Case 30 of 40
Reassess new drowsiness in a person with Parkinson’s disease and delirium
Example case for staff education
Select an illustration to enlarge it.
Read the case transcript
Page 1
Panel 1: Day 1
Pneumonia causes new confusion in a man with Parkinson disease.
Kelly: His thinking is usually much clearer than this.
Panel 2: Day 1
Delirium is diagnosed and treatment begins.
Ward doctor Amira: We need his usual abilities and exact medication times.
Panel 3: Day 2
Vomiting and transfer have disrupted regular doses.
Kelly: Some tablets did not stay down before he came in.
Panel 4: Day 2
The team seeks advice on delivering time-critical treatment.
Nurse Tom: He cannot reliably take the tablets in their usual form.
Panel 5: Day 2
An appropriate administration plan is arranged promptly.
Neurologist Mira: Do not leave the missed doses unresolved.
Panel 6: Day 3
Movement improves, while attention still fluctuates.
Physiotherapist Lin: We will give you time to begin each movement.
Panel 7: Day 4
Distress is managed with support and assessment of needs.
Nurse Tom: I will tell you what happens before we begin.
Panel 8: Day 5
Breathing improves and clearer periods appear.
Kelly: He managed more of our conversation today.
Panel 9: Day 6
A marked new change interrupts the improvement.
Nurse Tom: He is much less responsive than yesterday.
Page 2
Panel 10: Day 6
Immediate assessment comes before an explanation based on delirium.
Ward doctor Amira: Check his observations and examine him now.
Panel 11: Day 6
Urinary retention is found and treated.
Nurse Tom: We will check how he responds after the bladder is relieved.
Panel 12: Day 6
A new respiratory infection is investigated and treated.
Ward doctor Amira: There is more than one problem contributing today.
Panel 13: Day 7
The swallowing plan is revised after the deterioration.
Speech and language therapist Eva: His support needs have changed since the last assessment.
Panel 14: Day 9
The new illness improves, but delirium continues.
Douglas: Have you been here all day?
Panel 15: Day 12
Mobility returns slowly with regular treatment and assistance.
Physiotherapist Lin: Let us rest before the next few steps.
Panel 16: Week 3
Current care needs exceed his pre-admission needs.
Kelly: He cannot manage the evenings without someone there.
Panel 17: Week 4
The handover includes medication timing and continuing delirium.
Nurse Tom: Report any new change rather than assuming it is expected.
Panel 18: Week 6
He remains more dependent, with only partial cognitive improvement.
Ward doctor Amira: We will reassess both his recovery and the support he needs.
Sources
- [G01] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
- [P43] Dharmarajan K, Swami S, Gou RY, Jones RN, Inouye SK. Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality. Journal of the American Geriatrics Society. 2017;65:1026–1033.
- [T02] MacLullich AMJ. Persistent delirium. CHG Singapore teaching presentation, 2025. Teaching slides.
- [G07] National Institute for Health and Care Excellence. Parkinson’s disease in adults. NG71.
Commentary
Douglas has Parkinson’s disease and delirium, but each new change still needs assessment. Missed or disrupted doses of his regular medicines contribute to worsening movement and swallowing early in the admission. Check both the prescription and whether each dose was given at the intended time. If he has difficulty taking oral medicines, seek prompt specialist advice. Do not omit doses or improvise substitutes without appropriate advice [G07].
After some improvement, Douglas becomes more drowsy. Staff compare his condition with the previous day and assess him again. They find urinary retention and a new respiratory infection. Choose investigations according to the history and examination rather than repeating the same tests for every deterioration [G01].
Parkinson’s disease also affects medication choices. Antipsychotics can be particularly harmful, so a general prescription for agitation should not be used automatically. Staff explain care, assess Douglas’s needs and seek specialist advice. Difficulty moving him is not by itself a reason to prescribe a drug.
Douglas only partly recovers and needs more help than before admission. Evidence about hospital complications supports continuing assessment of swallowing, movement and devices such as catheters during delirium [P43]. Describe new changes precisely: what he could do yesterday, what he is unable to do now and any accompanying signs. Continue assessment even when delirium has already been diagnosed.