New Agitation at 02:00 on Day Three
Mrs D is 79 and was admitted three days ago with community-acquired pneumonia. At home she lived alone, managed her own affairs and was fully orientated. At 02:00 she is agitated, trying to climb over the bed rails, pulling at her urinary catheter and does not recognise her son. She is plucking at the bedclothes and her speech is rambling. Observations: temperature 37.9 °C, HR 96, BP 138/74, RR 20, SpO2 93% on room air, blood glucose 8.1 mmol/L. The night doctor has prescribed haloperidol 2 mg orally 'if agitated'. Her other medicines are IV ceftriaxone, regular oxybutynin, and codeine 60 mg four times a day as required, last given at 20:00.
1. What is the most likely explanation for her presentation, and how would you distinguish it from dementia or a primary psychiatric cause?
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Most likely: delirium - probably hypoactive/mixed delirium with hyperactive features, superimposed on pneumonia.
Features that fit delirium
- Acute onset (hours) and fluctuation over the day and night.
- Inattention - she cannot follow a thread, speech is rambling.
- Disorientation to a familiar person (her son).
- Perceptual/behavioural features - plucking, climbing out of bed.
- Disrupted sleep–wake cycle (worst at night).
- A clear precipitant: infection, temperature 37.9 °C, SpO2 93%, plus catheter, opioids and an anticholinergic.
Distinguishing it
- Dementia: insidious, progressive over months to years, no acute fluctuation, attention relatively preserved early; her son's account of baseline is the key evidence.
- Depression: psychomotor slowing, low mood, no perceptual disturbance, course over weeks.
- Psychosis/mania: no clouding of consciousness, no acute physical precipitant, previous psychiatric history.
Use a validated tool (4AT or CAM) and, crucially, take a collateral history - the score means little without knowing her baseline. Delirium is a medical emergency: it signals an underlying cause and carries high mortality and long-term cognitive risk, so it must never be written off as 'confusion'.
2. Before giving the haloperidol, what reversible causes would you screen for, drawing on her observations and her medicines?
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From her drug chart
- Codeine 60 mg four times a day: constipation/faecal impaction (a classic and frequently missed cause), urinary retention, sedation, and possible accumulation in an older adult.
- Oxybutynin: strongly anticholinergic - a recognised contributor to confusion, especially in combination and in a patient with infection.
- Ceftriaxone: check whether the infection is actually responding.
From her observations
- SpO2 93% - hypoxia. Check a blood gas/VBG; hypoxia alone can cause agitation.
- Temperature 37.9 °C - is the pneumonia worsening, or is there a new source, including catheter-associated UTI?
- Blood glucose 8.1 is acceptable, but check it has not fallen since.
- BP and HR are not alarming, but check for dehydration and review recent fluid balance and renal function.
Also screen for
- Pain (she may be unable to report it - assess at rest and on movement).
- Urinary retention - check the catheter is draining, consider a bladder scan.
- Bowel action - when did she last open her bowels?
- New electrolyte disturbance, infection markers, or a new neurological event.
- Alcohol or benzodiazepine withdrawal if relevant.
- Sensory impairment - is her hearing aid or glasses missing?
3. What will you do in the next 30 minutes, and what will you document?
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Immediate actions
- Safety without restraint: do not raise the bed rails as a restraint or tie her; move her to a visible area, use a low bed or crash mat, and arrange 1:1 supervision.
- Reorientate gently: say who you are, where she is and what is happening, repeatedly and calmly. Reduce noise, dim lights at night, keep day–night cues.
- Check the catheter for kinks, drainage and bladder distension; perform a bladder scan.
- Repeat observations including SpO2 and glucose, obtain a VBG, and send urine for dipstick and culture if not already done.
- Treat the causes: oxygen if hypoxic to target 94–98%, analgesia with paracetamol rather than more codeine, laxatives and bowel assessment.
- Ask the doctor to review her now - she needs a medical assessment for the precipitant, not just a sedative.
About the haloperidol 2 mg is a substantial dose for a 79-year-old. Antipsychotics are for severe distress or risk of harm only, at the lowest dose for the shortest time; they are hazardous in Parkinson's disease or Lewy body dementia and prolong QT. Query the dose and discuss alternatives first.
Document The 4AT score, the fluctuating course, collateral baseline from her son, every precipitant screened and the result, what you did and the response, the escalation, and the medical review.