Two days after surgery your 72 year old patient who is hard of hearing has new onset of agitation and confusion. The severity fluctuates throughout the day. Their medications include hydromorphone (Dilaudid), amlodipine (Norvasac), Alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect?

• A. Dementia
• B. Depression
• C. Medication side effects
• D. Delirium

Answer: (D)

Delirium is a sudden, fluctuating disturbance of consciousness and cognition that commonly occurs in older adults after surgery. It presents with an acute onset of confusion, agitation, or disorganized thinking, and the level of impairment often varies over the course of a day. In this scenario, two days after a procedure, a 72-year-old who is hard of hearing develops new agitation and confusion with symptoms that wax and wane. That pattern—acute change in mental status with fluctuation—fits delirium much more than a chronic process.

Dementia would typically show a gradual, steady decline over weeks to months, not a new abrupt change that fluctuates daily. Depression can cause cognitive symptoms, but it rarely produces this abrupt, fluctuating level of consciousness and acute confusion, especially in the immediate postoperative period. Medication effects can contribute to delirium risk—opioids like hydromorphone and benzodiazepines like alprazolam are particularly deliriogenic in older adults—so this presentation is consistent with delirium potentially precipitated by perioperative medications and other reversible factors such as pain, infection, dehydration, or electrolyte disturbances.

In short, the most likely condition is delirium, a treatable, acute neurocognitive syndrome in this context. Management focuses on identifying and treating underlying causes, minimizing deliriogenic meds, ensuring safety, addressing sensory deficits, promoting sleep, and using nonpharmacologic strategies; antipsychotics may be used short-term for severe agitation if needed.