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Delirium — ABIM Board MCQ

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ModerateGeneral Internal MedicineDeliriumABIM Board

An 82-year-old man develops an acute, fluctuating disturbance in attention with disorganized thinking on postoperative day 2. He has slept poorly, a bladder scan shows 650 mL of retained urine, and he has been receiving diphenhydramine at bedtime. He has no history suggesting alcohol or sedative withdrawal. He is calm and is not endangering himself, staff, or essential medical therapy. Which of the following is the most appropriate initial management?

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Correct answer: B — Correct reversible precipitants and provide multicomponent nonpharmacologic delirium care

This patient has postoperative delirium, indicated by acute, fluctuating inattention and disorganized thinking. Initial treatment is correction of reversible precipitants—here, discontinuing diphenhydramine and relieving urinary retention—plus multicomponent nonpharmacologic measures such as reorientation, sleep normalization, early mobilization, hydration, and provision of hearing or visual aids. Benzodiazepines generally worsen delirium and are reserved primarily for alcohol or sedative withdrawal. Routine restraints can increase agitation, immobility, and injury and should be avoided. Donepezil does not provide acute treatment for delirium. Oxybutynin has anticholinergic effects and may worsen both delirium and urinary retention. Because the patient poses no safety threat, sedating pharmacologic therapy is not indicated.

Reference: Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017;318(12):1161-1174. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/649062