Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Delirium prevention after hip fracture
Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute behavioural change can signal deterioration
New reduced responsiveness, agitation, focal neurology, hypoxia, shock, hypoglycaemia, sepsis or opioid toxicity requires immediate physiological assessment before it is attributed to delirium.
Action: Use ABCDE, check bedside glucose and oxygenation, review medicines and pain, treat the time-critical cause and obtain urgent senior help for instability or new neurological findings.
Role and principles
Recognise hip-fracture patients at high delirium risk, deliver a coordinated multicomponent prevention bundle and detect hypoactive or fluctuating change early enough to treat causes.
Delirium is an acute, fluctuating disturbance of attention, awareness and cognition produced by vulnerability plus physiological insults. Hip fracture combines pain, inflammation, immobility, emergency surgery, sleep disruption, unfamiliar surroundings and high medicine exposure in a population often living with frailty or dementia. The risk assessment begins at presentation: age, known or suspected cognitive impairment, current hip fracture and severe illness are NICE risk factors. Label risk visibly and assign prevention actions rather than waiting for confusion to occur.
Establish baseline before sedatives, anaesthesia and changing ward environments obscure it. Ask family or carers about memory, attention, usual speech, independence, sleep, sensory aids and recent change. Document communication needs and capacity for the current decision, recognising that capacity is decision and time specific. Look for dehydration, hypoxia, infection, urinary retention, constipation, pain, head injury, alcohol dependence and medicine withdrawal. Review anticholinergics, benzodiazepines, opioids and other psychoactive medicines without abrupt unsafe cessation.
Assessment and patient selection
Acute fluctuating attention
Inability to sustain conversation or follow commands that varies through the day is more characteristic than isolated forgetfulness.
Hypoactive presentation
Quiet withdrawal, slow answers, drowsiness, reduced movement and poor intake can be missed because they do not disrupt the ward.
Hyperactive presentation
Restlessness, pulling devices, hallucinations and agitation are visible but still require a cause search rather than automatic sedation.
Baseline dementia vulnerability
Pre-existing cognitive impairment increases risk, but a sudden change from usual behaviour remains delirium until assessed.
Pain or retention signal
Grimacing, guarding, agitation or repeated attempts to stand may communicate pain, urinary retention or constipation when speech is impaired.
Medication-associated change
Temporal deterioration after opioid, benzodiazepine, anticholinergic or medicine withdrawal should direct urgent reconciliation and review.
Red flags requiring action
A fall in consciousness, respiratory depression or pinpoint pupils after opioid administration may be toxicity and needs immediate airway and reversal assessment.
New focal weakness, unequal pupils, speech change, seizure or severe headache after the fall requires an acute neurological and head-injury pathway.
Baseline assessment
01First-line 4AT assessmentFirst stepFirst line
Why
Evaluate alertness, orientation, attention and acute change or fluctuation when delirium indicators appear.
Interpretation and limitations
Use as the recommended bedside assessment in most settings; diagnose clinically and investigate causes rather than treating the score alone.
02CAM-ICU or ICDSC in critical care
Why
Assess delirium when intubation, recovery or critical illness makes ordinary conversation and 4AT less appropriate.
Interpretation and limitations
A negative screen does not override convincing fluctuation; repeat with clinical change and optimise arousal and communication.
03First-line physiological and bedside cause screenFirst line
3Place glasses, hearing aids, dentures, clock and orientation support within reach and avoid unnecessary transfers.
4Assign the tailored multicomponent prevention plan to the orthogeriatric and ward team within twenty-four hours.
02Perioperative preventionReduce simultaneous insultsThe patient awaits or recovers from hip-fracture surgery.+
1Provide scheduled paracetamol and titrated additional analgesia, monitoring sedation and respiratory status and using nerve block where trained.
Medicines and treatment safety
Provides consistent baseline analgesia because untreated pain promotes delirium and impedes breathing, sleep and mobilisation.
Scheduled paracetamol for hip-fracture pain
Give 1 g orally every 6 hours before and after surgery unless contraindicated, using a lower dose or daily maximum for body weight below 50 kg, frailty, malnutrition or hepatic risk.
Check all combination products and liver or alcohol risk; reassess severe pain for displacement, haematoma or another complication and do not exceed the individualised daily maximum.
Targets, monitoring and follow-up
Observe each shift for acute or fluctuating attention, perception, movement, appetite, sleep and social-behaviour change, including quiet withdrawal.
Record pain before and after analgesia together with sedation score, respiratory rate, oxygen saturation and functional response.
Review hydration, oral intake, bowel movement, urinary retention, oxygen need, infection indicators and sensory-aid access daily.
Repeat 4AT or critical-care assessment when behaviour changes; do not schedule repeated scores without clinical interpretation.
Track mobilisation, sleep disruption, room moves and exposure to catheters, restraints and deliriogenic medicines.
At discharge, document delirium course, unresolved cognitive change, medicine changes and who will review cognition and function.
Special situations
Quiet delirium is dangerous
Hypoactive patients may receive less attention despite poor intake, immobility, aspiration and pressure-injury risk.
A lucid interval misleads
Fluctuation means one coherent conversation cannot exclude delirium when staff or family describe marked recent change.
Pain and opioids both matter
Undertreatment provokes stress and immobility, while excessive opioid exposure causes sedation and respiratory compromise.
Bundles need personal targets
Glasses matter to one patient, constipation to another and withdrawal to a third; generic checklists need clinical linkage.
Capacity is decision specific
Delirium can impair one complex decision while the person may still express preferences or decide a simpler matter later.
Common pitfalls
01
Looking only for agitation and missing hypoactive delirium with withdrawal and reduced intake.
