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Delirium superimposed on dementia — SCE Neurology MCQ

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HardCognitive NeurologyDelirium superimposed on dementiaSCE Neurology

An 82-year-old woman with stable mild Alzheimer disease becomes inattentive and agitated 24 hours after oxybutynin is started for urgency. Alertness fluctuates during the interview and her 4AT is 7. She also has constipation and new suprapubic discomfort. Which immediate plan best reflects the diagnostic uncertainty?

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Correct answer: D — Withhold oxybutynin, begin delirium care and assess concurrent precipitants

The acute onset, fluctuation and impaired attention with a positive 4AT support delirium on a background of established dementia. NICE advises that when delirium and dementia overlap, delirium should be managed first. The new anticholinergic should be withheld, but medication timing must not end the search for other precipitants: constipation, urinary pathology, pain, infection, hypoxia and metabolic disturbance may coexist. Antipsychotic treatment is not the routine diagnostic response, while chronic dementia relabelling and EEG-first management would divert attention from the acute syndrome.

Reference: NICE CG103, Delirium — recommendations: https://www.nice.org.uk/guidance/cg103/chapter/recommendations