Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data

  • Nasim Ahmed
    Corresponding author at: Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States.
    Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States

    Hackensack Meridian School of Medicine, Nutley, NJ, United States
    Search for articles by this author
  • Yen-Hong Kuo
    Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, United States
    Search for articles by this author
Published:January 27, 2022DOI:


      • Approximately 30% of geriatric patients following hip fracture and hemi-arthroplasty developed in-hospital delirium.
      • Certain patient's characteristics, comorbidities and immobility were associated with higher risk for delirium.
      • Using the DRIGHA score at the bedside can identify the high risk patients early in the hospital coarse and timely intervention may mitigate the overall incidence.



      In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study.


      Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients.


      The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created.


      Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78–0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%.


      Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Hospitalization for Total Hip Replacement Among Inpatients Aged 45 and Over: United States, 2000–2010 Access date February 5, 2021.

        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        5th ed. American Psychiatric Association, Washington, DC:2013
        • Kalish V.B.
        • Gillham J.E.
        • Unwin B.K.
        Delirium in older persons: evaluation and management.
        Am Fam Physician. 2014; 90 (Aug 1Erratum for: Am Fam Physician. 2014 Dec 15;90(12):819. Dosage error in article text. Erratum in: Am Fam Physician. 2014 Dec 15;90(12):819. Erratum in: Am Fam Physician. 2015 Sep 15;92 (6):430. PMID: 25077720): 150-158
        • Shehabi Y.
        • Riker R.R.
        • Bokesch P.M.
        • Wisemandle W.
        • Shintani A.
        • Ely E.W.
        SEDCOM (safety and efficacy of dexmedetomidine compared with midazolam) study group. delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients.
        Crit Care Med. 2010; 38: 2311-2318
        • Kiely D.K.
        • Marcantonio E.R.
        • Inouye S.K.
        • Shaffer M.L.
        • Bergmann M.A.
        • Yang F.M.
        • et al.
        Persistent delirium predicts greater mortality.
        J Am Geriatr Soc. 2009; 57: 55-61
        • Leslie D.L.
        • Marcantonio E.R.
        • Zhang Y.
        • Leo-Summers L.
        • Inouye S.K.
        Oneyear health care costs associated with delirium in the elderly population.
        Arch Intern Med. 2008; 168: 27-32
        • Inouye S.
        • Westendrop R.
        • Saczynski J.
        Delirium in elderly people.
        Lancet. 2014; 383 ([PMC free article] [PubMed] [Google Scholar]): 911-922
        • Lee K.H.
        • Ha Y.C.
        • Lee Y.K.
        • Kang H.
        • Koo K.H.
        Frequency, risk factors, and prognosis of prolonged delirium in elderly patients after hip fracture surgery.
        Clin Orthop Relat Res. 2011; 469: 2612-2620
        • Santana Santos F.
        • Wahlund L.O.
        • Varli F.
        • Tadeu Velasco I.
        • Eriksdotter Jonhagen M.
        Incidence, clinical features and subtypes of delirium in elderly patient treated for hip fractures.
        Dement Geriatr Cogn Disord. 2005; 20: 231-237
        • Wang Cg.
        • Qin Yf.
        • Wan X.
        • Song L.C.
        • Li Z.J.
        • Li H.
        Incidence and risk factors of postoperative delirium in the elderly patients with hip fracture.
        J Orthop Surg Res. 2018; 13
        • Guo Y.
        • Jia P.
        • Zhang J.
        • Wang X.
        • Jiang H.
        • Jiang W
        Prevalence and risk factors of postoperative delirium in elderly hip fracture patients.
        J Int Med Res. 2016; 44 (Epub 2016 Feb 26. PMID: 26920926; PMCID: PMC5580064): 317-327
        • Malik A.T.
        • Quatman C.E.
        • Phieffer L.S.
        • Ly T.V.
        • Khan S.N.
        Incidence, risk factors and clinical impact of postoperative delirium following open reduction and internal fixation (ORIF) for hip fractures: an analysis of 7859 patients from the ACS-NSQIP hip fracture procedure targeted database.
        Eur J Orthop Surg Traumatol. 2019; 29 (FebEpub 2018 Sep 18. PMID: 30229446): 435-446
        • Harris M.J.
        • Brovman E.Y.
        • Urman R.D.
        Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture.
        J Clin Anesth. 2019; 58 (DecEpub 2019 May 14. PMID: 31100691): 61-71
        • Moerman S.
        • Tuinebreijer W.E.
        • de Boo M.
        • Pilot P.
        • Nelissen R.G.
        • Vochteloo A.J.
        Validation of the risk model for delirium in hip fracture patients.
        Gen Hosp Psychiatry. 2012; 34 (Mar-AprEpub 2012 Jan 9. PMID: 22227031): 153-159
      2. Access data, February 9, 2021.

      3. Access date, February 11, 2021.

        • Inouye S.K.
        • Leo-Summers L.
        • Zhang Y.
        • Bogardus S.T
        • Leslie D.L.
        • Agostini J.V.
        A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.
        J Am Geriatr Soc. 2005; 53: 312-318
        • R. Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2020 (URL
        • Agostini J.V.
        • Inouye S.K.
        • Delirium
        • Hazzard W.R.
        • Blass J.P.
        • Halter J.B.
        • Ouslander J.G.
        • Tinetti M.E.
        Principles of Geriatric Medicine and Gerontology.
        (ed.)5th ed. McGraw-Hill, New York2003: 1503-1515
        • Oh E.S.
        • Fong T.G.
        • Hshieh T.T.
        • Inouye S.K.
        Delirium in older persons: advances in diagnosis and treatment.
        JAMA. 2017; 318: 1161-1174
        • De J.
        • Wand A.P.
        Delirium screening: a systematic review of delirium screening tools in hospitalized patients.
        Gerontologist. 2015; 55: 1079-1099
        • The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults, American Geriatrics Society, New York City, New York
        American geriatrics society expert panel on postoperative delirium in older adults.
        J Am Geriatr Soc. 2015; 63 (American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults) ([PubMed: 25495432]): 142-150
        • Ravi B.
        • Pincus D.
        • Choi S.
        • Jenkinson R.
        • Wasserstein D.N.
        • Redelmeier D.A.
        Association of duration of surgery with postoperative delirium among patients receiving hip fracture repair.
        JAMA Netw Open. 2019; 2e190111
        • Zhang Xin
        • Tong D.K.
        • Ji F.
        • Duan X.Z.
        • Liu P.Z.
        • Qin S.
        • et al.
        Predictive nomogram for postoperative delirium in elderly patients with a hip fracture.
        Injury. 2019; 50 (Pages): 392-397
        • Schreiber M.P.
        • Colantuoni E.
        • Bienvenu O.J.
        • et al.
        Corticosteroids and transition to delirium in patients with acute lung injury.
        Crit Care Med. 2014; 42: 1480-1486