A 68-year-old woman is admitted to the hospital due to a femoral neck fracture after a traumatic fall. The fracture is repaired, and her pain is treated with as-needed opioid medications. Over the course of her hospitalization, the patient develops nocturnal disorientation and mild agitation. Her husband says she is not like this at home. During morning rounds, the patient is pleasant and answers questions appropriately. Her condition resolves over the next few days, and she is discharged to the rehabilitation facility on day 7. Because of this patient's mental status changes, she is at increased risk for which of the following?

Question

A 68-year-old woman is admitted to the hospital due to a femoral neck fracture after a traumatic fall.  The fracture is repaired, and her pain is treated with as-needed opioid medications.  Over the course of her hospitalization, the patient develops nocturnal disorientation and mild agitation.  Her husband says she is not like this at home.  During morning rounds, the patient is pleasant and answers questions appropriately.  Her condition resolves over the next few days, and she is discharged to the rehabilitation facility on day 7.  Because of this patient's mental status changes, she is at increased risk for which of the following?

Quizplus · Accepted Answer

11ec25c8_d5a1_cc20_bc81_e160d9883cfb_MD0003_00 This patient has fluctuating, nocturnal disorientation and agitation in the setting of a medical illness (eg, hip fracture, surgery) consistent with delirium. Delirium is typically worse at night; however, fluctuation may allow patients to seem lucid during the day, resulting in underdiagnosis. Hyperactivity (eg, agitation) is classic, although hypoactive delirium (eg, lethargy, somnolence) is more common in the elderly (often misdiagnosed as depression). In this patient, either uncontrolled postoperative pain or opioid use was the most likely cause of her delirium. Although the acute symptoms of delirium are usually transient and resolve with treatment of the underlying cause, some patients experience persistent cognitive dysfunction. Delirium also accelerates the progression of dementia, likely because it causes direct neurologic injury through similar mechanisms (eg, neuroinflammation, decreased cerebral blood flow, impaired neurotransmitter function). Even in patients without a history of dementia, a single episode of acute delirium increases the risk for further cognitive decline. In addition, delirium can portend a downward spiral of functional loss, long-term facility placement, and death. (Choice A) Acute mania can present with agitation similar to that in hyperactive delirium. However, expansive symptoms (eg, elevated mood, grandiosity, pressured speech) are usually present, and fluctuations in consciousness do not occur. Delirium does not increase the risk of mania. (Choice C) Major depressive disorder can have psychotic features (eg, hallucinations, delusions) similar to those of delirium. Delirium is distinguished by the acute onset of confusion/fluctuating consciousness, and it is not associated with psychotic depression. (Choice D) Nonconvulsive status epilepticus (NCSE) describes ongoing or intermittent seizures without convulsions. Both NCSE and delirium are more frequent in the setting of critical illness and present with fluctuating levels of consciousness. However, NCSE usually demonstrates additional symptoms (eg, catatonia, automatisms, eye deviation), and delirium is not a risk factor. (Choice E) Opioids are the primary treatment for postoperative pain. All postsurgical patients have an increased risk for opioid dependence, especially those requiring opioids beyond 5 days. The risk of opioid dependence is also increased by a previous history of substance abuse, chronic pain, or psychiatric disorder. The acute mental status changes of delirium do not increase the risk of opioid dependence. Educational objective: Delirium is characterized by acute-onset, fluctuating consciousness, most frequently seen in elderly hospitalized patients. It usually resolves with treatment. However, cognitive dysfunction can be persistent, and a single episode of delirium increases the risk of further cognitive decline.

A 68-Year-Old Woman Is Admitted to the Hospital Due to a Femoral