My father is experiencing hospital delirium after ankle surgery. Please help.

Question

Hi doctor,

I am concerned about drug interaction with my father. He is experiencing hospital delirium after surgery. My concern is he has been taking Cymbalta, Gabapentin, and Tramadol, as well as numerous other medications. I have read about serotonin syndrome as well as other interactions. He has many of the symptoms, including hallucinations, confusion, etc. He is on so many medications. They stopped the Cymbalta about ten days ago when they put him on Seroquel. I am also concerned he had been taking Tramadol along with Gabapentin 300 mg and Cymbalta for over a year before his ankle surgery three weeks ago. Before ankle surgery, his baseline was slight dementia but very manageable. At this time, he has hallucinations, at times severe confusion, etc. He also takes medications for slight dementia, including Aricept. His doctor said to wean him off of the Gabapentin and use the Tramadol only when needed. But could there have been interactions prior with the Cymbalta and other medications mentioned? His dosage of Aricept was 10 mg until going into the hospital for surgery about three weeks ago, and they reduced it to 5 mg. He was released from the hospital five days ago, and there has been little improvement in the hallucinations and confusion. I need to stress the confusion he is having now is dramatically worse than before surgery. He did have hallucinations before surgery. He started to slur his words after surgery. I have attached the medication details for your reference. Please guide me.

Answer 1

Hi,

Welcome to icliniq.com.

I read your query and saw the attachments (attachments removed to protect the patient's identity). First of all, I like to inform you that serotonin syndrome occurs with the addition of new medication or increasing the dose of a serotonergic medicine. Since he was fine on all those medications before his ankle surgery, I do not see the possibility of serotonin syndrome while reducing the dose of medication. Now regarding hospital delirium, I feel we need to understand that it is caused by multiple factors rather than one. Scores of medicine are a definite contributor, and they should be addressed as far as possible. I am glad to see that your doctor proactively decided to decrease the dose of Gabapentin and discontinued Duloxetine as both medications are psychotropics and can contribute toward delirium. After these two medications, none of the prescribed medications have psychotropic properties other than Finasteride, which can be replaced with a suitable alternative.

In my opinion, the possible causes for your father's condition are as follows:

1) Old age, but this can not be changed.

2) Hospitalization can not be changed, but keeping the patient in a well-lighted area, avoiding overstimulation and under-stimulation, and repeated attempts to orient him around surroundings can help to a large extent.

3) Electrolyte imbalance needs to be checked and should be corrected as per guidelines. Please remember that even slight derangement can be the precipitating factor for delirium.

4) Pain, I think this needs to be aggressively treated. I understand that Tramadol is part of the prescription, but it may not be adequate.

5) Bowel or bladder disturbance, constipation, and urinary tract infections are frequent causes and should be explored.

6) Underlying dementia.

Having said this, I must assure you that we can increase the dose of Donepezil for better control of dementia as well as Quetiapine among the current medications. As per my own experience with the elderly use of Quetiapine could be quite beneficial for the treatment of delirium and hallucination. With consultation with your doctor, the dose can be increased to 100 mg per day in divided dosages.

I hope this helps you.

My father is experiencing hospital delirium after ankle surgery. Please help.

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