, consisting in RCTs (n = 5), quasi-experimental (n = 6) and retrospective studies (n = 5). Multicomponent interventions led by nurses, systemic level changes (eg, protocolized orders), and single-component strategies (eg, sensory aid management) were all significantly associated with a decrease in POD rates. Effect size differed with large trials demonstrating small but significant effects (e.g., OR 0.59 in an orthopaedic subgroup) and smaller or non-randomized studies describing larger reductions (e.g., 35–68% relative risk reduction). An example is provided by a pragmatic trial of preprinted orders which eliminated delirium from 51% to 33% (P=. 001), especially in those with dementia (97% to 60%, P<. 001). There was too much heterogeneity in interventions and outcome parameters for formal meta-analysis. Conclusions The evidence is consistent in demonstrating that nursing interventions, especially multicomponent protocols and systems-level changes which empower nurses, are effective in preventing postoperative delirium among older orthopaedic surgery patients. Even concentrated, single-agent treatments can make a significant difference. Standardised outcome reporting should be uer for future research to facilitate meta-analysis and implementation science needs to be addressed to support uptake of these evidence-based practices. Trial registration PROSPERO CRD420251140913. Registered 05 September 2025. https//www.crd.york.ac.uk/PROSPERO/view/CRD420251140913 postoperative delirium nursing interventions older adults orthopedic surgery hip fracture systematic review delirium prevention Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Mar, 2026 Reviews received at journal 20 Mar, 2026 Reviews received at journal 02 Mar, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 26 Jan, 2026 Editor assigned by journal 22 Jan, 2026 Submission checks completed at journal 22 Jan, 2026 First submitted to journal 17 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8624240","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":576588744,"identity":"bcee30d0-8f21-490d-a433-806e40326a91","order_by":0,"name":"Sunee Kraonual²","email":"","orcid":"","institution":"Yala Rajabhat University","correspondingAuthor":false,"prefix":"","firstName":"Sunee","middleName":"","lastName":"Kraonual²","suffix":""},{"id":576588748,"identity":"48796c2e-bbd5-431e-8053-ce1a29bdb21d","order_by":1,"name":"Wichayaporn Thongpeth¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDACZgY2JF4FnHWASC0HzsBYCXi0MCBrOdhGhBaD48zPHvxss8vjlz57gPnjvDv2BgeYH35g/HEHt5bDbOaGvW3JxZJ9eQkMB7c9S9xwgM1YgiHhGU4tZod52CR425gTN5zhMQBqOZxgcIDBDOiww3i1SP5tq4dqmXMY6DD2bwS1SPO2HYZqaTjMuOEAD35b7A+zmUnLnDteLNnDY3DgzLFniTMP8xRLJKTh1iLZf/iZ5Juy6jx+Hh7DBxU1d+z5jrdv/PDBBrcWMGBkY0gA0QfAiBnISsCvAQj+wNUcIKh2FIyCUTAKRh4AAO1MWGO+ImVgAAAAAElFTkSuQmCC","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":true,"prefix":"","firstName":"Wichayaporn","middleName":"","lastName":"Thongpeth¹","suffix":""},{"id":576588750,"identity":"a0162519-6cab-4b23-8bd4-b03ec67c078a","order_by":2,"name":"Thaworn Thongpet³","email":"","orcid":"","institution":"Suratthani Hospital","correspondingAuthor":false,"prefix":"","firstName":"Thaworn","middleName":"","lastName":"Thongpet³","suffix":""}],"badges":[],"createdAt":"2026-01-17 07:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8624240/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8624240/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100700771,"identity":"8286195f-28ce-4ba2-9268-07eb2868449e","added_by":"auto","created_at":"2026-01-20 15:56:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1485867,"visible":true,"origin":"","legend":"","description":"","filename":"25691701ManuscriptBMCNursingCOMPLETE.docx","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/1acc820cf29396a0f6ebeaa5.docx"},{"id":100700665,"identity":"285114c9-de6a-4f13-b69d-9aa2917129ea","added_by":"auto","created_at":"2026-01-20 15:55:06","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6721,"visible":true,"origin":"","legend":"","description":"","filename":"33510e4b628941e19902121b2d15cf59.json","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/df035b9146087f6214c3f884.json"},{"id":100700655,"identity":"e8609e10-7cf7-429c-b91b-3769bb84d83f","added_by":"auto","created_at":"2026-01-20 15:54:38","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":18694,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020Checklist2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/00b404f58329b5f010e40cbc.docx"},{"id":100701003,"identity":"e2a571a8-bbfa-4df9-8b9a-955be5446bc1","added_by":"auto","created_at":"2026-01-20 15:59:19","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80042,"visible":true,"origin":"","legend":"","description":"","filename":"33510e4b628941e19902121b2d15cf591enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/ef0df9a26367c22165904387.xml"},{"id":100700666,"identity":"53f5be6e-21f5-4240-a815-0831e0dabea7","added_by":"auto","created_at":"2026-01-20 15:55:11","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44049,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/914763736cbaa139d8690af1.png"},{"id":100700682,"identity":"87ffbf9a-508c-4896-af50-8f3a67fb04c4","added_by":"auto","created_at":"2026-01-20 15:55:49","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65841,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/c81224a160cd8fda1db77463.png"},{"id":100700658,"identity":"a7366620-3310-4f85-b61c-5840f74d634a","added_by":"auto","created_at":"2026-01-20 15:54:53","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":50677,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/e0cba54aafa3206b8117c732.png"},{"id":100701026,"identity":"e22db1c3-28a6-487f-b950-95da67b2690d","added_by":"auto","created_at":"2026-01-20 