Delirium in older adults — structured clinical viva

Working diagnosis: postoperative delirium in a vulnerable older adult with MCI (high DSD risk). Confirm with CAM/3D-CAM/4AT and collateral. Midazolam for non-withdrawal "settling" is the wrong reflex — treat causes and deliver multicomponent non-drug care first.[1][3][4]

Diagnosis. Delirium = acute fluctuating inattention and awareness with additional cognitive change due to physiological causes. CAM rule: acute onset + fluctuating course AND inattention, plus disorganised thinking OR altered LOC. Distinguish from progressive dementia and depression using tempo, attention, and arousal.[1][3]

Motor subtypes. Hyperactive, hypoactive, mixed. Hypoactive is most missed; mixed is common longitudinally; subtypes can change within an episode.[3][4]

Causes. Map predisposing (age, MCI, sensory loss, frailty) and precipitating (surgery, anaesthesia, pain, opioids, infection, constipation, retention, hypoxia, sleep disruption, ward environment). Reverse every modifiable factor.[3][4]

Non-drug first. HELP-style multicomponent package: orientation, family, sleep hygiene, mobilisation, sensory aids, hydration, avoid restraints/catheters when possible — proven prevention signal in older inpatients.[2][3]

Drugs. Avoid benzodiazepines unless alcohol/BZD withdrawal. Antipsychotics are not disease-modifying (MIND-USA, AID-ICU). If severe distress or danger after non-drug measures: start low (e.g. haloperidol 0.25–0.5 mg PO/IM), short course, ECG/EPS monitoring, daily review.[4][5][6]

Capacity and prognosis. Capacity is decision-specific and often impaired. Document and reassess. Delirium associates with death, institutionalisation, dementia (Witlox); longer delirium links to worse later cognition (BRAIN-ICU). Plan carer education and cognitive follow-up.[7][8][3]