02
Using a positive urine dipstick as the automatic cause without urinary or systemic infection evidence.
03
Prescribing sedatives before checking oxygenation, glucose, pain, bladder, bowel and medicine toxicity.
04
Withholding adequate analgesia because opioids can cause delirium, leaving severe pain untreated.
05
Diagnosing dementia during an acute fluctuating episode without obtaining baseline collateral history.
06
Ending prevention after surgery even though delirium risk continues during recovery and transition home.
Practice
Two practice questions
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Question 1 of 2
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Musculoskeletal medicine and orthopaedicsOriginal SBA
Quiet postoperative change
The day after hip-fracture surgery, an older patient becomes withdrawn, answers slowly, eats little and remains still but is not agitated. What is the best next action?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE recommends a tailored multicomponent intervention delivered by a trained multidisciplinary team. Reorient through clear introductions, visible time information and familiar people. Maintain hydration and nutrition, correct oxygenation, identify infection, avoid unnecessary catheters, treat constipation, ensure dentures, hearing aids and glasses are available and promote normal sleep. Provide effective analgesia while monitoring sedation and respiratory function. Mobilise early and reduce environmental changes. Each component should answer a risk identified in that patient.
Observe for recent hours-to-days change or fluctuation in cognition, perception, physical function and social behaviour. Hyperactive features include restlessness and agitation; hypoactive signs include slowed responses, withdrawal, reduced mobility and appetite. If indicators are present, use 4AT in routine hospital settings or CAM-ICU or ICDSC in critical care or recovery. A positive assessment supports a clinical delirium diagnosis and a systematic cause search. If distinction from dementia remains difficult, manage delirium first and reassess after recovery.
When delirium develops, repeat ABCDE and examine for pain, urinary retention, faecal loading, wound or chest infection, hypoxia, anaemia, electrolyte or glucose disturbance and medicine effects. Treat causes and continue the prevention bundle. Use calm de-escalation and familiar support for distress. NICE permits short-term haloperidol only when a distressed or dangerous patient does not respond to de-escalation, using the lowest appropriate dose and considering cardiac and neurological risk, particularly Parkinson disease or dementia with Lewy bodies. Communicate the episode and arrange cognitive follow-up if recovery is incomplete.
Key points
Current hip fracture itself is a NICE delirium risk factor; age 65 or over, cognitive impairment and severe illness further increase vulnerability.
Record baseline cognition, function, communication and behaviour from the patient and someone who knows them before surgery whenever possible.
First-line diagnosis in most clinical settings is the 4AT after a recent change or fluctuation; use CAM-ICU or ICDSC in critical care or recovery.
Start a tailored multicomponent bundle within 24 hours: orientation, hydration, oxygenation, infection and constipation care, mobility, pain control, medication review, nutrition, sensory aids and sleep protection.
Use consistent staff and environment where feasible, visible clock and calendar, repeated explanation and family involvement; avoid unnecessary ward or room moves.
Give paracetamol 1 g orally every 6 hours before and after hip-fracture surgery unless contraindicated, reducing the dose for low weight, frailty, malnutrition or liver risk; add opioids cautiously and consider trained nerve block.
Do not use prophylactic antipsychotics or sedatives as a substitute for prevention; when delirium causes distress, treat causes and use verbal and non-verbal de-escalation first.
Hypotension, rising oxygen requirement, oliguria, fever or mottling suggests physiological deterioration or sepsis rather than uncomplicated postoperative confusion.
Severe agitation that creates immediate danger requires de-escalation, correction of causes and senior support; restraint or sedation can worsen harm.
Hypoactive delirium presents with withdrawal, slow responses, reduced movement and poor intake and carries serious risk despite appearing quiet.
Persistent cognitive change after acute causes settle needs follow-up for underlying dementia, depression or neurological disease without diagnosing chronic impairment during fluctuation.
Interpretation and limitations
Avoid reflex urine culture for asymptomatic bacteriuria or indiscriminate tests; interpret results against symptoms and pretest probability.
05Collateral baseline and serial cognitive observation
Why
Distinguish acute fluctuation from longstanding impairment and measure recovery across shifts and settings.
Interpretation and limitations
Family reports and nursing trajectory are diagnostic data; a single lucid encounter does not exclude delirium.
2
Maintain appropriate fluids, oxygenation, nutrition, infection control and bowel and bladder care without unnecessary catheters.
3Reconcile medicines and minimise deliriogenic exposure while preventing withdrawal from necessary long-term treatment.
4Protect sleep at night and mobilise with physiotherapy on the day after surgery unless contraindicated.
03New changeDiagnose delirium and its causesStaff or family notices acute or fluctuating cognitive, perceptual, physical or behavioural change.+
1Use ABCDE, bedside glucose and focused neurological assessment before assuming delirium.
2Perform 4AT, or CAM-ICU or ICDSC in critical care, and document phenotype and fluctuation.
3Search systematically for pain, hypoxia, infection, retention, constipation, metabolic disturbance and medicine toxicity or withdrawal.
4Treat identified causes and intensify the multicomponent bundle with frequent reassessment.
04Distress or dangerDe-escalate before medicationEscalationDelirium produces severe distress or immediate risk to the patient or others.+
1Reduce noise, use familiar staff and family, explain simply and meet pain, toileting, hunger and sensory needs.
2EscalationUse verbal and non-verbal de-escalation and the least restrictive safe environment.
3If these measures fail, obtain senior review before short-term lowest-dose haloperidol and assess cardiac and extrapyramidal risk.
4Review at least daily, stop medication as soon as possible and document the delirium episode in discharge communication.
Mobilise with physiotherapy on the day after surgery unless medically or surgically contraindicated, and reassess daily for both hyperactive and hypoactive change.