Prompt

You are the psychiatry registrar on call. Medical team asks for review of a 74-year-old man on the respiratory ward: fluctuating confusion for 36 hours, pulls oxygen tubing at night, sleeps most of the day. They want 'haloperidol QID until clear' and ask whether he can consent to a CT-guided procedure this afternoon. Discuss diagnosis tools, differentials, causes, non-drug care, antipsychotic evidence, ICU differences if he deteriorates, and capacity.

Interpretation

Reveal interpretationShow

Reject scheduled high-dose haloperidol as a "clear the confusion" plan. Delirium is not treated as primary psychosis with QID antipsychotic until mental status normalises.^[2]^[3]

Diagnosis tools. State CAM: acute/fluctuating + inattention + (disorganised thinking OR altered consciousness). Offer 4AT as rapid screen. Note mixed/hypoactive pattern (day sleep, night agitation).^[1]^[6]

Differentials. Dementia baseline vs DSD; depression; primary psychosis (unlikely); withdrawal if alcohol/BZD; Wernicke; NCSE if indicated.^[6]

Management. Reverse causes; multicomponent non-drug care (HELP-style); antipsychotics only for severe distress/danger, low dose, short term; cite MIND-USA and AID-ICU humility.^[4]^[2]^[3]

ICU deterioration. CAM-ICU, light sedation, ABCDEF/PADIS — not automatic antipsychotic escalation.^[5]

Capacity. Decision-specific; likely impaired for complex procedural consent while delirious; treat, reassess, substitute decision-making under local law.^[6]

References6Show

[1]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
[2]Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness N Engl J Med, 2018.PMID 30346242
[3]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254
[4]Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
[5]Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
[6]Marcantonio ER Delirium in Hospitalized Older Adults N Engl J Med, 2017.PMID 29020579

Interpretation

Reveal interpretationShow

Reject scheduled high-dose haloperidol as a "clear the confusion" plan. Delirium is not treated as primary psychosis with QID antipsychotic until mental status normalises.^[2]^[3]

Differentials. Dementia baseline vs DSD; depression; primary psychosis (unlikely); withdrawal if alcohol/BZD; Wernicke; NCSE if indicated.^[6]

Management. Reverse causes; multicomponent non-drug care (HELP-style); antipsychotics only for severe distress/danger, low dose, short term; cite MIND-USA and AID-ICU humility.^[4]^[2]^[3]

ICU deterioration. CAM-ICU, light sedation, ABCDEF/PADIS — not automatic antipsychotic escalation.^[5]

Capacity. Decision-specific; likely impaired for complex procedural consent while delirious; treat, reassess, substitute decision-making under local law.^[6]

References6Show

[1]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
[2]Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness N Engl J Med, 2018.PMID 30346242
[3]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254
[4]Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
[5]Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
[6]Marcantonio ER Delirium in Hospitalized Older Adults N Engl J Med, 2017.PMID 29020579

Delirium — structured clinical viva

Interpretation

Delirium — structured clinical viva

Interpretation