What is the best approach to manage confusion in an elderly patient post hip repair surgery, with no history of narcotic use?

Management of Postoperative Confusion in Elderly Hip Repair Patients

Postoperative confusion in elderly hip repair patients requires multimodal optimization including adequate analgesia, hydration, electrolyte balance, appropriate medication review, and identification of underlying complications such as infection or silent myocardial ischemia. 1

Immediate Assessment and Treatment Priorities

Identify and Treat Underlying Medical Causes

• Systematically evaluate for common precipitants: chest infection, silent myocardial ischemia, urinary tract infection, electrolyte imbalances, and hypoxia 1
• Check oxygen saturation and provide supplemental oxygen for at least 24 hours postoperatively, as elderly patients are at high risk of postoperative hypoxia 1
• Assess fluid status—hypovolaemia is common and should be corrected, though early oral fluid intake is preferred over routine intravenous fluids 1
• Remove urinary catheters as soon as possible to reduce urinary tract infection risk, which can precipitate confusion 1
• Review all medications and discontinue any with antimuscarinic properties, particularly cyclizine, which should be used with caution in older persons due to antimuscarinic side effects 1

Optimize Pain Control Without Opioids

• Continue regular paracetamol (acetaminophen) as baseline analgesia 1
• Minimize or avoid opioid analgesics entirely, as they carry relatively greater risk of respiratory depression and postoperative confusion in elderly patients 1
• Consider peripheral nerve blockade if pain is inadequately controlled with non-opioid approaches 1
• Pain evaluation should be included as part of routine postoperative nursing observations 1

Pharmacologic Management of Agitation (Use Sparingly)

Short-Term Symptom Control Only

• Haloperidol or lorazepam should only be used to control symptoms in the short term, not as primary treatment 1
• These medications treat symptoms but do not address the underlying causes of delirium 1
• Haloperidol should be used cautiously in elderly patients with cardiovascular disorders due to risk of transient hypotension 2
• Monitor for extrapyramidal symptoms and neuroleptic malignant syndrome, particularly in patients with Parkinson's Disease or Lewy Body Dementia 3

Important Contraindications and Cautions

• Risperidone can cause confusion, obtundation, postural instability with frequent falls, and extrapyramidal symptoms in patients with Parkinson's Disease or Dementia with Lewy Bodies 3
• Both haloperidol and risperidone may lower seizure threshold in patients with history of seizures 2
• Monitor complete blood count if using antipsychotics, as leukopenia and agranulocytosis have been reported 2

Supportive Care Measures

Nutritional Support

• Up to 60% of hip fracture patients are clinically malnourished on admission 1
• Provide nutritional supplementation, as mortality and possibly length of stay may be reduced through adequate nutrition 1

Environmental and Nursing Care

• Ensure adequate mobilization as soon as medically appropriate, as oxygenation and respiratory function improve with mobilization 1
• Maintain normal bowel function 1
• Provide ward care with nurse:patient ratio of 1:4, with regular input from physicians specialized in medicine for the elderly 1

Prevention Considerations for Future Cases

Anesthetic Technique Selection

• Spinal/epidural anesthesia should be considered for all patients undergoing hip fracture repair unless contraindicated, as regional anesthesia may reduce the incidence of postoperative confusion 1, 4, 5
• However, a large 2021 trial found no significant difference in delirium rates between spinal (20.5%) and general anesthesia (19.7%) 6
• Peripheral nerve blockade as an adjunct to either spinal or general anesthesia extends postoperative non-opioid analgesia and should always be considered 1

Common Pitfalls to Avoid

• Do not use opioid analgesics as the sole adjunct to anesthesia in elderly patients 1
• Avoid simultaneous administration of spinal and general anesthesia, as this is associated with precipitous falls in blood pressure 1, 4
• Do not routinely prescribe medications with antimuscarinic properties 1
• Bone cement implantation syndrome may manifest postoperatively as hypoxia and confusion—maintain high index of suspicion 7