Night Two After Hip Surgery: Dementia or Delirium?
Mrs. A, 78, is day 2 after an emergency hip repair. She lived independently with mild cognitive impairment (MoCA 22/30 six months ago). Overnight she was awake and agitated, pulling at her IV and catheter, and says she can see 'children crawling on the floor.' Observations: temp 37.9 °C, HR 104, BP 138/76, SpO2 94% on room air, Na 134 mmol/L, CRP 88. Medications include oxycodone 10 mg q4h, diphenhydramine 50 mg at night, and donepezil, which has been held since admission. She has not opened her bowels in four days. Her daughter arrives and asks, 'Is this just her dementia getting worse? Should we move her to a care home?' You have fifteen minutes before handover.
1. What is your working formulation, and which assessments must be completed before handover? Justify your priorities.
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Formulation: delirium superimposed on MCI, not 'dementia getting worse.' The discriminating features are acute onset, fluctuating attention, visual hallucinations and a new nocturnal pattern - dementia alone does not appear in 48 hours with fluctuating attention.
Likely contributors (multiple, as usual):
- Drugs: oxycodone, plus diphenhydramine - a strong anticholinergic in an older adult already on a cholinesterase inhibitor, which is a straightforward prescribing cascade.
- Infection: temp 37.9, HR 104, CRP 88, catheter in situ - urine dip and culture, and a respiratory check with SpO2 94%.
- Constipation/four days: faecal loading is a classic, frequently missed cause.
- Others: pain, dehydration (Na 134), catheter and IV tethering, poor sleep, missing glasses/hearing aids, held donepezil, unfamiliar ward.
Why these priorities: delirium is a medical emergency with raised mortality, and the single commonest error is attributing it to dementia and doing nothing. My priorities in fifteen minutes are: (1) repeat observations including temperature, SpO2 out of bed, and a 4AT; (2) pain score and bowel/bladder assessment; (3) check the drug chart against the anticholinergic burden; (4) flags to the receiving nurse and a same-day prescriber review.
Also needed this shift: capillary glucose, hydration status, urine specimen, and a falls/aspiration risk review - she is pulling at lines with an unhealed hip.
2. The daughter asks whether this is dementia progression and whether she should arrange a care home. Draft your response.
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'It is a fair question, and I want to answer it honestly: we don't know yet, and that is exactly why we act now.'
- What I can say. 'Your mother's memory was already mildly affected. What is happening now is different - this came on over a day or two, her attention is coming and going, and she is seeing things that aren't there. That pattern usually means an acute illness or a medication effect on top of her memory problem, not a step change in her dementia.'
- Why a care-home decision now would be premature. Decisions made during a delirium are made about a person who is not currently herself. Her thinking should be reassessed weeks after recovery, when she is back to baseline, and placement discussed then with her involved.
- What I ask of her tonight. Reorient gently, bring glasses and hearing aids, sit with her at meals, keep the room lit softly rather than dark, and bring familiar objects. Family presence is one of the few interventions with a decent evidence base.
- What I don't say. I don't promise full recovery, and I don't give a prognosis. I say we will know more in 24–72 hours, and that I will update her after the medical review.
Why this framing: it answers the real fear ('is my mother lost?') without closing a door that shouldn't be closed yet, and it recruits the daughter as part of the treatment.
3. Which three interventions would you start tonight, and how would you evaluate them?
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1. Medication review and a stop. Request prescriber review to stop diphenhydramine and reconsider the oxycodone regimen, with paracetamol and non-drug comfort measures optimised. Rationale: removing an anticholinergic is the single highest-yield act tonight. Clozapine-style assumptions don't apply here - the principle is 'review every drug, stop what can be stopped'.
2. Bowel and bladder. Abdominal assessment, a prescribed bowel regimen, and a documented bowel chart; review whether the catheter is still indicated. Rationale: four days without a bowel movement plus a urinary catheter are two of the most common reversible causes and are nursing-owned, not doctor-owned.
3. A non-pharmacological night bundle. Low-level lighting, noise reduction, a clock and calendar in view, glasses and hearing aids on, mobilisation and fluids in the day, and clustering observations so she is not woken hourly. Rationale: sleep architecture is what the diphenhydramine was meant to fix; replacing it means giving her a night that is actually sleepable.
Evaluation: repeat 4AT each shift; documented sleep hours and agitation episodes; number of falls and line/catheter pulls; oral intake and fluid balance; bowel chart; and a clear note of her cognitive baseline to compare against after recovery.
Escalation trigger: rising temperature, new confusion with focal signs, or reduced consciousness - same-day medical review, not a wait-and-see.