Osteoarthritis is common in elderly patients and is one of the most prevalent joint diseases affecting 151 million people worldwide and its incidence is expected to increase in industrialized countries.1 The knee and hip joints are the most common sites of osteoarthritis with a lifetime prevalence of 18% in men and 27% in women.2 Total hip arthroplasty (THA) is indicated in osteoarthritis patients who remain symptomatic despite conservative therapy.3 Besides, THA is frequently performed in geriatric femoral neck fractures.4 It is estimated that the demand for THA is projected to increase by 174% between 2005 and 2030 in the United States.5 THA resulted in improved function, reduced pain, and better health-related quality of life.6 However, due to the poor physical function and many basic diseases of elderly patients, the incidence of complications during the perioperative period is significantly higher, which has seriously affected the postoperative rehabilitation of patients.7 Therefore, it is urgent to improve perioperative management to promote rapid recovery after THA and increase the quality of life of patients.
The aging population has become a focus of society as a whole and the number of elderly patients undergoing surgery with anesthesia also increases annually due to the continuous progress of science and the advanced development of medical technology.8 This group is more vulnerable to developing postoperative cognitive dysfunction (POCD).9 POCD refers to a disturbance of brain function activity after surgical anesthesia in patients without mental disorders before surgery, manifesting as memory impairment, cognitive decline, anxiety, delirium, and personality changes.10,11 POCD severely interferes with the compliance of postoperative treatment and impairs prognosis and life quality.12 Although great advancements have been achieved in surgical techniques and anesthetic methods, the incidence of POCD in patients remains high, especially in elderly patients up to 13%-41%.8,13 Fu et al identified several inflammatory markers such as CRP, S-100B, and IL-6 in POCD for patients undergoing THA.14 Feng et al compared the effect of different approaches to the fascia iliaca compartment block on POCD in THA patients.15 It has also been demonstrated that elderly patients with type A blood had a higher risk of developing early POCD than those with type O blood.16 Nevertheless, little is known about the comprehensive intervention methods to reduce POCD in THA patients from various aspects.
In this study, we designed six intervention therapy models including cognitive intervention, emotion intervention, environment intervention, education intervention, nutrition support, and sleep intervention to explore its application value in elderly patients with THA from four aspects: mini-mental state examination (MMSE) score, incidence and duration of POCD, out-of-bed activity time, hospital stay, and patient satisfaction score.
Materials and Methods
We selected 50 elderly patients who underwent THA in the Department of Orthopedics of Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine between June 2017 and June 2019 for a prospective study. The study was approved by the ethics committee of our hospital: No. ZJHZ-019-22-01. All patients who were familiar with the contents and processes of the study and able to complete all the scheduled study processes signed the informed consent.
(1) Aged 65–85 years; (2) unilateral THA was required due to the condition, with surgical indications; (3) no previous history of mental illness and no verbal communication problems.
(1) With contraindications for THA; (2) had a previous history of central nervous system disease, mental illness, or family history of mental illness; (3) a long-term use of drugs affecting the nervous or psychiatric system; (4) long-term alcohol addiction; (5) with severe cardiopulmonary dysfunction or other systemic diseases; (6) patients with severe trauma, need emergency surgery, multi-site surgery, or are critically ill in need of resuscitation; (7) with craniocerebral trauma and coma could not cooperate with treatment workers. Fifty patients were randomly divided into the control group (n=25) and the experimental group (n=25) according to the random number table method.
After completing the preoperative examinations and excluding the contraindications of the operation, the enrolled patients underwent unilateral THA under combined spinal and epidural anesthesia. In the perioperative period, the types of drugs, time of use, and dosage of drugs were consistent between the two groups. The patients in the control group received routine basic treatment during the perioperative period, while the patients in the experimental group were given intervention treatment. All interventional procedures performed by trained nurses included cognitive intervention, emotion intervention, environment intervention, education intervention, nutrition support, and sleep intervention (Figure 1A-F).
Figure 1 Six interventional procedures. (A) Cognitive intervention. (B) Emotion intervention. (C) Environment intervention. (D) Education intervention. (E) Nutrition support. (F) Sleep intervention.
