Case 13: An older man who pulls out his drip after surgery

01The case

A psychiatrist is called to the surgical intensive care unit to see an 82-year-old man who had an operation for rectal cancer a few days ago. The night staff say he has been frightened and restless, has talked in a way no one could follow, has tried to pull out his intravenous line and get out of bed, has waved his arms as if fighting someone off, and has refused his medication.

02Summary

Diagnosis

Delirium not due to alcohol or other substances, after surgery.

What points to it

• Acute confusion with a disturbance of consciousness and attention, and disorientation.
• Fear, psychomotor agitation, incoherent speech, waving his arms as if fighting someone: probably hallucinations.
• A broken sleep-wake cycle, worse at night.
• Risk factors: great age, major surgery, general anaesthesia, pain, cancer, and likely disturbed fluids and electrolytes.

What else it could be

Alcohol withdrawal, if he drank more than anyone knows, which would change the treatment to benzodiazepines. A dementia not known before, which delirium often unmasks. Hypoactive delirium is common too, and easily missed when a patient is quiet.

Management

• Find and treat the causes, often several: infection (wound, chest, urine), low oxygen, pain, urinary retention, constipation, dehydration and electrolytes, low or high glucose, and drugs (opioids, anticholinergics, sedatives). Review every medicine.
• Non-drug care: a calm, well-lit room, the same staff, clocks and calendars, glasses and hearing aids, family visits, sleep at night, early mobilising.
• An antipsychotic such as haloperidol only if he is very distressed or a danger to himself (pulling out lines), at a low dose (0.5 to 1 mg), by mouth if he will take it, reviewed daily and stopped as soon as possible. Check the ECG for a long QT, and avoid it in Parkinson's disease or Lewy body dementia.
• Avoid benzodiazepines, which worsen delirium, unless the cause is alcohol withdrawal.

Outlook

Delirium often clears in days to weeks once its cause is treated, but in an elderly man after cancer surgery it marks a poor outlook: a higher risk of death, longer stay, loss of function and later dementia.