Delirium in an Older Adult With a Hip Fracture on Apixaban
Mrs. L, 78, fell at home and has a right intertrochanteric femur fracture. She takes apixaban 5 mg twice daily for atrial fibrillation, with her last dose 16 hours ago; creatinine clearance is 42 mL/min. She also takes metoprolol and oxycodone. Surgery is scheduled for the morning but was postponed because of the anticoagulant. Overnight she becomes restless and confused, trying to climb out of bed. HR 112, BP 98/58, RR 24, temperature 37.9°C, SpO2 93% on room air, urine output 15 mL/hr over the last 4 hours, bladder scan 620 mL, and she reports hip pain 8/10. She is normally independent and alert at home.
1. What is your differential for the new confusion, and what will you do first?
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This is delirium in a high-risk older adult, likely multifactorial. The main candidates:
- Urinary retention - bladder scan 620 mL is a clear contributor and is quickly treatable.
- Pain and under-treated fracture pain - pain 8/10 drives agitation; paradoxically, both pain and opioids cause delirium.
- Hypovolemia - urine output 15 mL/hr and BP 98/58; dehydration is a common delirium precipitant.
- Hypoxia or pulmonary embolism - SpO2 93% and tachycardia; PE is a real risk after fracture and immobility.
- Infection - temperature 37.9°C, and urine stasis raises the risk of UTI.
- Cardiac event or medication effect - metoprolol and oxycodone, plus possible myocardial infarction.
First: ABCs, oxygen, continuous monitoring, point-of-care glucose, ECG, bladder scan and catheterization if retention is confirmed, IV fluids, reassess pain, review medications, and use the CAM to document delirium. Avoid restraints and bed alarms that increase agitation; use a sitter, family, and reorientation.
2. How do you reason about the timing of surgery and the apixaban? What options exist for reversal, and when should prophylaxis resume?
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Apixaban is a direct factor Xa inhibitor with a half-life of about 12 hours (longer with renal impairment). For neuraxial anesthesia, guidelines such as those from the American Society of Regional Anesthesia recommend stopping apixaban 72 hours before the procedure; for surgical incision, waiting 24–48 hours after the last dose is often sufficient but depends on renal function and institutional protocol. Her CrCl of 42 mL/min prolongs drug clearance, so the team should lean toward the longer interval and involve anesthesia and hematology.
Options if urgent surgery is needed:
- Andexanet alfa (specific reversal agent) where available and approved for the indication.
- Four-factor procalcitonin complex (4F-PCC) as an alternative.
- Check an anti-Xa level if the lab can measure apixaban and the result will change management.
Hip fracture surgery should not be delayed unnecessarily - delay beyond 48 hours increases mortality and complications. VTE prophylaxis should resume postoperatively when hemostasis is secure, typically 12–24 hours after surgery per surgeon order, and continue for about 35 days after hip fracture.
3. What nursing plan will you put in place to prevent falls, pressure injury, and further delirium during this admission?
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The plan must be multicomponent, because no single intervention prevents delirium.
- Falls: keep the bed low, call light and personal items within reach, nonskid footwear, bed alarm with caution (it can agitate), a sitter for high-risk periods, and assist with every transfer. Do not use restraints; they increase injury and delirium.
- Delirium: reorient with each contact, use glasses and hearing aids, maintain a day–night light cycle, cluster care to allow sleep, involve family, mobilize early, keep the bladder empty, treat pain with multimodal analgesia (scheduled acetaminophen, nerve block if placed, opioids only as needed), and avoid anticholinergics and benzodiazepines.
- Pressure injury: turn every 2 hours, use a pressure-redistribution mattress, inspect the sacrum and heels, keep skin clean and dry, and start nutrition screening - she is likely undernourished after a fall.
- Communication: give a structured handoff each shift with the delirium status, last bladder scan, pain plan, and mobility goal. Report new confusion, fever, or hypoxia immediately, because deterioration is often subtle in this population.