Psychological counseling and communication were provided to patients immediately after admission to improve their disease cognition, self-awareness, self-supervision, self-control, self-strengthening, correct the wrong cognition of the disease, environment, and themselves, and establish a positive optimism. The nursing staff strengthened communication with the patient’s families. The psychological invention was carried out indirectly through family members to avoid the stimulation of their speech and behavior toward the patients.
To eliminate the anxiety of patients, help them increase their sense of security and establish confidence to overcome the disease, and actively cooperate with medical staff through encouragement and suggestions. Actively assist patients to vent bad emotions so that they can relieve negative emotions and pressure. Soothing music is played on demand to ease their anxiety, divert their attention and keep their mood at peace.
Provide patients with a comfortable ward environment, ensure ventilation twice a day, suitable temperature (25–26 °C) and humidity (50–60%), reasonable arrangement of light, and increase green decorations, so that they can completely relax, reduce feelings of fear and anxiety for being in an unfamiliar environment. Color pages of disease-related knowledge were hung at appropriate positions in the ward to improve patients’ awareness of the disease. Improve the safety management of wards to reduce adverse events as a consequence of environmental stimulation or falling out of bed.
Take the initiative to introduce the hospital and department’s workflow and inpatient system to the doctor and nurse in charge to increase patients’ sense of security. The THA-related knowledge was explained to patients through mind mapping and other ways to improve their understanding of the disease. Take the initiative to guide patients’ rehabilitation exercises, and improve patients’ understanding of perioperative rehabilitation exercises. Take the initiative to explain the current treatment and treatment measures to patients, so that patients understand the whole process of their disease treatment; improve the treatment and treatment cooperation of patients.
An individualized diet was designed, and the proportion of calories required by patients was calculated according to the patient’s weight and condition to ensure their three meals reached the standard. Meanwhile, guide patients to eat more easily digestible, vitamin- and fiber-rich foods and avoid stimulating foods. To guide the perioperative nutrition knowledge of patients and their families, and improve the perioperative dietary habits of patients.
Guide patients to sleep according to circadian rhythms and ensure that the patients maintain adequate sleep every day. To ensure the quality of sleep according to the environmental intervention plans. Guide patients to schedule work and rest and establish good habits. For patients with sleep difficulties, timely treatment ensures that patients get enough rest.
The MMSE scale was used to evaluate the function of the patients in two groups at 1 day before the operation, 1 day, 7 days, and 14 days after the operation, including the following seven aspects: time orientation, place orientation, immediate memory, attention and calculation, delayed memory, language, and visual space, with a total score of 30 points.
Incidence and Duration of POCD
A patient was considered to have POCD if the postoperative MMSE score decreased by more than 3 points compared with the preoperative score. The cumulative number of POCD cases at 1 day, 7 days, and 14 days after operation was recorded, and the duration of POCD was calculated.
Out-of-Bed Activity Time and Hospital Stay
In the unit of the day (d), the out-of-bed activity time and the total length of hospital stay were recorded, and the hospitalization conditions of the two groups were compared.
Patient Satisfaction Score
According to the self-designed satisfaction scale, four dimensions of treatment mode, emotion management, treatment situation, and environment comfort were evaluated before discharge. Five scores were set for each dimension, namely satisfaction (5), basic satisfaction (4), general (3), need to be improved (2), and unsatisfactory (1). The satisfaction scores of patients in the two groups were compared during hospitalization.
Postoperative Pain Management
Postoperative pain levels were assessed every 2 hours for the first 24 hours after surgery. Patients routinely received analgesics (non-steroid anti-inflammatory drugs, opioids, central or neuropathic analgesics) for 3 days, and adjustment of the dose if necessary. The use of multimodal analgesia in patients with large surgical trauma or obvious pain can reduce the incidence of adverse reactions. Pain department intervention, physiotherapy, traditional Chinese medicine technique, and relaxation therapy were adopted to assist in pain relief.
All data analyses were performed using the SPSS 17.0 software. Measurement data were expressed as mean ± SD, comparisons between two groups were assessed by independent sample t-test, and comparisons among multiple groups were evaluated using a one-way analysis of variance. The count data were expressed as the number of cases (frequency) and analyzed using the chi-square test. P <0.05 was considered statistically significant. The effect size of the study was calculated as 0.86 using G*Power software version 18.104.22.168 (Franz Faul, Universitat Kiel, Germany) based on the two-sided significance level (α), sample size (n=25 in each group), power (1-β=0.85), and independent t-test.
