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Delirium — MRCPsych Paper B MCQ

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ModerateLiaison PsychiatryDeliriumMRCPsych Paper B

A 55-year-old woman is admitted following surgical repair of a hip fracture. On the second postoperative day, she develops an acute, fluctuating disturbance of attention and awareness. She is distressed, agitated and repeatedly pulls at her intravenous line. No de-escalation measures have yet been attempted. According to NICE CG103, what is the most appropriate initial approach?

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Correct answer: C — Treat likely precipitants and use reorientation and de-escalation

The correct answer is C. Her acute, fluctuating disturbance of attention and awareness after surgery is characteristic of delirium. NICE recommends first identifying and managing contributing causes, such as pain, infection, hypoxia, dehydration, constipation or medication effects. Communication, reassurance, reorientation and an appropriate care environment should be provided. If the patient is distressed or poses a risk, verbal and non-verbal de-escalation should be attempted first. Short-term, cautiously titrated haloperidol may be considered only when de-escalation is ineffective or inappropriate. Lorazepam and midazolam are not NICE first-line treatments for agitation in non-withdrawal delirium. Physical restraint is not routine initial management and may increase distress and injury risk.

Reference: National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103), recommendations 1.7.1–1.7.4. Updated 2023. https://www.nice.org.uk/guidance/cg103/chapter/Recommendations