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Delirium — MRCPsych Paper B MCQ

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ModerateLiaison PsychiatryDeliriumMRCPsych Paper B

A 70-year-old man on a medical ward has hyperactive delirium. The underlying causes are being investigated and treated, but he remains severely distressed and repeatedly attempts to climb over the bedrails, posing an immediate risk to himself. Verbal and non-verbal de-escalation techniques have been ineffective. He has no parkinsonism or dementia with Lewy bodies, his QTc interval is normal, and any electrolyte abnormalities have been corrected. According to NICE CG103, which medication should be considered for short-term treatment?

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Correct answer: A — Haloperidol

The answer is A, haloperidol. NICE CG103 recommends considering short-term haloperidol, usually for 1 week or less, when delirium causes distress or risk and verbal and non-verbal de-escalation is ineffective or inappropriate. It should be started at the lowest clinically appropriate dose and titrated cautiously. In older adults, contraindications must be excluded and cardiac and neurological adverse effects monitored. Diazepam is not routine treatment for delirium under CG103 and would require a separate indication, such as withdrawal. Quetiapine and chlorpromazine are not recommended by this NICE recommendation. Olanzapine is a plausible distractor because it appeared in older CG103 wording, but NICE removed it from recommendation 1.7.4 in March 2019. NICE also does not recommend automatically substituting lorazepam when haloperidol is contraindicated in Parkinson's disease or dementia with Lewy bodies.

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