Mr. Frank is a 76 year old man who has been admitted to the hospital for a hip fracture. Mr. Frank had fallen at home and when he was admitted he was very alert, friendly, quiet and pleasant. Yes, he was in some pain before his surgery, but it was well controlled with medication. Now that he has come out of anesthesia, after his successful surgery, he is yelling, throwing his bed sheets as well as everything on his bedside table, on the floor. He is very agitated, and keeps trying to climb out of bed, even though the staff instruct him to use the call light for assistance. Mr. Frank is suddenly a completely different patient. A very difficult patient.

The hospital staff are sure that Mr. Frank has delirium because of the suddenness of his change in mental status. Having delirium following a bone fracture and surgery isn’t all that uncommon for the older patient. Studies show that physical or mental illness affects 15-53% of older surgical patients. Delirium is more common in the older patient than younger patients. And the person with delirium is also more likely to have other complications as well. Actually 48% of patients older than 65 years are shown to have had acute confusion before and after surgery.

Delirium before surgery can be related to pain or sleep disturbances due to pain. Or an electrolyte imbalance, medications the patient has been taking, or possibly an infection that was related to the fall in the first place. All of the possibilities require extensive evaluation of current medications, lab work for complete blood count, urinalysis and serum electrolytes. After consulting with the physician, many other tests may be ordered to assess the source of the delirium and  create a treatment plan.

Care of this older, confused patient will include being very present for Mr. Frank. Making good eye contact when staff speak to him, as well as using soft reassuring words. If Mr. Frank is having hallucinations giving him one-on-one care to reassure him that what he is experiencing is not real. Making sure that if Mr. Frank uses glasses, that they are clean and on when he is awake. If Mr. Frank uses a hearing aid that the battery is working and that the hearing aid is in and turned on when he is awake.

Maintain a quiet and peaceful environment while decreasing noise as much as possible. This is the time to also reassure the family, while you educate them on the subject and course of delirium. While teaching them how to be involved with the patient, to assure a positive outcome. Watching a loved one struggling with anxiety and agitation is very difficult on the family as well as the patient.

It is reported that post operative delirium in the older patient, is costing 164 billion annually. While that is certainly an impressive number, it doesn’t even touch on the real cost to the elderly patient and his family.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing