The 71-year-old with confusion after hip surgery
A 71-year-old man is day two after an emergency hip repair. He has become agitated, is pulling at his catheter, and is convinced the nurses are 'poisoning' him. He is oriented to person only, with fluctuating attention. He has a history of hypertension, type 2 diabetes and mild cognitive impairment, and takes ramipril, metformin, atorvastatin and occasional codeine. Observations: temperature 37.8°C, pulse 96, blood pressure 148/86, oxygen saturation 94% on air, respiratory rate 20. Bloods show a mild rise in creatinine from 90 to 130 µmol/L and a CRP of 60. The night staff want to give haloperidol 5 mg intramuscularly because he is disturbing the ward. His daughter says he was 'sharp as a button' last week.
1. What is the diagnosis and what is the immediate management priority?
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This is delirium, probably multifactorial, in a patient with pre-existing mild cognitive impairment. The fluctuating attention, disorientation, acute onset and perceptual disturbance fit the criteria. The priority is to find and treat the causes, not to sedate. Look for infection (temperature, CRP, urinary catheter - consider urine dip and culture, chest examination), pain (codeine may be inadequate after hip surgery), constipation, urinary retention, dehydration, hypoxia (sats 94%), metabolic disturbance (creatinine rise suggests dehydration or sepsis) and drug effects (codeine, and any anticholinergics). Check glucose, electrolytes, calcium, and consider an ECG. The rise in creatinine and CRP with a low-grade temperature should prompt a search for sepsis. Non-pharmacological measures come first: orient him repeatedly, involve family, correct sensory deficits (glasses, hearing aids), maintain a day-night routine, mobilise early, avoid restraint and catheter if possible, and treat pain. Haloperidol 5 mg IM is too high a dose for an older adult and may cause extrapyramidal effects and QT prolongation; if medication is needed for severe distress or danger, use the lowest dose, preferably oral, and review frequently.
2. How would you distinguish delirium from dementia and from a psychotic disorder here, and what would you tell the daughter?
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Delirium is distinguished by acute onset, fluctuating course and impaired attention; dementia has a gradual onset with preserved attention until late, though the two commonly coexist, and this man's mild cognitive impairment makes him vulnerable. A primary psychotic disorder is unlikely given age, acuity, the medical context and the absence of a prior history; the 'poisoning' belief is a delusion but is typical of delirium. The daughter's report that he was sharp last week is key evidence for an acute change and should be documented. Tell her that this is a common and usually reversible complication of surgery and illness, that it is not 'going mad' and not necessarily dementia, and that it often improves as the underlying causes are treated, though it can take days to weeks and increases the risk of later cognitive problems. Explain that the team will avoid sedation where possible and will use familiar faces and orientation. Involve her in care: bring his glasses and hearing aids, sit with him, and keep the lights on during the day. Document the conversation and offer a follow-up cognitive assessment after recovery.