Delirium diagnosis, work-up, and management (MEQ)

(i) Diagnosis and CAM. Working diagnosis: delirium superimposed on dementia (DSD), currently hypoactive (quiet, delayed responses) after overnight hyperactive features — likely mixed motor course over 24 hours. CAM reasoning: acute change from baseline with fluctuation (overnight agitation to morning quiet); inattention (fails months backward); plus altered level of consciousness (drowsy/slow). Visual or behavioural disturbance overnight supports the syndrome. This is not primary psychosis and is not "just dementia progression."[1][2]

(ii) Precipitants, work-up, non-drug plan. Precipitants: infection (pneumonia), anticholinergic (oxybutynin), benzodiazepine (temazepam), opioid (oxycodone), hospital environment/sleep disruption, possible hypoxia, dehydration, constipation/retention. Immediate plan: ABCDE and oxygen/glucose; cultures/CXR as indicated; bloods (FBC, U&E, Ca/Mg, CRP, LFTs); bladder scan; medication review — stop or minimise oxybutynin/temazepam/oxycodone where possible; sensory aids; reorientation; family presence; day-night cues; early mobilisation; hydration; avoid restraint. Multicomponent non-pharmacological care is first-line prevention and treatment infrastructure.[2][5][6]

(iii) Antipsychotics. Do not treat the syndrome itself with antipsychotics. Evidence: MIND-USA — no benefit of haloperidol/ziprasidone vs placebo for ICU days without delirium/coma; Agar — risperidone/haloperidol worse than placebo for palliative delirium symptoms; systematic reviews do not support routine use. Reserve low-dose short-term agent only if severe distress or imminent danger persists after non-drug measures and medical optimisation — e.g. haloperidol 0.25–0.5 mg PO/IM with ECG/QTc and EPS monitoring, or quetiapine 12.5–25 mg, or olanzapine 2.5–5 mg, daily review, stop early. Not "something strong for psychosis."[3][4][6]

(iv) Capacity and disposition. Capacity is decision-specific. A cheerful "yes" to going home does not prove understanding, retention, or weighing of pneumonia treatment risks. Document impairment, treat delirium, reassess in a lucid window if possible, use least-restrictive local legal frameworks and substitute decision-makers as required. Do not process unsafe self-discharge while CAM-positive without a safety plan.[2][6]