Data were collected from June 2017 to June 2019 and 50 participants (25 experimental and 25 control participants) completed the study. There were 8 males (32.0%) in the experimental group and 10 males (40.0%) in the control group. The mean age was 71.5±5.8 and 74.6±7.2 for the experimental group and the control group, respectively. The body mass index was 65.8±9.3 in the experimental group and 60.3±8.4 in the control group. No significant difference was found in demographic data between the two groups. Moreover, there were no significant differences in etiology, operative site, operative time, and intraoperative blood loss between the two groups (all P >0.05) (Table 1).
Table 1 Basic Information of Participants in the Two Groups
Comparison of MMSE Scores Between the Two Groups
The MMSE scores of patients in the two groups were evaluated 1 day before the operation and 1, 7, and 14 days after the operation. The MMSE scores of the experimental group decreased 1 day after the operation (P <0.05), but returned to the normal level 7 and 14 days after the operation (P >0.05). However, the MMSE scores in the control group receiving traditional treatment mode showed a downward trend at 1 day and 7 days after the operation (all P <0.05) and returned to normal levels 14 days after the operation (P >0.05). Besides, at 7 days and 14 days after the operation, MMSE scores were significantly higher in the experimental group than in the control group (all P <0.05) (Table 2).
Table 2 Mini-Mental State Examination Scores of Patients in the Two Groups
Comparison of the Incidence and Duration of POCD Between the Two Groups
One case of POCD occurred in the experimental group, and two cases in the control group 1 day after the operation. There were two POCD cases in the experimental group and six POCD cases in the control group 7 days after the operation. No new cases occurred 7–14 days after the operation. The incidence of POCD in the control group (24.0%) was relatively higher in the control group than that in the experimental group (8.0%), but there was no significant difference between the two groups (Table 3). In addition, the duration of POCD in the experimental group was 3.6±1.0 days, which was shorter than that in the control group (5.4±1.4 days).
Table 3 The Incidence of Postoperative Cognitive Dysfunction in the Two Groups
Comparison of the Out-of-Bed Activity Time and Hospital Stay Between the Two Groups
The out-of-bed activity time of the experimental group was 3.8±1.1 days, and the total hospital stay was 13.2±1.7 days. In the control group, the out-of-bed activity time was 6.5±2.8 days, and the total hospital stay was 16.7±2.1 days. The experimental group had significantly shorter out-of-bed activity time and hospitalization time (P <0.05).
Comparison of the Satisfaction of Patients in the Two Groups
Through the satisfaction rating scale before discharge, we found that the experimental group showed significantly greater patient satisfaction than the control group in terms of the treatment mode, emotional management, treatment condition, and environmental comfort level during hospitalization (P <0.05) (Table 4).
Table 4 Comparison of Inpatient Satisfaction Scores Between the Two Groups
With the accelerating rate of population aging in China, the proportion of the elderly population is also increasing.17 By the end of 2019, the number of people aged 60 years and older in China was 254 million, accounting for 18.1% of the total population; meanwhile, the population aged 60 and above had reached 264 million, accounting for 18.7% of the total population by the end of 2020.18,19 Along with the progress of population aging, various social problems were emerging especially the increase in medical issues.20 In recent years, the tremendous progress made by medical science has extended the overall life span of populations and made it possible to treat many formerly untreatable diseases through various means, such as surgery.21 However, elderly patients are prone to having perioperative complications since they often have various underlying diseases and poor physical function, which will affect their postoperative rehabilitation and quality of life.22
POCD is one of the most common postoperative complications in elderly patients and is associated with increased morbidity and mortality.23,24 In an international multicenter study of POCD, a decline in memory function was observed in 25.8% of patients undergoing non-cardiac surgery.25 In 2009, the International Study of POCD group investigated possible consequences for patients experiencing persistent cognitive decline Orthopedic patients often have obvious traumatic pain symptoms, and the incidence of POCD is higher.26 Evered et al reported that POCD occurred in 25% to 40% of elderly patients undergoing cardiac surgery, non-cardiac surgery, and even minor non-invasive procedures under sedation, indicating that elderly patients experience POCD regardless of the type of surgical procedure.27 Geng et al demonstrated that isoflurane and sevoflurane aggravated POCD compared to propofol in elderly patients.28 Although the mechanisms by which surgery and anesthesia affect cognitive function remain elucidated, many risk factors such as old age, poor education, duration of surgery and anesthesia, the severity of coexisting illness, and respiratory complications have been identified.29 How to promote the rapid recovery of patients after surgery, and reduce the incidence of POCD in elderly patients has become a hot spot in modern medical research.
Under the guidance of certain scientific treatment theories, a series of active treatment activities and specific methods are used to actively intervene in all aspects of patients during hospitalization. The interventional treatment model has been successfully applied to patients with myocardial infarction, hypoglycemia, and neuropsychiatric diseases.30–32 Caroline et al exhibited that nutritional intervention in elderly patients after hip fracture improved nutritional intake/status but did not affect the length of hospital stay.33 All types of exercise were effective in increasing global cognition, and resistance exercise had the highest probability of being the intervention in slowing cognitive decline in patients with cognitive dysfunction, especially in patients with dementia.34 Compared with the patients undergoing routine orthopedic nursing, those undergoing the concept of accelerated rehabilitation surgery nursing had shorter out-of-bed activity time, the average time of hospital stay, and lower total treatment costs.35 In this study, all participants were divided into the control group (routine basic treatment during the perioperative period) and the experimental group (intervention treatment). No significant difference was found in demographic data or surgical procedures between the two groups. Of note, the distribution of the fracture neck of the femur and the osteoarthritis was relatively balanced between the two groups with no statistical significance. Our study employed six intervention treatment modules of cognition, emotion, environment, education, nutrition, and sleep in the perioperative period of elderly patients undergoing THA, and systemically explored the application value of the intervention treatment model in postoperative rehabilitation of elderly patients.
The MMSE score comprises seven sections including time orientation, location orientation, immediate memory, attention, computational power, delayed memory, language, and visual space.36 Through the study, we found that the postoperative MMSE score of patients in the experimental group receiving intervention treatment mode was significantly higher than that of the control group receiving traditional treatment mode, suggesting that intervention treatment mode can significantly improve the cognitive level of patients. In addition, the incidence of POCD in the experimental group was lower and its duration was shorter than in the control group but without statistical significance, which may be due to the small number of sample cases included in this study. The effect of intervention treatment on the incidence and duration of POCD requires further evaluation in the future. Besides, the experimental group was significantly better than the control group with regard to out-of-bed activity time, length of hospital stay, and satisfaction degree. This further confirmed that the intervention treatment mode is helpful to promote the early recovery of patients after surgery and reduce the economic burden and psychological stress of patients during hospitalization.
Although the effect size of the study was as high as 0.86, it would be much better if the patient sample size is larger and the research time is longer. Additionally, the lack of observation of postoperative delayed cognitive dysfunction needs to be further improved in the future. However, this comprehensive study revealed that the intervention therapy might promote recovery of elderly patients after THA, and improve the quality of life of patients.
In conclusion, the application of the interventional treatment model after THA in elderly patients can significantly improve the cognitive level of patients, shorten the out-of-bed time and hospital stay, and improve patient satisfaction, hence improving the quality of postoperative rehabilitation of patients.
Data Sharing Statement
The dataset used and/or analyzed during the current study is available from the corresponding author on reasonable request.
The study was approved by the Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine. All patients who were familiar with the contents and processes of the study and able to complete all the scheduled study processes signed the informed consent. Our study complies with the Declaration of Helsinki.
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
No funding was received for conducting this study.
The authors have no conflicts of interest to declare in this work.
