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Stem
A 79-year-old man is admitted to the orthopaedic ward 24 hours after a hemiarthroplasty for a fractured neck of femur. The nursing staff report that he was his usual self yesterday but has become restless and agitated this evening, repeatedly trying to climb out of bed and reporting that he can see strangers at the window. He is distractible, cannot follow a conversation, and cannot recite the months of the year backwards. His past history includes hypertension, benign prostatic hyperplasia (on oxybutynin), and mild Alzheimer's disease. Observations: temperature 38.2 degrees C, HR 102, BP 104/64, RR 22, SpO2 94 percent on air. Bedside capillary glucose is 6.2 mmol/L.
Questions
a) What is the clinical diagnosis, and which two features make it most likely? (2 marks)
Delirium — specifically hyperactive, postoperative delirium superimposed on Alzheimer's disease. The two defining features are (i) acute onset with fluctuating course (was well yesterday, agitated tonight) and (ii) inattention (distractible, cannot recite months of the year backwards). The visual hallucinations and altered behaviour are consistent with the hyperactive subtype.
b) List FOUR high-yield precipitating factors operating in this patient. (2 marks)
(1) Postoperative state (hip-fracture surgery — high-risk). (2) Infection — fever 38.2 degrees C, likely UTI or chest infection (needs urinalysis and CXR). (3) Anticholinergic drug — oxybutynin (high anticholinergic burden, strongly precipitates delirium). (4) Pre-existing dementia — multiplies delirium risk two- to three-fold ("delirium superimposed on dementia"). Also relevant: possible dehydration, pain, hypoxia (SpO2 94 percent), and immobility.
c) Outline your stepwise management. (4 marks)
- ABCDE — give oxygen to target SpO2 94-98 percent; secure IV access; check glucose (already 6.2 — normal); treat the new fever as possible sepsis (Surviving Sepsis hour-1 bundle: blood cultures, lactate, broad-spectrum antibiotics within 1 hour, fluids).
- FIND AND TREAT EVERY PRECIPITANT — send urinalysis and MC&S, chest X-ray, FBC, CRP, U&E, LFTs, calcium; STOP the oxybutynin (anticholinergic); treat pain adequately (regular paracetamol 1 g QDS); bladder scan for retention (BPH); treat constipation; review all medications for anticholinergic burden.
- Non-pharmacological first-line (HELP bundle) — calm, well-lit single room; clock, calendar, glasses/hearing aids; one-to-one nursing; family presence; repeated reorientation; encourage oral fluids; early mobilisation; sleep hygiene (cluster night observations).
- Pharmacological ONLY for severe agitation risking harm — if non-pharmacological measures fail and he endangers himself, haloperidol 0.5 mg PO or IM, repeated cautiously. Benzodiazepines are AVOIDED (not alcohol withdrawal). Caution: he has Alzheimer's — antipsychotics carry an FDA black-box for increased mortality; use lowest dose, shortest duration.
d) Two complications and the prognostic significance of this episode. (2 marks)
Complications: (i) increased in-hospital mortality and longer stay; (ii) accelerated long-term cognitive decline — delirium superimposed on dementia predicts worse functional and cognitive outcomes, and may accelerate the trajectory of the underlying Alzheimer's disease (delirium is both a consequence of, and a driver of, dementia).
Prognostic significance: delirium is a medical emergency with in-hospital mortality up to 25 percent and doubled 6-month mortality in older adults; this patient has multiple poor-prognosis markers (age, pre-existing dementia, postoperative, possible sepsis). Resolution may take weeks, and a substantial minority never return to cognitive baseline.