Postoperative Delirium After Hip Fracture Repair: "Just Sundowning" or Something Else?

This is delirium until proven otherwise, and the pattern points to identifiable causes that are still evolving.

Differential - multifactorial delirium with at least four active contributors:

• Acute blood loss / anemia: Hb fell 2.7 g/dL postoperatively. Look for a drain, wound swelling, retroperitoneal bleeding, and occult GI loss. A dropping Hb in a cemented hemiarthroplasty patient is not benign.
• Hypoxemia: new oxygen requirement plus immobility plus pelvic/hip surgery is a PE and atelectasis setup (Wells/PERC, ECG, ABG or VBG, lower-extremity assessment).
• Hypovolemia/prerenal AKI: creatinine 1.4 from 0.9, urine output 20 mL/hr, tachycardia. Distinguish hypovolemia from retention (catheter is in, but is it draining?).
• Sedative and anticholinergic burden: scheduled opioid plus two hydromorphone doses plus diphenhydramine - diphenhydramine is a classic delirium-precipitating anticholinergic in older adults and should not have been given.
• Also assess: pain, constipation, urinary retention, occult infection, hypoglycemia, electrolytes, vision/hearing deficits, unfamiliar environment.

First actions (first 2 hours):

1. Nonstimulating safety measures - sitter or family at bedside, bed low and locked, avoid restraints.
2. Oxygen to maintain SpO2 at his baseline range; reassess work of breathing.
3. Stop diphenhydramine. Reassess the opioid regimen - convert to multimodal (scheduled acetaminophen, limited opioid) rather than layering more sedation.
4. Type and screen, CBC, CMP, VBG, ECG, bladder scan; orthostatic vitals; focused wound and drain exam.
5. Escalate for imaging (CT chest/CTA) if hypoxemia persists after oxygen and recruitment.
6. Fluids only after assessing volume status - he may be dry, but he is also postoperative with cardiac risk.

Agree to treat the patient's distress; disagree with treating the delirium with a drug before addressing its causes.

What to say and do:

• Antipsychotics do not treat delirium and do not shorten its course. They are a short-term option for severe agitation that threatens safety, or for distressing symptoms such as frightening hallucinations, when nonpharmacologic measures have failed and reversible causes are being addressed.
• Haloperidol is not a sleeping pill and is not indicated for sundowning. It prolongs QT and carries extrapyramidal risk; it is relatively contraindicated in Parkinson disease and Lewy body dementia.
• He is not currently agitated - he is quiet and disoriented. The trigger for pharmacologic treatment has passed; the 0200 event is the problem to prevent.

Negotiated plan:

1. Nonpharmacologic first-line: reorientation, daylight exposure, sleep hygiene (lights down, cluster care, no 0400 vitals), glasses and hearing aids, early mobility with PT, hydration, bowel/bladder program, family presence, familiar objects.
2. A written PRN with explicit criteria, if needed: reserve an antipsychotic for agitation causing immediate harm despite the above, lowest dose, shortest duration, with ECG/QTc documented and a mandatory reassessment - not "q6h scheduled."
3. Define what would make you call him back: worsening hypoxemia, dropping Hb, decreasing urine output, or new fever.
4. Document the conversation - the recommendation, the rationale, and the agreed escalation criteria.

Frame it as shared safety: "I want him calm and out of the ICU, and the fastest route is fixing what got him here."

Delirium is a unit-level outcome as much as a patient-level one - build the bundle around what the unit controls.

Multicomponent nonpharmacologic bundle (adapt from established delirium prevention programs):

• Orientation and cognition: daily reorientation, clocks/calendars, family involvement, cognitive stimulation.
• Sleep: protected sleep window, cluster nighttime care, minimize overnight labs and vitals, earplugs/eye masks.
• Mobility: out of bed with PT/OT on POD 0–1 per protocol; avoid immobilizing tethers (catheter, IV, telemetry) unless indicated.
• Sensory: glasses on and hearing aids in and working - a frequent, cheap, ignored fix.
• Hydration/nutrition: oral intake tracking, bowel and bladder program, avoid catheter unless indicated.
• Pain: scheduled multimodal analgesia; avoid diphenhydramine, benzodiazepines, and anticholinergics in this population.

Metrics:

• Outcome: delirium incidence by a validated tool (e.g., CAM-ICU or 4AT) documented each shift; hospital-acquired delirium rate per 1,000 patient-days.
• Process: documented CAM/4AT on ≥90% of shifts; percentage of at-risk patients with a documented prevention plan; early mobility within 24 hours of surgery; percentage receiving a potentially inappropriate medication (diphenhydramine, benzodiazepine) - a deprescribing measure.
• Balancing: falls with injury, restraint use, unplanned ICU transfers, length of stay, 30-day readmission.

Display on a run chart or SPC chart with interventions annotated. A successful bundle shows process measures shifting first, then fall-with-injury and length-of-stay trends - not a same-month drop in delirium coding.