1. Corciulo C, Castro CM, Coughlin T., et al. Intraarticular injection of liposomal adenosine reduces cartilage damage in established murine and rat models of osteoarthritis. Sci Rep. 2020;10(1):13477. doi:10.1038/s41598-020-68302-w
2. Beck H, Beyer F, Gering F, et al. Sports Therapy Interventions Following Total Hip Replacement. Dtsch Arztebl Int. 2019;116(1–2):1–8. doi:10.3238/arztebl.2019.0001
3. Cook MJ, Lunt M, Board T, O’Neill TW. The impact of frailty on short-term mortality following primary total Hip and knee arthroplasty due to osteoarthritis. Age Ageing. 2022;51:6. doi:10.1093/ageing/afac118
4. He Y, Xiao J, Shi Z, He J, Li T. Supplementation of enteral nutritional powder decreases surgical site infection, prosthetic joint infection, and readmission after Hip arthroplasty in geriatric femoral neck fracture with hypoalbuminemia. J Orthop Surg Res. 2019;14(1):292. doi:10.1186/s13018-019-1343-2
5. Hambright D, Hellman M, Barrack R. Intra-operative digital imaging: assuring the alignment of components when undertaking total Hip arthroplasty. Bone Joint J. 2018;100-B(1 Supple A):36–43. doi:10.1302/0301-620X.100B1.BJJ-2017-0596.R1
6. Shibuya M, Nanri Y, Kamiya K, et al. The maximal gait speed is a simple and useful prognostic indicator for functional recovery after total Hip arthroplasty. BMC Musculoskelet Disord. 2020;21(1):84. doi:10.1186/s12891-020-3093-z
7. Chen P, Yang J, Hu D, Jing X, Liu D. Safety of Different Anesthesia Methods Combined with Intravenous Fast Channel Anesthesia in Lower Extremity Orthopedic Surgery of the Elderly. Evid Based Complement Alternat Med. 2021;2021:9787879. doi:10.1155/2021/9787879
8. Zhang J, Zhang X, Yang Y, Zhao J, Yu Y. Correlation Analysis of Serum Vitamin D Levels and Postoperative Cognitive Disorder in Elderly Patients With Gastrointestinal Tumor. Front Psychiatry. 2022;13:893309. doi:10.3389/fpsyt.2022.893309
9. Schulte PJ, Roberts RO, Knopman DS, et al. Association between exposure to anaesthesia and surgery and long-term cognitive trajectories in older adults: report from the Mayo Clinic Study of Aging. Br J Anaesth. 2018;121(2):398–405. doi:10.1016/j.bja.2018.05.060
10. Evered L, Silbert B, Knopman DS, et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth. 2018;121(5):1005–1012. doi:10.1016/j.bja.2017.11.087
11. Liu Z, Liu F, Liu X, Ma C, Zhao J. Surgical incision induces learning impairment in mice partially through inhibition of the brain-derived neurotrophic factor signaling pathway in the hippocampus and amygdala. Mol Pain. 2018;14:1744806918805902. doi:10.1177/1744806918805902
12. Li WX, Luo RY, Chen C, et al. Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: a randomized controlled preliminary trial. Chin Med J. 2019;132(4):437–445. doi:10.1097/CM9.0000000000000098
13. Shi HJ, Xue XH, Wang YL, Zhang WS, Wang ZS, Yu AL. Effects of different anesthesia methods on cognitive dysfunction after Hip replacement operation in elder patients. Int J Clin Exp Med. 2015;8(3):3883–3888.
14. Fu C, Lin J, Gong G, Zhong W, Chen H, Luo X. Inflammatory markers in postoperative cognitive dysfunction for patients undergoing total Hip arthroplasty: a meta-analysis. Aging Clin Exp Res. 2022;34(2):277–288. doi:10.1007/s40520-021-01919-7
15. Feng T, Zhao J, Wang J, Sun X, Jia T, Li F. Anesthetic Effect of the Fascia Iliaca Compartment Block with Different Approaches on Total Hip Arthroplasty and Its Effect on Postoperative Cognitive Dysfunction and Inflammation. Front Surg. 2022;9:898243. doi:10.3389/fsurg.2022.898243
16. Li J, Zhou J, Wan Y, Liu L, Ou C. Association Between ABO Blood Type and Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Unilateral Total Hip Arthroplasty Surgery in China. Med Sci Monit. 2017;23:2584–2589. doi:10.12659/MSM.901736
17. Zhang K, Qi J, Zuo P, et al. The mortality trends of falls among the elderly adults in the mainland of China, 2013-2020: a population-based study through the National Disease Surveillance Points system. Lancet Reg Health West Pac. 2022;19:100336. doi:10.1016/j.lanwpc.2021.100336
