A 72-year-old man is hospitalized due to a leg injury following a high-speed motor vehicle collision. Medical history is significant for hypertension, hypercholesterolemia, and hearing loss. The patient drinks a glass of wine every day. Examination shows localized swelling and severe tenderness under the right knee; the presence of a tibial fracture is confirmed by imaging. The patient undergoes open reduction and internal fixation without any perioperative complications. On the first postoperative night, he describes visual hallucinations of his deceased brother in the hospital room with him and perseverates about people invading his home. Vital signs are normal. The patient is disoriented and unable to cooperate with the mental status examination. He appears to respond to internal stimuli. Which of the following interventions is most likely indicated to prevent further worsening of his condition?
Delirium prevention | |
Risk factors |
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Prevention strategies |
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*Anticholinergics (eg, antihistamines, tricyclics), benzodiazepines, opioids, muscle relaxants, corticosteroids. | |
Delirium is a common confusional state characterized by altered consciousness and cognitive disturbances such as disorientation or altered perception (eg, hallucinations, delusions). The key features of acute onset and fluctuating course distinguish it from other cognitive (eg, dementia) and perception (eg, psychosis) disorders. Delirium most commonly affects patients with predisposing risk factors (eg, advanced age, dementia, sensory impairment).
Because sleep-wake cycle disruption can be both a risk factor as well as a manifestation of delirium, facilitation of nocturnal sleep is helpful in prevention and management. Delirium and sleep disturbances are both significantly increased by the hospital environment (eg, ambient noise, frequent awakenings). Minimizing noise and patient interventions at night promotes uninterrupted sleep, and physiologically appropriate lighting (ie, bright day/dim night) helps maintain circadian alignment. These measures significantly decrease delirium incidence and sedative-hypnotic use (an additional delirium risk factor).
(Choice B) Benzodiazepines have a limited role in the treatment of delirium because they frequently precipitate or prolong (rather than resolve) it. They are most useful in the setting of alcohol withdrawal (which can cause hallucinations but would also cause abnormal vital signs).
(Choice C) Closing window blinds during the day restricts the ability of the intrinsic circadian system to synchronize with the 24-hour day, which disrupts the sleep-wake cycle and increases delirium risk.
(Choice D) Removing hearing aids contributes to disorientation and sensory deprivation, thus increasing delirium risk. Providing hearing aids helps reduce delirium incidence.
(Choice E) Nonpharmacologic and nonopioid pain management is desirable because opioids frequently precipitate delirium. However, postsurgical pain also significantly increases delirium risk and typically requires pharmacologic treatment.
Educational objective:
Because disruption of the sleep-wake cycle is both a risk factor and manifestation of delirium, facilitation of nocturnal sleep (eg, minimizing noise & patient interventions, appropriate day/night lighting) is helpful for delirium prevention and management.