How to manage a patient with irrelevant speech and restlessness after hemiarthroplasty (half joint replacement) surgery?

Management of Irrelevant Speech and Restlessness After Hemiarthroplasty Surgery

This presentation represents postoperative delirium, which requires immediate systematic assessment for reversible causes, environmental modifications, and cautious pharmacological management only when non-pharmacological measures fail and the patient poses a safety risk.

Immediate Assessment and Recognition

The combination of irrelevant speech and restlessness following hemiarthroplasty surgery indicates postoperative delirium, a common and serious complication in elderly hip fracture patients 1. Approximately 25% of hip fracture patients have moderate or severe cognitive impairment preoperatively, with an additional 15-25% having mild cognitive impairment 1.

Critical Evaluation Steps

Systematically evaluate for reversible physiological causes:

• Hypoxemia: Verify oxygen saturation and ensure adequate oxygenation, as supplemental oxygen should be administered to maintain acceptable arterial oxygen saturation 1
• Hypotension: Check blood pressure and compare to baseline, aiming for systolic pressure within 20% of pre-induction value 1
• Pain: Assess using static/dynamic pain scores, as inadequate analgesia is a common precipitant 1
• Medication effects: Review all administered opioids and sedatives, as systemic opioids increase risk of respiratory depression and delirium 1
• Metabolic derangements: Check electrolytes, particularly sodium (<120 or >150 mmol/L) and potassium (<2.8 or >6.0 mmol/L), as these require correction 1
• Urinary retention: Assess bladder distension 1
• Infection: Monitor for signs of chest infection, urinary tract infection, or surgical site infection 1

Non-Pharmacological Management (First-Line)

Environmental and supportive interventions should be implemented immediately:

• Reorientation: Provide frequent verbal reorientation to time, place, and situation 1
• Sensory optimization: Ensure hearing aids and glasses are in place if normally used 1
• Mobilization: Encourage early mobilization with physiotherapy involvement, as this is part of the interdisciplinary care that decreases complications 1
• Sleep hygiene: Minimize nighttime disruptions and maintain day-night orientation 1
• Family presence: Allow family members at bedside when possible for familiar faces 1
• Hydration and nutrition: Ensure adequate fluid intake and nutritional support 1

Pharmacological Management (Only When Necessary)

Medications should be used sparingly and only when the patient poses a safety risk to themselves or others, or when non-pharmacological measures have failed:

• Minimize opioid use: Regional analgesic techniques rather than systemic opioids reduce adverse outcomes in patients at increased perioperative risk 1
• Avoid benzodiazepines: These worsen delirium and should be avoided unless treating alcohol withdrawal 1
• Low-dose antipsychotics: Consider only for severe agitation posing safety risk, using the lowest effective dose for the shortest duration 1

Monitoring and Ongoing Care

Implement structured monitoring protocols:

• Vital signs: Continuous monitoring of pulse oximetry, respiratory rate, ECG, non-invasive blood pressure, and core temperature 1
• Delirium assessment: Regular screening using validated tools to track progression or resolution 1
• Fall prevention: Implement fall precautions given the high risk in cognitively impaired patients with hip surgery 2, 3
• Pressure care: Ensure adequate pressure relief as immobilization increases pressure sore risk 1

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Over-sedation: Avoid excessive use of sedatives or opioids, which can precipitate or worsen delirium and respiratory depression 1
• Delayed recognition: Do not dismiss confusion as "expected" in elderly patients; actively search for reversible causes 1
• Physical restraints: Avoid restraints when possible, as they increase agitation and risk of injury 1
• Inadequate pain control: Undertreated pain worsens delirium, but balance this against opioid-related cognitive effects 1
• Ignoring cognitive impairment: Patients with neurological or cognitive impairment have additional risks including higher dislocation rates and reduced ability to engage with rehabilitation 2, 3

Interdisciplinary Approach

Coordinate care across multiple specialties:

• Orthogeriatrics consultation: Interdisciplinary care involving orthogeriatricians should be provided to decrease complications and improve outcomes 1
• Anesthesia team: Communicate regarding postoperative pain management strategies that minimize opioid use 1
• Nursing staff: Ensure protocols for monitoring, thermoregulation, and pressure care are followed 1
• Physiotherapy: Early mobilization reduces complications including pneumonia and thromboembolic events 1