Postoperative Hip Fracture in an Older Adult with Cognitive Impairment
An 82-year-old woman is day 2 after a right hemiarthroplasty for a displaced femoral neck fracture. She lives alone in a second-floor apartment with no lift. Before the fracture she walked indoors with a stick and needed help with shopping. Her admission MMSE was 22/30; overnight she became agitated, pulled at her urinary catheter, and repeatedly said, 'my hip is broken.' She is now refusing to stand with the physiotherapist. Weight-bearing is as tolerated. Pain is 5/10 at rest. Hemoglobin is 9.8 g/dL and sodium 132 mmol/L. She is prescribed regular paracetamol and PRN morphine. She has a history of hypertension and mild hearing loss.
1. Differentiate delirium from dementia in this patient. What factors in the case increase her delirium risk, and what immediate actions are indicated?
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The acute overnight change in behaviour, agitation, catheter pulling, and refusal suggest delirium superimposed on pre-existing cognitive impairment, not dementia alone. Dementia is chronic and stable; delirium fluctuates over hours and is associated with inattention.
Risk factors here: advanced age, hip fracture surgery, anaemia (Hb 9.8 g/dL), hyponatraemia (Na 132 mmol/L), opioid use, urinary catheter, sleep disruption, pain, and an unfamiliar ward.
Immediate actions:
- Screen with a validated tool such as the 4AT or CAM.
- Check for infection, urinary retention, constipation, dehydration, pain, hypoxia, and medication effects.
- Correct electrolytes and review haemoglobin and opioid burden with the medical team.
- Remove the catheter as soon as safe, reorient her, use daylight and a sleep protocol, involve family, and ensure hearing aids and glasses are available.
- Avoid antipsychotics unless there is immediate danger; document capacity and best-interests decisions.
2. How would you proceed with mobilization given her refusal and agitation? Include safety, consent, and alternatives.
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Respect the refusal first. Assess whether she has capacity to refuse; if delirium is causing lack of capacity, act in her best interests with the medical team and family. Do not force standing.
Practical approach: treat pain 30 min before, reduce noise, sit at eye level, use short sentences and her hearing aid, and explain that standing is to help her get home. Try a later session when she is calmer. Use a hoist or standing frame with two staff if she assents and is safe. Keep the bed low, call bell within reach, non-slip footwear, and supervision to prevent falls.
Alternatives: bed-based range of motion, sitting balance, breathing exercises, and family education. Document the refusal, capacity assessment, and plan to retry. Escalate if agitation is unmanageable or if she cannot be mobilised safely.
3. Outline discharge planning priorities for returning to a second-floor flat alone.
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Discharge home alone is unsafe until she can negotiate stairs, transfer, and mobilize with supervision. Priorities:
- Assess stair ability and home environment; refer occupational therapy for a home visit and equipment such as a raised toilet seat, walking frame, and stair rail.
- Arrange social work and home-care support; she will need help with shopping and meals.
- Resolve delirium and correct anaemia and hyponatraemia before discharge.
- Teach hip precautions if applicable and falls prevention.
- Consider an interim rehabilitation bed if she cannot manage the stairs or has no carer.
- Provide written emergency contacts and a follow-up physiotherapy appointment.