An 82-year-old woman is agitated after a total knee replacement 1d ago. The nurse in the bay has asked for help from the on call team as the patient is trying to leave her bed unattended and is shouting out non-specifically. The nurse reports that the patient settles if asked to remain in bed. The patient is often sleeping during the day but awake and eating throughout the night. She pushed over one of the physiotherapists earlier in the morning but there have been no further instances of aggression. The patient has no significant past medical or social history.

What is the first step in the management of this patient?

Options:
explanation: This is a likely case of delirium precipitated by recent orthopaedic surgery. Despite the previous injury to staff earlier in the day, it would be most appropriate for you to try and de-escalate the situation using verbal reassurance and orientation before you consider pharmacological management. This is since it recognised that some of the drugs to treat delirium, for example, benzodiazepines, can worsen it and nonpharmacological measures if used appropriately can be quite effective. Interventions, such as reducing noise by nursing in a side room if safe, using familiar nurses, orientating with a clock and calendar, using photographs and inviting in the family, can often have a positive effect on these patients in their transient delirium.
name: Verbal reassurance and orientation
label: a
answer: yes
explanation: Haloperidol is a recognised treatment for delirium. However, nonpharmacological interventions should be trialled in the first instance in this case. On occasion, pharmacological interventions may be tried as first-line treatment if necessary and proportionate, that is, if the patient poses an immediate risk to themselves or others. There is no evidence in this case that the patient is currently posing an immediate risk to herself or anyone around her. Haloperidol is a butyrophenone antipsychotic and antagonises the dopamine (D2) receptor. Therefore, it is avoided in patients with Parkinson's disease or Lewy body dementia, due to the risk of precipitating rigidity. The QTc should be checked before providing haloperidol wherever possible due to the risk of causing prolongation. Haloperidol may also worsen delirium in some patients.
name: Haloperidol
label: b
answer: no
explanation: Lorazepam is a benzodiazepine given intravenously or orally. It can be used in the treatment of delirium alongside other types of benzodiazepines. However, it should not be used before nonpharmacological interventions in this case. Side effects include drowsiness and worsening of delirium. It is a suitable alternative to haloperidol in patients with Parkinson's disease or Lewy body dementia.
name: Lorazepam
label: c
answer: no
explanation: Olanzapine is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological treatments first. In the elderly, olanzapine has also been associated with increased episodes of venous thromboembolism and may also worsen delirium. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity.
name: Olanzapine
label: d
answer: no
explanation: Risperidone is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological interventions first. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity. It can also cause worsening of delirium in some patients.
name: Risperidone
label: e
answer: no

Correct answer: a


Learning point: Delirium in elderly patients post-surgery can often be managed effectively with verbal reassurance and orientation before considering pharmacological interventions.