Case 28 of 40
Check for harm when medication reduces agitation during delirium
Example case for staff education
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Page 1
Panel 1: Day 1
Pneumonia and poor intake accompany an acute cognitive change.
Anita: He was walking and talking normally two days ago.
Panel 2: Day 2
He believes he must escape and repeatedly puts himself at risk.
George: I need to get out before they come.
Panel 3: Day 2
Illness, pain, retention and other unmet needs are assessed.
Nurse Tom: Tell me what you need. We will stay with you.
Panel 4: Day 2
Explanation and familiar support give only brief relief.
Anita: You are in hospital. I am staying with you.
Panel 5: Day 2
Severe distress and immediate risk persist.
Ward doctor Amira: Check contraindications before considering short-term medication.
Panel 6: Day 2
The target symptoms and review time are recorded.
Nurse Tom: We will check benefit, alertness and adverse effects.
Panel 7: Day 3
He is quieter but drowsier.
Anita: This is not how he usually sits or moves.
Panel 8: Day 3
New movement difficulty and swallowing concerns prompt reassessment.
Nurse Tom: He is much stiffer, and he coughed with a drink.
Panel 9: Day 3
The team considers medication effects and new medical causes.
Ward doctor Amira: Pause and reassess. Quietness alone is not a good outcome.
Page 2
Panel 10: Day 3
Medication is reduced or stopped with close observation.
Pharmacist Samir: We should review the cause before adding another medicine.
Panel 11: Day 4
Eating and drinking support reflects the current swallowing assessment.
Speech and language therapist Eva: We will adjust the plan to what is safe today.
Panel 12: Day 4
Drowsiness lessens, but fear returns at times.
George: Will you stay until I know where I am?
Panel 13: Day 5
Staff continue practical support and reassurance.
Nurse Tom: First we will wash your hands. Then we can stop if you need.
Panel 14: Day 6
Movement improves after the medication change.
Physiotherapist Lin: You are less stiff, but still need help to turn.
Panel 15: Day 7
Inattention persists despite better movement and breathing.
Ward doctor Amira: His delirium is improving more slowly than the other problems.
Panel 16: Day 10
The temporary medication is no longer required.
Ward doctor Amira: We will explain what was given and why it was stopped.
Panel 17: Week 3
He needs fewer prompts but remains easily tired.
George: I manage better when we do one thing at a time.
Panel 18: Week 4
Physical, cognitive and emotional outcomes are discussed separately.
Anita: Being quieter was only one part of what happened.
Sources
- [S12] Yamaguchi, J., Hirayama, T., Sadahiro, R., Nakahara, R. and Matsuoka, H. (2023) ‘Delirium due to Trousseau syndrome treated with memantine and perospirone: A case report’, Psychiatry and Clinical Neurosciences Reports, 2(4), e159.
- [S31] Temple, M. (2003) ‘Use of atypical anti-psychotics in the management of post-traumatic confusional states in traumatic brain injury’, Journal of the Royal Army Medical Corps, 149(1), pp. 54–55.
- [S32] Stocker, L., Jellestad, L., Jenewein, J. and Boettger, S. (2015) ‘Challenges in the management of delirium: a case of augmentation with donepezil following inadequate response and adverse effects with risperidone’, Psychiatria Danubina, 27(1), pp. 64–66.
- [T01] MacLullich AMJ. Conceptualising distress in delirium. Usher teaching presentation, May 2026. Teaching slides.
- [G01] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
Commentary
George has severe distress and is at immediate risk of harm during delirium. Staff first assess illness, discomfort and communication needs. These measures do not sufficiently reduce the immediate danger. After an individual clinical assessment, the team prescribes a short course of medication for specific symptoms. They record the reason for treatment and review contraindications and possible adverse effects [G01].
The next morning, George is less agitated but more drowsy and stiff, with difficulty swallowing. Being easier to care for does not make these changes a successful outcome. The team reassesses him promptly for acute illness and medication effects. Medication is contributing, so staff reduce the relevant treatment and monitor him rather than automatically adding another medicine.
The cited reports describe movement problems caused by medicines and additional prescribing during delirium [S12, S31, S32]. They do not provide a sequence of medicines to copy. A treatment may improve one symptom and worsen another while delirium continues.
Assess agitation, fear, alertness, attention and movement separately. Improvement in one does not guarantee improvement in the others. In this case, staff stop the temporary medicine and its adverse effects improve. Thinking improves more slowly. Continue rehabilitation and explanation after the immediate danger has passed.