Alasdair MacLullich

@amaclullich.bsky.social

Professor of Geriatric Medicine, University of Edinburgh. Delirium, 4AT and hip fracture. Chair, Scottish Hip Fracture Audit. Practical guidance for clinicians and families. Free chapter: https://www.the4at.com/family-delirium-guide
alasdairmaclullich.com

@amaclullich.bsky.social Oct 11, 2026, 12:35 PM

In a hip fracture trial, 1,600 people had spinal anaesthetic (a numbing injection in the back) or general anaesthetic (being put to sleep).

Results were similar. At 60 days, 18.5% (spinal) and 18.0% (general) had died or couldn't walk about 3 metres.

pubmed.ncbi.nlm.nih.gov/346...

@amaclullich.bsky.social Oct 11, 2026, 9:10 AM

At one Oxford hospital, delirium (sudden confusion) affected 23 in 100 acute medical admissions, aged 16 to 102.

It rose with age: 2 in 100 under 50, 20 in 100 at 65 to 74, 46 in 100 at 90 and over.

Limits: one hospital, and the study only observed.

doi.org/10.1016/j.la...

@amaclullich.bsky.social Oct 11, 2026, 5:45 AM

Myth: antipsychotic drugs are the treatment for delirium. Fact: SIGN cites a Cochrane review: in acute care they did not reduce severity, resolve symptoms or change the number of deaths. NICE allows brief haloperidol only for distress or risk when calming fails. The cause must still be treated.

@amaclullich.bsky.social Oct 11, 2026, 2:20 AM

A trial in 17 countries put 2,970 hip fracture patients by chance into fast surgery (typically 6 hours) or usual care (typically 24 hours).

By 90 days, 9% of the fast group and 10% of the usual care group had died. That could be chance.

pubmed.ncbi.nlm.nih.gov/320...

@amaclullich.bsky.social Oct 10, 2026, 10:55 PM

The Scottish Hip Fracture Audit counts all hip fracture patients treated in Scottish hospitals. Its 2025 report found 80% were admitted from their own home, and fewer than 70% had returned home within 30 days. I chair the audit. A hip fracture often changes where a person can live.

@amaclullich.bsky.social Oct 10, 2026, 7:30 PM

NICE says to try talking and calming a distressed person first. Short-term haloperidol is for when that fails or is not suitable.

A 2019 review found haloperidol and newer antipsychotics did not shorten delirium or reduce deaths compared with a dummy pill.

pubmed.ncbi.nlm.nih.gov/314...

Left Exit 12 meme. A motorway sign marked "LEFT EXIT 12" offers "MORE HALOPERIDOL" straight on and "FIND THE CAUSE" at the exit. Below, a blue car labelled "ACUTE MEDICINE AT 3AM" slews sideways across the road toward the exit, tyres smoking.

@amaclullich.bsky.social Oct 10, 2026, 4:00 PM

NHS advice, age 65 and over: Be active daily, even lightly. Do strength, balance and flexibility activities on 2 or more days a week. Aim for 150 minutes of moderate activity a week, or 75 of vigorous if already active. Sit less. Inactive for a while, or have a medical condition? See a GP first.

@amaclullich.bsky.social Oct 10, 2026, 12:35 PM

4 is the number to know on the 4AT, scored 0 to 12. 4 or more suggests delirium and should lead to a clinical assessment. 1 to 3 suggests memory and thinking problems but not delirium. A score of 0 does not completely rule out either. If staff or family report a sudden change, assess anyway.

@amaclullich.bsky.social Oct 10, 2026, 10:09 AM

If you deliberately ignore #delirium you will never be a good doctor.

@amaclullich.bsky.social Oct 10, 2026, 9:10 AM

SNAP-3: 7,128 UK surgery patients aged 60 and over.

Allowing for age, frailty, illnesses and surgery type, delirium added 5.2 days in hospital, and the odds of death within a year doubled.

It only observed patients; some influences were not measured.

doi.org/10.1016/j.bj...

@amaclullich.bsky.social Oct 10, 2026, 5:45 AM

In 15 pooled studies of 47,471 adults, death risk in people 60 and over fell as daily steps rose, up to about 6,000 to 8,000.

The authors said the 10,000 steps target had little evidence behind it.

These observational studies show a link only.

doi.org/10.1016/S2468-2667(...

@amaclullich.bsky.social Oct 10, 2026, 2:20 AM

When staff find delirium (sudden confusion), NICE says they should find and manage possible causes. They should also speak clearly, help the person know where they are, and consider involving family. SIGN adds: check for recovery, and consider specialist referral if the person is not recovering.

@amaclullich.bsky.social Oct 9, 2026, 10:55 PM

SIGN lists these triggers of delirium: infection, dehydration, severe constipation, urinary retention (the bladder not emptying) and pain. Others are critical illness, surgery (especially heart and hip operations), and side effects of new medicines or stopping medicines.

@amaclullich.bsky.social Oct 9, 2026, 7:30 PM

In a Singapore study of 114 people aged 55 to 86, scores on two common memory tests were 2.8% and 3.5% lower for every 10 decibels (a unit of sound level) of hearing loss.

On a ward, put hearing aids in before anyone is assessed.

A case example.

pubmed.ncbi.nlm.nih.gov/295...

Two-panel meme of a young man taking off and putting on glasses. Top: Hearing aid in the locker: 'Confused, poor historian, unable to give an account'. Bottom: Hearing aid in his ears: 'Orientated, clear account, wants to go home Thursday'. Below: Same man. Same morning. One battery.

@amaclullich.bsky.social Oct 9, 2026, 5:22 PM

Delirium is sudden confusion, usually caused by illness, surgery or medicines. It affects about 1 in 4 older people in hospital, and most cases are missed.

The 4AT is a bedside test for delirium. It takes less than 2 minutes and is free to use.

www.the4AT.com

@amaclullich.bsky.social Oct 9, 2026, 4:00 PM

From a worked example on the 4AT website: a man of 70 is treated for a chest infection. His 4AT on admission scores 0. Three days in, he is restless and confused overnight. A repeat 4AT scores 6 out of 12; 4 or more suggests delirium. A normal score on admission does not rule out delirium later.

@amaclullich.bsky.social Oct 9, 2026, 12:35 PM

A US trial put 1,635 inactive people aged 70 to 89 with some difficulty walking, by chance, into exercise or health education.

After an average of 2.6 years, 30.1% of the exercise group could no longer walk 400 metres, against 35.5% of the education group.

pubmed.ncbi.nlm.nih.gov/248...

@amaclullich.bsky.social Oct 9, 2026, 9:10 AM

In a French trial, intensive care patients on breathing machines got melatonin 0.3 mg nightly or a dummy.

Delirium: 54 in 100 on melatonin, 55 in 100 on the dummy.

Half of 24 patients checked reached the target blood level. Lower doses were not tested.

doi.org/10.1007/s001...

@amaclullich.bsky.social Oct 9, 2026, 5:45 AM

About 9 in 10 Scottish hip fracture patients had a 4AT delirium test.

49 in 100 scoring 4 or more (suggesting delirium) died in a year, against 18 in 100 scoring 0.

High scorers were older and sicker, probably explaining part of the gap.

doi.org/10.1302/0301-620X.1...

@amaclullich.bsky.social Oct 9, 2026, 2:20 AM

In 9 studies of 34,485 people aged 65 and over, each 0.1 metres per second faster walking (average about 2 miles an hour) went with a 12% lower risk of dying during follow-up.

It shows a link; it wasn't designed to show if walking faster adds years.

pubmed.ncbi.nlm.nih.gov/212...

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