Synopsis
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.
- 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.
- Mobilise with physiotherapy on the day after surgery unless medically or surgically contraindicated, and reassess daily for both hyperactive and hypoactive change.
Key red flags
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.
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.
Investigation priorities
Evaluate alertness, orientation, attention and acute change or fluctuation when delirium indicators appear.
Find hypoxia, hypoglycaemia, hypotension, fever, retention, constipation, pain and opioid excess immediately.
Management branches
An adult presents with hip fracture for operative or non-operative management.
- Record NICE risk factors and obtain baseline cognition, function, communication and behaviour from collateral sources.
- Assess pain, hydration, oxygenation, infection, retention, constipation, medicines, withdrawal and sensory needs.
- Place glasses, hearing aids, dentures, clock and orientation support within reach and avoid unnecessary transfers.
- Assign the tailored multicomponent prevention plan to the orthogeriatric and ward team within twenty-four hours.