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

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