In an 80‑year‑old man who underwent right humeral fracture repair yesterday and now has acute delirium while receiving oxycodone, what is the most appropriate immediate management step?

Management of Postoperative Delirium in an 80-Year-Old Man

Discontinue oxycodone immediately and implement non-pharmacological interventions (option D with modification), as opioids are a well-documented precipitant of delirium in elderly patients, and this patient's confusion began after humeral fracture repair while receiving oxycodone. 1, 2, 3

Immediate Priority: Address the Opioid-Induced Delirium

• Stop oxycodone now because opioids—particularly in elderly patients—are among the most common causes of postoperative delirium, and this patient's acute confusion temporally correlates with oxycodone administration following surgery. 1, 2, 4, 3

• Oxycodone specifically has been documented to cause delirium and agitation in elderly patients within 24 hours of administration, even when switched from another opioid like morphine. 2, 3

• The American Geriatrics Society strongly recommends avoiding or minimizing opioid use for pain management to prevent postoperative delirium, as opioids are high-risk medications that precipitate delirium. 1

Non-Pharmacological Interventions (First-Line Treatment)

Before considering any medication for agitation, implement these evidence-based strategies:

• Environmental modifications: Ensure adequate lighting (especially during late afternoon/evening), reduce excessive noise, provide a quiet room, and use easily visible clocks and calendars for orientation. 1, 5

• Communication strategies: Use calm tones, simple one-step commands, gentle touch for reassurance, frequently reorient the patient (explain where he is, who you are), and carefully explain all activities. 1

• Family involvement: Ask family members to visit daily, stay at bedside when possible, and bring familiar objects from home to foster familiarity and reduce anxiety. 1

• Sleep-wake cycle optimization: Minimize nighttime disruptions, ensure at least 30 minutes of daytime sunlight exposure, reduce time in bed during the day, and establish predictable daily routines. 1, 6

• Mobility and sensory aids: Increase supervised mobility, provide glasses and hearing aids if needed, and minimize physical restraints. 1

Systematic Medical Evaluation (Concurrent with Opioid Discontinuation)

Rule out and treat reversible causes of delirium before any pharmacological intervention:

• Infection screening: Check for urinary tract infection (urinalysis/culture), pneumonia (repeat chest examination), and other occult infections, as these are major contributors to delirium in elderly patients. 1, 7, 5

• Metabolic assessment: Evaluate for hypoxia (oxygen saturation is 94%—consider supplemental oxygen), dehydration, electrolyte disturbances (sodium is 134, borderline low), and hyperglycemia (glucose 100 is acceptable). 1, 7, 5

• Pain assessment: Ensure adequate pain control using non-opioid alternatives such as acetaminophen (paracetamol) as first-line, regional nerve blocks if feasible, or cautious use of NSAIDs with gastroprotection and renal monitoring given his age and comorbidities. 1

• Bowel and bladder function: Check for constipation and urinary retention, both of which significantly contribute to agitation in elderly patients. 1, 7

• Medication review: Identify and discontinue any anticholinergic medications (antihistamines, atropine) or other deliriogenic drugs. 1, 4

Why NOT the Other Options

Option A: Scheduled Haloperidol 0.5 mg IV Every 8 Hours – INCORRECT

• Haloperidol should NOT be given on a scheduled basis for this patient because he is not severely agitated, not threatening substantial harm to self or others, and is compliant with examination. 1, 5

• The American Geriatrics Society explicitly states that antipsychotics should not be prescribed for hypoactive or mild delirium without significant agitation threatening safety. 1

• Scheduled antipsychotic use (rather than PRN for severe agitation only) increases the risk of adverse effects—including QT prolongation, dysrhythmias, sudden death, hypotension, falls, and extrapyramidal symptoms—without proven benefit in modifying delirium duration or severity. 1, 5

• Patients over 75 years respond less well to antipsychotics, and this 80-year-old man is at particularly high risk for adverse effects. 1, 6

Option B: One Dose of Lorazepam – INCORRECT

• Benzodiazepines should NOT be used as first-line treatment for delirium except in cases of alcohol or benzodiazepine withdrawal (not applicable here). 1, 5

• The American Geriatrics Society provides strong evidence that benzodiazepines increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, and worsen cognitive function. 1, 6

• A study comparing haloperidol, chlorpromazine, and lorazepam for delirium terminated the lorazepam arm early due to significant adverse effects. 1

• Benzodiazepines carry additional risks of respiratory depression, tolerance, addiction, and falls in this population. 1, 6

If Non-Pharmacological Measures Fail and Severe Agitation Develops

Only if the patient becomes severely agitated, distressed, or threatens substantial harm to self or others after documented failure of behavioral interventions:

• Consider haloperidol 0.5–1 mg orally or subcutaneously PRN (not scheduled), with a strict maximum of 5 mg per 24 hours in elderly patients. 1, 6, 7, 5

• Use the lowest effective dose for the shortest possible duration, with daily in-person examination to reassess ongoing need. 1, 6, 5

• Mandatory monitoring: ECG for QTc prolongation, blood pressure for orthostatic hypotension, falls risk assessment, and evaluation for extrapyramidal symptoms. 1, 6, 5

• Discuss with family the 1.6–1.7-fold increased mortality risk associated with antipsychotic use in elderly patients. 1, 6, 5

Alternative Pain Management Strategies

Since opioids must be discontinued, use multimodal non-opioid analgesia:

• Acetaminophen (paracetamol): Safe first-line option for moderate pain in elderly patients. 1

• Regional anesthesia/nerve blocks: Highly effective for humeral fracture pain without systemic side effects; consider consultation with anesthesia/pain service. 1

• NSAIDs (with extreme caution): Use lowest dose for shortest duration with proton pump inhibitor gastroprotection and routine monitoring for gastric and renal damage, given his age, diabetes, and peripheral arterial disease. 1

• Non-pharmacological pain management: Postural support, immobilization/sling optimization, ice application, and patient warming. 1

Common Pitfalls to Avoid

• Do NOT add antipsychotics without first discontinuing oxycodone and addressing reversible causes (pain, infection, metabolic issues). 1, 7, 5

• Do NOT use benzodiazepines for this presentation—they will worsen the delirium. 1, 5

• Do NOT continue opioids "because the patient needs pain control"—find non-opioid alternatives. 1

• Do NOT prescribe scheduled (standing) antipsychotics—reserve them for PRN use only in severe agitation. 1, 5

• Do NOT assume confusion is "just postoperative delirium" without systematically ruling out infection, metabolic disturbances, and medication effects. 1, 7, 5

Monitoring and Reassessment

• Daily evaluation of mental status using validated tools (Brief Confusion Assessment Method) to track delirium trajectory. 1

• Continuous reassessment of pain control adequacy with non-opioid regimen. 1

• Family education that delirium typically resolves within days to weeks after precipitating factors are removed, and that behavioral symptoms are manifestations of the medical condition rather than intentional actions. 1, 6