15:59:32","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72685,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/2187e7c096bc93e3e0edb1fe.png"},{"id":100700659,"identity":"4d5d08cb-6597-4ae5-a67b-8513916049c2","added_by":"auto","created_at":"2026-01-20 15:54:54","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74255,"visible":true,"origin":"","legend":"","description":"","filename":"33510e4b628941e19902121b2d15cf591structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/533b7ebe833dea5a8950a870.xml"},{"id":100700669,"identity":"32987011-d900-4a60-b597-87da26095db5","added_by":"auto","created_at":"2026-01-20 15:55:26","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95175,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1/9d8599378d9f5d4c21fb0eb1.html"},{"id":100708941,"identity":"478ac67f-afa8-4c34-b7a6-4be66a28115b","added_by":"auto","created_at":"2026-01-20 17:38:30","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":650639,"visible":true,"origin":"","legend":"","description":"","filename":"25691701ManuscriptBMCNursingCOMPLETE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8624240/v1_covered_e6e69d19-45f3-4cca-936a-e67537828cde.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effectiveness of Nursing Interventions for Preventing Postoperative Delirium in Older Adults Undergoing Major Orthopedic Surgery: A Systematic Review","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"postoperative delirium, nursing interventions, older adults, orthopedic surgery, hip fracture, systematic review, delirium prevention","lastPublishedDoi":"10.21203/rs.3.rs-8624240/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8624240/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative delirium (POD) is a common adverse event in elderly patients following\u0026ensp;major orthopedic surgery. Non-pharmacological interventions delivered by nurse are\u0026ensp;at the heart of prevention, however, the evidence is mixed. We conducted this systematic review to provide an overview of the evidence on effective nursing interventions aimed at\u0026ensp;reducing POD in this vulnerable population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn agreement with PRISMA 2020 pattern, we performed a systematic search in five databases for studies published between\u0026ensp;2010 and 2025. We enrolled studies investigating nursing-led delirium prevention\u0026ensp;interventions in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years after major orthopedic surgery. Two reviewers independently screened\u0026ensp;529 records, full-text appraised articles and extracted information about study design, population, intervention and outcomes. Quality assessment Quality was assessed using design-specific\u0026ensp;tools.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventeen studies (N\u0026thinsp;=\u0026thinsp;4945\u0026ensp;participants) met the inclusion criteria, consisting in RCTs (n\u0026thinsp;=\u0026thinsp;5), quasi-experimental (n\u0026thinsp;=\u0026thinsp;6) and retrospective studies (n\u0026thinsp;=\u0026thinsp;5). Multicomponent interventions led by nurses, systemic\u0026ensp;level changes (eg, protocolized orders), and single-component strategies (eg, sensory aid management) were all significantly associated with a decrease in POD rates. Effect size differed with large trials demonstrating small but significant effects (e.g., OR 0.59 in an orthopaedic subgroup) and smaller or non-randomized\u0026ensp;studies describing larger reductions (e.g., 35\u0026ndash;68% relative risk reduction). An example is provided by a pragmatic trial of preprinted\u0026ensp;orders which eliminated delirium from 51% to 33% (P=. 001), especially in those with dementia (97% to\u0026ensp;60%, P\u0026lt;. 001). There was too much heterogeneity in\u0026ensp;interventions and outcome parameters for formal meta-analysis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe evidence is consistent in demonstrating that nursing interventions, especially multicomponent protocols and systems-level changes\u0026ensp;which empower nurses, are effective in preventing postoperative delirium among older orthopaedic surgery patients. Even concentrated, single-agent treatments can make a significant\u0026ensp;difference. Standardised outcome reporting should be uer for\u0026ensp;future research to facilitate meta-analysis and implementation science needs to be addressed to support uptake of these evidence-based practices.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003ePROSPERO CRD420251140913. Registered 05 September 2025. https//www.crd.york.ac.uk/PROSPERO/view/CRD420251140913\u003c/p\u003e","manuscriptTitle":"The Effectiveness of Nursing Interventions for Preventing Postoperative Delirium in Older Adults Undergoing Major Orthopedic Surgery: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 13:09:09","doi":"10.21203/rs.3.rs-8624240/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T20:06:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T09:02:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T13:38:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43749318877169974879721311638871096122","date":"2026-02-23T00:22:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70291435323334646928506587895762859643","date":"2026-02-17T18:48:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-26T08:17:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T06:22:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-22T06:20:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-17T07:31:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01d481a5-a307-4936-96a9-6ca8c1201674","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T06:09:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 13:09:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8624240","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8624240","identity":"rs-8624240","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}