A 75-year-old diabetic, hypertensive smoker presents with cough, fever and altered sensorium; he is incoherent and abusive — differential diagnosis, trigger factors, evaluation and ward management One-line formulation: This is hyperactive delirium in a multi-morbid older adult, most probably precipitated by community-acquired pneumonia. The abusive, incoherent behaviour is a symptom of acute brain failure, not a psychiatric illness — the task is to find and treat the precipitant, not to sedate the patient.

sensorium; he is incoherent and abusive — differential diagnosis, trigger factors, evaluation and ward management One-line formulation: This is hyperactive delirium in a multi-morbid older adult, most probably precipitated by community-acquired pneumonia. The abusive, incoherent behaviour is a symptom of acute brain failure, not a psychiatric illness — the task is to find and treat the precipitant, not to sedate the patient.

18 High-Yield Points

A. Recognising the syndrome

B. Differential diagnosis of altered sensorium in this patient

C. Trigger factors in this specific patient

D. Evaluation

E. Ward management

Domain Action

Treat the precipitant Empirical antibiotics for CAP per severity and local antibiogram, started within 1 hour if sepsis is present; oxygen to target saturation (88–92% if COPD is suspected, otherwise 94–98%); chest physiotherapy; nebulised bronchodilators Fluids & glucose Correct dehydration and electrolytes; treat hyperglycaemia with basal-bolus insulin, avoiding sliding scale alone; target roughly 140–180 mg/dL; hypoglycaemia is more dangerous than modest hyperglycaemia in delirium Medication review Stop every deliriogenic drug; apply Beers / STOPP-START; avoid anticholinergics, sedative-hypnotics, pethidine and H2-blockers; regular paracetamol for pain to reduce opioid load Non-pharmacologic bundle Repeated reorientation; clock, calendar and familiar objects; spectacles and hearing aids restored; (the mainstay) well-lit room by day, dark and quiet at night; non-drug sleep protocol; early mobilisation three times daily; oral hydration and feeding assistance; remove tethers — catheter, IV line, telemetry — as early as possible Behaviour T-A-DA: Tolerate non-dangerous behaviour, Anticipate needs (toilet, thirst, pain, position), Don't Agitate. Give the hands something to do (folding cloths) instead of pulling lines. Avoid physical restraints — they worsen delirium Family Keep a relative at the bedside for reassurance, orientation, feeding and mobilising. Explain that fluctuation is expected and that apparent improvement by day does not mean recovery. In Indian wards the attendant culture is a major asset — use it deliberately Drugs (last resort) Only if the patient is severely agitated or distressed and dangerous to himself or others, and only after non-pharmacologic measures have failed. Haloperidol 0.25–0.5 mg orally or IM, lowest dose and shortest duration, with ECG monitoring for QTc; avoid in Parkinson's disease and Lewy body dementia (use quetiapine). Do not use benzodiazepines unless this is alcohol or benzodiazepine withdrawal Nicotine Consider nicotine replacement therapy — withdrawal is a genuine, easily missed precipitant in an admitted smoker Complication prevention Aspiration precautions and swallow assessment; VTE prophylaxis; pressure-injury prevention; falls precautions with low bed and floor mats rather than restraints; bowel and bladder care Monitoring & discharge Daily CAM/4AT screening; document trajectory; medication reconciliation at discharge; cognitive reassessment at 4–8 weeks because delirium may unmask or accelerate dementia Latest Updates (2023–Present)

APA 2025 guideline explicitly links delirium management to medication history and deprescribing as a first-line intervention, and confines restraints to situations of imminent harm — directly relevant to the "abusive" patient in this vignette.

NICE CG103 (2023) names benzodiazepines, opioids and anticholinergics as the commonest pharmacological precipitants and recommends the 4AT for rapid ward assessment.

AGS Beers 2023 / Alternatives List 2025 emphasise cumulative anticholinergic burden and offer non-drug alternatives for insomnia and agitation — useful when the ward wants "something for sleep". Non-pharmacologic prevention remains the only intervention with consistent benefit; a 2025 meta-analysis of family involvement in critically ill patients supports formally recruiting relatives into the delirium care plan. Antipsychotic caution reinforced: the AID-ICU trial and the PADIS 2025 focused update together show haloperidol has minimal or no effect on length of stay or duration of delirium — it is a behavioural rescue, not a treatment. Indian relevance: in a febrile elderly patient with cough and confusion, CBNAAT for tuberculosis should be sent early; TB remains a leading cause of subacute confusion with fever in Indian older adults and is easily missed when pneumonia is assumed.

Current Practice Update

Issue Textbook position Current practice

Sedating the abusive patient Antipsychotic in lowest dose only if dangerous Same, but with an explicit "imminent harm" threshold, mandatory baseline ECG and a documented stop date Glycaemic target Individualised control Ward target roughly 140–180 mg/dL; avoid sliding-scale-only insulin; hypoglycaemia treated as a delirium precipitant Routine CT head Not required in all Unchanged and reinforced — targeted imaging only Family role Encouraged A formal, evidence-supported component of the care bundle Tuberculosis Not emphasised In India, CBNAAT early in any elderly patient with fever, cough and confusion Exam One-Liners — Q2 Abusive + incoherent + fever = hyperactive delirium, not psychosis.

Check glucose before anything else; thiamine before glucose if alcohol is possible. Commonest precipitants in this patient: infection, hypoxia, drugs, dehydration, retention. CURB-65 for pneumonia severity; qSOFA/NEWS2 for sepsis.

Restraints worsen delirium — low bed and a bedside relative are safer.

Haloperidol 0.25–0.5 mg is a rescue, not a treatment; check QTc.

Don't forget nicotine withdrawal in an admitted smoker.

Reassess cognition 4–8 weeks after discharge.