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Clinical Atlas Prestige · Evidence-first

Psych VivasConsultation-liaison psychiatry

Psych Vivas · Consultation-liaison psychiatry

Delirium — structured clinical viva

Fellowship viva on CAM/4AT, hypoactive delirium, multicomponent care, MIND-USA/AID-ICU limits of antipsychotics, and capacity.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
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 interpretation

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]

Escalating questions (model points)

Expect candidates to define delirium (attention/awareness, short onset, fluctuation, extra cognitive change, physiological cause); state the CAM rule (1+2 and (3 or 4)); explain why hypoactive disease is dangerous (missed; worse outcomes); name five precipitants; state that MIND-USA found no benefit of haloperidol/ziprasidone versus placebo for the primary delirium outcome; justify antipsychotics only for severe distress/danger after non-drug care with cautious low doses; and treat capacity for a same-day invasive procedure as decision-specific and often deferred until optimisation.[1][2][3][6]

Key points

CAM one-liner

Features 1 and 2 plus 3 or 4.

Drugs last

Antipsychotics do not reverse delirium pathophysiology.

Capacity

Decision-specific; delirium often impairs it.
[1] [2] [6]

References

  1. [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. [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. [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. [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. [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. [6]Marcantonio ER Delirium in Hospitalized Older Adults N Engl J Med, 2017.PMID 29020579