NU677 Unit 7 Delirium or Dementia After Hip Surgery Example

What Is New and What Was Already There: A Delirium and Dementia Differential Two Days After Hip Fracture Surgery in a 79-Year-Old Retired Piano Tuner

[Student Name]

Purdue University Global

NU677: PMHNP Diagnosis and Management Across the Lifespan III

Unit 7 Delirium and Dementia Differential

[Instructor Name]

[Date]

The patient is composite; scores, times and details are bracketed.

The Presentation

Mr. [T.], [79], a retired piano tuner and widower who lives alone, fell at home and fractured his left hip. He had a hemiarthroplasty the next day under spinal anesthesia with sedation. On the evening of the second day after surgery, the nurse found him agitated and pulling at his IV line. By morning he was drowsy, dozing mid-sentence and waking confused. He called his daughter by her mother's name. He had not had a bowel movement since admission, his urine output was low, and he had received [four] doses of oxycodone and one dose of diphenhydramine for sleep.

His daughter reports a slower change over the past year: he repeats the same stories, has missed two bills, and stopped doing the crossword he had done every morning for decades. He still drives short distances, cooks simple meals and keeps his house tidy.

Two Questions, Two Timelines

The central clinical task is to separate an acute change, over hours to days, from a chronic change over months. Delirium comes on over hours or days, disturbs attention and awareness, swings in severity across the day and has a medical, drug or withdrawal cause. Dementia is a gradual decline in cognition over months to years with preserved attention until late. Older adults with dementia are at higher risk of delirium, and the two often coexist.

Is There Delirium Now?

The Confusion Assessment Method was used. Its algorithm requires an abrupt start with a fluctuating course and inattention, plus one of two further features, rambling or illogical thought, or drowsiness or hypervigilance, and in its original validation it showed high sensitivity and specificity against expert diagnosis (Inouye et al., 1990).

1. Acute onset and fluctuating course: yes. He was oriented and conversing on the day of surgery, according to nursing notes, and has swung between agitation at night and drowsiness in the morning.

2. Inattention: yes. He stopped after two months when asked to recite the months in reverse, and he lost the thread of the conversation several times.

3. Disorganized thinking: yes. His answers drifted to his workshop and to his late wife.

4. Altered level of consciousness: yes, drowsy.

Result: positive for delirium.

Likely causes, several at once: opioids, the anticholinergic diphenhydramine, constipation, possible dehydration and urinary retention, pain, sleep disruption, the unfamiliar environment, and the surgery itself. Tests ordered: sodium, calcium, glucose, blood count, urinalysis, a bladder scan and a medication review.

Was There Dementia Before?

Delirium makes it impossible to test his baseline cognition now; any score today would reflect the delirium. The history must come from someone who knows him. An informant questionnaire, the IQCODE, asks someone close to the patient to compare the person's current abilities with ten years earlier, and a review found it reliable and valid for detecting dementia, including in settings where the patient cannot be tested directly (Jorm, 2004). His daughter completed it; the score of [3.6] suggests a decline beyond normal aging.

The IQCODE tells us what the delirium hides: that a year of forgetting came before the surgery and will still be there when the delirium clears.

The pattern she describes, repeated stories, missed bills and loss of a lifelong habit over a year, with preserved basic self-care, is consistent with probable mild dementia or mild neurocognitive disorder. The diagnosis cannot be confirmed until the delirium resolves.

Management on Two Timelines

Now, for the delirium:

1. Stop diphenhydramine; use a non-drug sleep routine.

2. Change to scheduled acetaminophen with the lowest effective opioid dose, since untreated pain also causes delirium.

3. Treat constipation; check for urinary retention with a bladder scan.

4. Hydration, glasses and hearing aids on, daylight during the day and dark at night, family visits, early mobilization with physical therapy.

5. Avoid physical restraints and routine antipsychotics; reserve a low-dose antipsychotic only for severe agitation that endangers him.

This approach reflects evidence that proactive, multicomponent care reduces delirium after hip fracture; in a randomized trial, patients who received proactive geriatric consultation developed delirium about a third less often than those receiving usual care (Marcantonio et al., 2001).

Later, for the possible dementia:

1. Reassess cognition [six to eight] weeks after discharge, when the delirium has cleared, with a standard cognitive test.

2. Review his safety at home, bills and driving with his daughter.

3. Consider a memory clinic referral if the test confirms impairment.

Why Not Test Cognition Now

The team was tempted to run a cognitive screening test on day two to settle the question of dementia. That would have produced a low score, but a score taken during delirium measures the delirium, not his underlying cognition, and could have labeled him with dementia on the basis of a temporary state. The informant questionnaire avoids this because it asks about change over years, reported by someone who knows him, and does not depend on his performance today. The formal test will wait until the delirium has cleared, when a low score will mean something.

Watching the Delirium Resolve

Recovery was tracked with the same screening method each morning and evening. On day three, after diphenhydramine was stopped, his bowels opened and his pain was controlled with scheduled acetaminophen, the evening agitation stopped, but morning drowsiness persisted. By day five he was attentive in the mornings, could recite the months backward with one error, and recognized his daughter by name. By discharge on day seven the screen was negative, though his daughter noticed he was slower than before the fall. That remaining slowness, and whether it resolves over the following weeks, will inform the later assessment.

What the Family Was Told

His daughter was told that the confusion since surgery is delirium, which is common after hip fracture, usually improves over days to weeks, and is being treated by removing its causes. She was also told that the forgetfulness she noticed over the past year is a separate matter, which will be assessed once he is recovered, and that his recovery from delirium may be slower because of it. She was asked to visit often and bring familiar objects from his workshop.

Why the Distinction Matters

Treating the whole picture as dementia would miss the reversible causes of delirium; treating it all as delirium would miss the year of decline. Separating the two lets each be managed on its own timeline.

References

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

Jorm, A. F. (2004). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): A review. International Psychogeriatrics, 16(3), 275-293. https://doi.org/10.1017/S1041610204000390

Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick, N. M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 49(5), 516-522. https://doi.org/10.1046/j.1532-5415.2001.49108.x