In the first days after major cancer surgery, some patients seem like a completely different person. They try to sit up despite instructions not to move, insist that someone is standing in the room, or cannot say what day it is or why they are in hospital. Symptoms often worsen in the evening and settle by morning. Clinicians call this delirium: an acute disturbance of brain function, not a change in personality, a new psychiatric illness, or deliberate stubbornness.
Two features define delirium. Attention and awareness become clouded over hours rather than months, and the picture fluctuates within a single day. A patient may understand an explanation and then react five minutes later as if hearing it for the first time. Doctors describe a hyperactive form (restless, agitated, pulling at tubes), a hypoactive form (withdrawn, drowsy, easily mistaken for simple fatigue and therefore often missed), and a mixed form that alternates between the two.
The causes usually stack rather than stand alone. Background vulnerability such as older age, pre-existing memory decline, or poor hearing and vision combines with triggers: long operations and anaesthesia, pain, blood loss and transfusion, infection and fever, low oxygen, electrolyte or glucose abnormalities, dehydration, constipation and urinary retention, certain medicines (sedatives, anticholinergic drugs, steroids, opioids), abrupt withdrawal from alcohol or nicotine, and the loss of any day-night rhythm in a brightly lit ward. That is why the first response of a good team is not sedation but a search for reversible causes, alongside checking whether anything suggests a stroke rather than delirium.
Families are often shocked by physical restraints. After free flap reconstruction, oral or tongue surgery, or when a tracheostomy tube, drains, or a central line are in place, an unaware patient who moves forcefully or pulls at a line can jeopardise the surgical site and the blood supply of transplanted tissue. Restraints are meant to be a minimum measure, used only as long as needed and reviewed frequently. When a familiar person is present and the patient settles, restraints can sometimes be reduced, so it is worth discussing with the team when and how far they will be used.
Non-drug measures come first. Open the curtains during the day and reduce light and noise at night to restore the sleep-wake rhythm; return glasses and hearing aids; keep a clock and calendar in view and calmly repeat where the patient is, what time it is, and what operation was done; bring familiar objects; treat pain, constipation, and urinary retention rather than tolerating them; and mobilise as early as the surgical team allows. If the patient cannot speak, a writing pad, letter board, or yes/no cards restore a channel of communication and can markedly reduce fear.
Do not argue with hallucinations or false beliefs. Insisting that nothing is there leaves the patient feeling disbelieved and more agitated. Acknowledge the emotion, state simply and briefly that they are safe and cared for, and gently redirect. When behaviour becomes dangerous, medication may be used at the team's discretion, but the goal is safety while the underlying causes are corrected, not deep sedation.
Most episodes improve over days to weeks, with ups and downs along the way; recovery can be slower and less complete in older patients or those with prior cognitive decline. Patients often remember little or nothing of the period afterwards. For caregivers, the swing between anger and guilt during those nights is an extremely common reaction, not a personal failing. Arranging shifts among family members, and asking the nursing staff in advance what to watch for overnight and what caregiving support is available, protects the patient as much as the family; an exhausted caregiver misses warning signs.
This article provides general information and does not replace medical care. Decisions about a patient's condition, the use of restraints, and any change in medication should be made together with the treating team.