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Delirium Superimposed on Dementia Assessment — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryDelirium Superimposed on Dementia AssessmentMRCPsych Paper B

A 75-year-old man with moderate Alzheimer's disease treated with galantamine is admitted to an older adult psychiatric ward. Over 3 days, he has become intermittently drowsy, more inattentive and less able to manage his personal care. His family reports that this is a marked change from his usual baseline. What is the most appropriate next step?

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Correct answer: D — Perform a 4AT and assess for underlying acute causes

The correct answer is D. A change developing over 3 days, with fluctuating drowsiness, inattention and functional deterioration from an established baseline, strongly suggests delirium superimposed on dementia rather than Alzheimer's progression. NICE recommends assessment with the 4AT when indicators of delirium are present, followed by identification and management of possible underlying causes, which may be multiple. Assessment should include physical examination, observations, medication review and investigation for causes such as infection, pain, constipation, dehydration, hypoxia or metabolic disturbance. Alzheimer's disease generally progresses more gradually, so routine review is inappropriate. Increasing galantamine or immediately switching to memantine would not address the acute syndrome. Haloperidol neither establishes nor treats the underlying cause and is not the initial response to uncomplicated drowsiness or inattention.

Reference: National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103), recommendations 1.3.1, 1.6.1, 1.6.3 and 1.7.1; updated 2023. https://www.nice.org.uk/guidance/cg103/resources/delirium-prevention-diagnosis-and-management-in-hospital-and-longterm-care-pdf-35109327290821