Mr. Chute, is a 76 year old man with right hip pain post-fall. He lives independently and has some early dementia and depression, NIDDM, hypertension.
- Meds: Donepezil, Fluoxetine, Metformin, HCTZ, ASA, Ramipril
- O/E: in pain, HR 90 BP 170/95; looks dry; a bit agitated and scattered; shortened and externally rotated right leg.
- What risk factors for delirium does this man have?
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In this very vulnerable brain, extreme care needs to be taken to avoid or at least minimize delirium.
- Avoid medications that will make it worse: benzodiazepines or anti-cholinergics like Gravol.
- Use medications to treat the treatable: opioids for the pain or if appropriate, consider non-opioid options initially which may include a femoral nerve block for hip fracture, Acetaminophen, comfortable positioning, etc.
- Maximize hydration status: Avoid restraints, promote orientation and stimulation.
Take Home point
In the older patient the cardio-vascular and the central nervous systems have a decreased ability to adapt to pharmacologic/physiological changes. Particular care and attention must be paid when patients are on medications involving these systems (which means almost everyone!) and when starting new medications involving these systems (which means almost all medications!)
To learn more about the management of delirium, visit the Cognitive Impairment module.
Discussion: Mr. Chute
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GOOD HYDRATION IS VERY IMPORTANT
A parte del manejo del dolor la mejor manera de evitar que haga delirium es, reincorporarlo rápidamente a su ambiente basal o lo más cercano a lo basal de el
Pain management, environmental orientation/cueing
multiple risk factors present
very high risk for delirium- ensure as many risk factors can be corrected or negated.
take an x-ray of the hip to rule out hip fx.
Caution with narcotic use in geriatric patients
AGREE. MULTIPLE POTENTIAL CONTRIBUTORS FOR DELERIUM.
age, depression, dementia
Patient has broken his hip. He is dry so he is probably dehydrated. he does have early dementia, probably forgets to drink. Has diabetes. Concern for med accuracy.
make sure to address pain
Get patient in quiet environment.
I agree. We really need to keep an eye on medlists in the ED to r/o causes of cognitive impairment.
Such good information!
Femoral nerve block sounds a good idea
back to delirium screening and its importance
I’ve never even heard of a femoral nerve block. Cool!
Opioids should be avoided in the elderly as much as is possible
careful attention to physiologic status. Fentanyl is my favorite for severe pain such as this–short acting, less general side effects
Pain management and support
NeCesita uso de analgésicos para manejo del dolor y reposición de líquidos eñy electrolitos
The patient needs hydration and analgesics
he has many delirium risks
that is exactly what i said
multiple delerium causes here
treat conservatively w/pain meds, avoid opiates if possible.
IV hydration may prevent hypotension.
Acute pain and dehydration on top of baseline cognitive impairment
hydration, adequate pain relief with lowest dose possible, surgery to stabilize fx, Then PT to get patient moving
pain management is important
Don’t forget glucose
He has multiple risk factors for delirium including age, dementia, severe pain, dehydration.
I wonder if pain should be a designated at precipating factors instead of a predisposing risk factor. Depression has 3.2 OR for delirium.
Isolation. lack of support
Pain management, frequent re-orientation, appropriate lighting and avoiding extended periods of isolation while in hospital.
Close observation and monitoring
Pain management and hydration
Yes opioids can be used, but important to start low and go slow
Also, when starting opioids in an elderly person with baseline cognitive impairment, it is imperative that the patient is in a supervised enviornment/has support in monitoring use and potential side effects.
pain control and mitigation of delirium
Sensitive use of narcotics in this case is essential
Is there a question?
Poor intake, inability to understand rx
admit to ortho..rehydrate, analgesia, watch out for interactions
many risk factors
Remember to make a complete evaluation
Multiple factors accounting for delirium is demonstrated here.
Analgesia important to control pain however must be careful with narcotic use in the elderly.
Pain management is very important here.
Make sure he is not restrained and get him out of the ER ASAP and on to a nursing floor to avoid possible delirium. Maintain hydration and do not put a foley in if possible.
agree…get him out of ER ASAP !
perhaps femoral nerve block may decrease the sue of analgesics
& lessen delirium risk