The Man Who Cannot Remember the Accident

This is delirium, a medical emergency, not a primary psychiatric agitation. The framing matters because the question 'does he need a psych consult for agitation' invites a symptomatic fix (sedation) instead of a search for the cause.

Features supporting delirium:

• Acute onset over 1–2 days.
• Fluctuating course - worse in the evening, better in the morning.
• Impaired attention and disorientation (oriented to person only).
• Perceptual disturbance ('back on the roof,' suggesting misidentification or hallucination).

Why the framing is wrong:

• Delirium is a syndrome with an underlying cause; the psychiatrist's role is to help identify and treat the cause and to advise on non-pharmacological management, not merely to sedate.
• Sedation can mask deterioration and increase morbidity, falls, and mortality.
• The ward team should be looking for causes: pain, constipation, urinary retention, infection, hypoxia, electrolyte disturbance, and medication effects.

So the correct framing is: 'This is delirium - help me find the cause and manage it safely,' not 'this is agitation - please sedate it.'

Likely contributors and actions:

1. Anticholinergic bladder antispasmodic - a classic delirium trigger, especially in an older or medically stressed patient. Stop or substitute it and review the indication.
2. Opioid (oxycodone) - can cause sedation, confusion, and constipation/urinary retention. Review dose, ensure adequate analgesia without over-sedation, and treat constipation.
3. Pain - undertreated pain is a common and overlooked cause of agitation. Assess and treat pain appropriately.
4. Infection - postoperative or catheter-associated urinary infection, pneumonia. Check temperature, urinalysis, chest exam, and inflammatory markers.
5. Metabolic and hypoxic causes - electrolytes, glucose, renal function, oxygen saturation. Order and correct.
6. Retention and constipation - bladder scan and bowel chart.
7. Sleep deprivation and unfamiliar environment - reorientation, daylight exposure, quiet nights, family presence.
8. Alcohol withdrawal - less likely given no history, but ask about alcohol use and consider it.

The principle: treat the cause, not the symptom. Non-pharmacological measures (reorientation, sleep hygiene, glasses/hearing aids, family involvement, minimizing tethers) are first-line.

Pharmacological management is reserved for severe agitation that threatens the patient's safety or the safety of staff, or that prevents essential medical care, and only after or alongside treating the cause.

If used:

• Choose the lowest effective dose of an antipsychotic (e.g., low-dose haloperidol or an atypical such as quetiapine), taking into account QTc, cardiac status, and interactions.
• Avoid benzodiazepines as first-line in delirium unless the cause is alcohol/benzodiazepine withdrawal or the patient is in a crisis; they can worsen confusion and falls.
• Avoid anticholinergic drugs and avoid physical restraint where possible.
• Monitor for sedation, QTc, extrapyramidal effects, and response; reassess frequently and stop as soon as possible.

Also:

• Document the target symptom and the rationale.
• Continue non-pharmacological measures - they are not optional add-ons.
• Re-examine the diagnosis if agitation persists or worsens; a deteriorating delirium may signal a new cause (sepsis, hypoxia, stroke).

The message to the ward: 'I will help you use medication safely if it is truly needed, but the priority is finding and fixing the cause.'