18. Shen L, Tang X, Li C, Qian Z, Wang J, Liu W. Status and Factors of Cognitive Function Among Older Adults in Urban China. Front Psychol. 2021;12:728165. doi:10.3389/fpsyg.2021.728165
19. Gong N, Meng Y, Hu Q, et al. Obstacles to access to community care in urban senior-only households: a qualitative study. BMC Geriatr. 2022;22(1):122. doi:10.1186/s12877-022-02816-y
20. Chen R, Xu P, Li F, Song P. Internal migration and regional differences of population aging: an empirical study of 287 cities in China. Biosci Trends. 2018;12(2):132–141. doi:10.5582/bst.2017.01246
21. Long HZ, Cheng Y, Zhou ZW, Luo HY, Wen DD, Gao LC. PI3K/AKT Signal Pathway: a Target of Natural Products in the Prevention and Treatment of Alzheimer’s Disease and Parkinson’s Disease. Front Pharmacol. 2021;12:648636. doi:10.3389/fphar.2021.648636
22. Hoehner PJ. Ethical decisions in perioperative elder care. Anesthesiol Clin North Am. 2000;18(1):159–181, vii–viii. doi:10.1016/S0889-8537(05)70155-3
23. Pappa M, Theodosiadis N, Tsounis A, Sarafis P. Pathogenesis and treatment of post-operative cognitive dysfunction. Electron Physician. 2017;9(2):3768–3775. doi:10.19082/3768
24. Wang F, Xie D, Xu H, Ye Q, Wu L, Gao XP. The effects of remifentanil-propofol combined with dexmedetomidine on cognitive dysfunction in elderly patients after ureteroscopic holmium laser lithotripsy: a double-blind randomized controlled trial. Trials. 2022;23(1):192. doi:10.1186/s13063-022-06121-2
25. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998;351(9106):857–861. doi:10.1016/S0140-6736(97)07382-0
26. Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS, Group I. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology. 2009;110(3):548–555. doi:10.1097/ALN.0b013e318195b569
27. Evered L, Scott DA, Silbert B, Maruff P. Postoperative cognitive dysfunction is independent of type of surgery and anesthetic. Anesth Analg. 2011;112(5):1179–1185. doi:10.1213/ANE.0b013e318215217e
28. Geng YJ, Wu QH, Zhang RQ. Effect of propofol, sevoflurane, and isoflurane on postoperative cognitive dysfunction following laparoscopic cholecystectomy in elderly patients: a randomized controlled trial. J Clin Anesth. 2017;38:165–171. doi:10.1016/j.jclinane.2017.02.007
29. Lertkovit S, Siriussawakul A, Suraarunsumrit P, et al. Polypharmacy in Older Adults Undergoing Major Surgery: prevalence, Association With Postoperative Cognitive Dysfunction and Potential Associated Anesthetic Agents. Front Med. 2022;9:811954. doi:10.3389/fmed.2022.811954
30. Ryan CT, Rosengart TK. Commentary: measure Twice, Cut Once. Semin Thorac Cardiovasc Surg. 2021;33(1):82–83. doi:10.1053/j.semtcvs.2020.06.036
31. Xu W, Hu X, Zhang X, Ling C, Wang C, Gao L. Cognitive Impairment and Related Factors Among Middle-Aged and Elderly Patients with Type 2 Diabetes from a Bio-Psycho-Social Perspective. Diabetes Metab Syndr Obes. 2021;14:4361–4369. doi:10.2147/DMSO.S333373
32. Xu X, Hu Y, Yan E, Zhan G, Liu C, Yang C. Perioperative neurocognitive dysfunction: thinking from the gut? Aging. 2020;12(15):15797–15817. doi:10.18632/aging.103738
33. Wyers CE, Reijven PLM, Breedveld-Peters JJL, et al. Efficacy of Nutritional Intervention in Elderly After Hip Fracture: a Multicenter Randomized Controlled Trial. J Gerontol a Biol Sci Med Sci. 2018;73(10):1429–1437. doi:10.1093/gerona/gly030
34. Huang X, Zhao X, Li B, et al. Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: a systematic review and network meta-analysis. J Sport Health Sci. 2022;11(2):212–223. doi:10.1016/j.jshs.2021.05.003
35. Lv H, Yang N. Clinical effect of application of nursing concept of rehabilitation surgery for improvement of quality of postoperative recovery in orthopedics. J Orthop Surg Res. 2021;16(1):471. doi:10.1186/s13018-021-02610-3
36. Yao S, Liu Y, Zheng X, et al. Do nonpharmacological interventions prevent cognitive decline? A systematic review and meta-analysis. Transl Psychiatry. 2020;10(1):19. doi:10.1038/s41398-020-0690-4