NUR 7633 Module 2 Delirium Case: CAM Assessment, Multicomponent Prevention and Antipsychotic Evidence Example

Pulling at the Lines on Day Three: Assessing and Managing Delirium in an 81-Year-Old After Hip Surgery

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

Pulling at the Lines on Day Three: Assessing and Managing Delirium in an 81-Year-Old After Hip Surgery

The Consult

Dorothy, an invented patient, is 81 and taught fourth grade in Cherry Hill for thirty years. She lives alone, drives to church and manages her own finances. She fell on her front step and broke her hip, and a hip repair was done the next day under spinal anesthesia. On the third night after surgery she pulled out her intravenous line, called the nurse by her sister's name and insisted she had to get home to feed a cat that died years ago. By morning she was drowsy and could not keep track of a simple conversation. The orthopedic team asks whether she has developed dementia and requests something to calm her at night.

Her daughter says she was sharp before the fall, still doing crossword puzzles in ink. Her medicines include oxycodone every four hours as needed for pain, a nightly zolpidem started in the hospital, oxybutynin for an overactive bladder and her usual amlodipine. She has not had a bowel movement since admission, and a bladder scan this morning showed 600 milliliters of retained urine. She is wearing neither her glasses nor her hearing aids, which are still at home.

The consult request itself is part of the problem the paper must address. Nights are thinly staffed, Dorothy has twice tried to get over the rails, and a sitter is not available until the weekend. The team is frightened she will dislocate the new hip, and that fear is real. The paper acknowledges it and promises a plan that protects the hip without sedating her into a longer delirium.

Confirming Delirium

Inouye et al. (1990) developed the Confusion Assessment Method so that clinicians without psychiatric training could identify delirium quickly. Experts drew nine features from the diagnostic manual, then boiled them down to a four-feature rule: sudden onset that comes and goes plus poor attention are required, plus either jumbled thought or a shift in arousal. Against psychiatrists' diagnoses at two sites, the method had a sensitivity of 100 and 94 percent and a specificity of 95 and 90 percent, with high agreement between raters, and it took less than five minutes.

Dorothy meets all four features. Her confusion began suddenly on the third night and comes and goes. She cannot name the months backward from December and loses the thread mid-sentence. Her speech wanders, and she is drowsy in the daytime. Delirium is confirmed, and the paper tells the team plainly that this is not new dementia, though delirium can unmask an underlying cognitive weakness and needs follow-up after discharge.

Finding the Causes

Delirium in an older person usually has more than one cause, and the search is the treatment. For Dorothy, the review finds several: the anticholinergic oxybutynin, the new zolpidem, oxycodone given often for pain that was poorly measured, constipation, urinary retention, a night of poor sleep in a noisy room and missing glasses and hearing aids. Blood work shows mild dehydration and a sodium of 132. Her urine is clear, and a chest film is normal. Oxygen levels are good.

Managing Without Harm

Care is built around her daily life in the hospital. Her daughter brings her glasses, hearing aids and a family photograph, and stays in the evenings when confusion is worst. Staff introduce themselves, tell her the day and why she is there, keep the room lit in the day and dark and quiet at night and group overnight checks so she can sleep. Physical therapy and the nurses get her up to sit in the recliner each morning and afternoon, within the surgeon's limits. Restraints are avoided because they increase agitation and injury.

The Question of Medicine

The team's request for a nighttime antipsychotic is answered with evidence. Girard et al. (2018) randomly assigned 566 critically ill adults with delirium to haloperidol, ziprasidone or placebo, given intravenously and adjusted twice a day. Over 14 days, neither drug changed the number of days alive without delirium or coma compared with placebo, and survival, time on the ventilator and length of stay did not differ. Although that trial was in an intensive care unit, its message matches other studies on wards: antipsychotics do not treat the causes of delirium.

For Dorothy, the paper recommends no routine antipsychotic. A low dose may be considered only for short-term use if she becomes so distressed or agitated that she is at risk of harming herself, such as trying to climb out of bed on a new hip, and only after other steps fail, with a plan to stop it within a few days. Benzodiazepines are avoided because they worsen delirium in older adults, except in alcohol withdrawal.

Prevention Next Time

Inouye et al. (1999) enrolled 852 general medicine patients over 70, pairing each on the program unit with a similar patient on one of two ordinary units, and applied set protocols to six targets: thinking problems, lost sleep, bed rest, poor eyesight, poor hearing and low fluids. On the HELP unit, delirium appeared in 9.9 percent of patients against 15.0 percent on the comparison units, and the total days and episodes of delirium were lower, though the severity and recurrence were not. Use of sleep medicines also fell.

Dorothy's discharge summary asks that these six areas be addressed in any future admission, that her glasses and hearing aids go with her, and that no zolpidem, diphenhydramine or anticholinergic bladder medicine be ordered. A cognitive screen is planned eight weeks after discharge, when she has recovered, to see whether an underlying cognitive problem remains.

Conclusion

Dorothy's confusion after hip surgery is delirium, confirmed by the Confusion Assessment Method, with several causes: anticholinergic and sedative drugs, poorly managed pain, urinary retention, constipation, dehydration, poor sleep and missing glasses and hearing aids. Treating each cause, supporting her orientation and sleep and involving her daughter form the core of care. Antipsychotics are not used routinely after a large trial found no benefit, and prevention steps drawn from the Hospital Elder Life Program are written into her record for future admissions, with a follow-up cognitive screen after recovery.

References

Girard, T. D., Exline, M. C., Carson, S. S., Hough, C. L., Rock, P., Gong, M. N., Douglas, I. S., Malhotra, A., Owens, R. L., Feinstein, D. J., Khan, B., Pisani, M. A., Hyzy, R. C., Schmidt, G. A., Schweickert, W. D., Hite, R. D., Bowton, D. L., Masica, A. L., Thompson, J. L., ... Ely, E. W. (2018). Haloperidol and ziprasidone for treatment of delirium in critical illness. New England Journal of Medicine, 379(26), 2506-2516. https://doi.org/10.1056/NEJMoa1808217

Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340(9), 669-676. https://doi.org/10.1056/NEJM199903043400901

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948. https://doi.org/10.7326/0003-4819-113-12-941