Agitation on day three after hip fracture surgery
An 84-year-old woman is on day three after a cemented hemiarthroplasty for a displaced neck of femur fracture. She was previously independent with a stick and lived alone. Her regular medicines are oxybutynin 5 mg twice daily for urge incontinence, amitriptyline 25 mg at night for neuropathic pain, lansoprazole 15 mg daily and paracetamol. Since surgery she has received morphine via patient-controlled analgesia and was started on oral ciprofloxacin yesterday because a urine dipstick showed nitrites and leucocytes. Overnight she became agitated, repeatedly tried to climb out of bed and pulled out her cannula; she is now catheterised. She is disorientated to time and place, with a 4AT score of 8. Temperature 37.1 °C, pulse 88, blood pressure 138/76, oxygen saturation 95% on air, respiratory rate 18. CRP 18 mg/L, sodium 133 mmol/L, potassium 4.2, creatinine 88 µmol/L. She has not opened her bowels for five days.
1. How do you interpret the 4AT score, and what is your differential for her agitation?
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Interpreting the 4AT
The 4AT screens for delirium and cognitive impairment using four items: alertness, the AMT4 (age, date of birth, place, current year), attention (months backwards or digit span), and acute change or fluctuating course. A score of 4 or more suggests possible delirium; 1–3 suggests cognitive impairment; 0 makes delirium unlikely. Her score of 8 is strongly positive, and the hyperactive, fluctuating picture is characteristic of delirium rather than dementia alone.
Differential and precipitants
- Pain and opioids - poorly controlled fracture pain plus morphine is a potent combination; look for undertreated pain and opioid toxicity (pinpoint pupils, drowsiness alternating with agitation).
- Drug effects - oxybutynin and amitriptyline carry a heavy anticholinergic burden, and ciprofloxacin is a recognised cause of CNS disturbance, especially in older people.
- Urinary retention and catheter-related discomfort, plus constipation (five days).
- Asymptomatic bacteriuria - nitrites on dipstick in a stable patient without urinary symptoms is not a delirium cause and should not automatically be treated.
- Environmental and sensory factors - unfamiliar ward, sleep disruption, missing glasses or hearing aids, immobility.
- Less likely here but worth screening: hypoxia, electrolyte disturbance, alcohol withdrawal, stroke, and intracranial pathology after a fall.
Avoid anchoring the whole picture on “UTI”.
2. Set out your management over the first 24 hours, including which drugs you would stop and whether you would prescribe an antipsychotic.
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Non-pharmacological measures first
- Reorientation, familiar faces, glasses and hearing aids, a visible clock, daylight exposure, quiet nights, mobilisation with physiotherapy and avoidance of bed rails or restraints.
- Regular paracetamol, review of the morphine patient-controlled analgesia and reduction or substitution if opioid-driven agitation is suspected.
- Remove the catheter as soon as possible, start a bowel regimen (for example senna plus a stool softener) and treat constipation.
- Hydration, monitoring of oxygen saturation and repeat electrolytes if clinically indicated.
Medication changes
- Stop oxybutynin (anticholinergic, likely contributing).
- Stop amitriptyline; it is anticholinergic and was prescribed for a questionable neuropathic-pain indication.
- Stop ciprofloxacin unless there are genuine urinary symptoms or systemic features - treating asymptomatic bacteriuria drives resistance and does not improve delirium.
- Reassess the need for lansoprazole.
Antipsychotics
Only for severe distress or immediate risk to herself or others, at the lowest dose for the shortest time - for example haloperidol 0.5 mg, with daily review and ECG/QT awareness. Avoid in Parkinson’s disease or suspected dementia with Lewy bodies, where the risk of severe sensitivity reactions is high. Avoid benzodiazepines, which worsen confusion and falls.
3. What would you put in place before discharge to reduce the chance of this happening again?
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Medication optimisation
- Formal anticholinergic burden review; oxybutynin and amitriptyline should not be restarted. If urge incontinence persists after the catheter is removed, try bladder training and pelvic-floor therapy first, then a bladder-stable agent with a lower CNS burden.
- Review analgesic requirements so she leaves hospital on a simple, regular regimen.
- Deprescribe anything without a current indication and record the reasons in the discharge summary.
Delirium and cognition
- Explain to her and her family what delirium is, that it may take weeks to settle, and how to recognise recurrence.
- Arrange cognitive follow-up; a delirium episode in an older person can unmask underlying dementia.
Falls and bone health
- Falls assessment, physiotherapy, walking aid review and home environment assessment.
- DEXA, calcium and vitamin D, and bone protection given the fragility fracture.
- Lying/standing blood pressures and review of any antihypertensives.
Care coordination
Send a clear GP letter listing stopped medicines, the fragility fracture, the delirium episode and a request not to treat asymptomatic bacteriuria with antibiotics in future.