Case 31 of 40
Assess continuing delirium even when blood tests improve and depression is present
Example case for staff education
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Page 1
Panel 1: Before illness
Ruth has had depression but normally manages independently.
Ben: Even when low, she could follow a conversation.
Panel 2: Day 1
Poor intake and an electrolyte disturbance accompany acute confusion.
Ward doctor Amira: This is a marked change over a few days.
Panel 3: Day 2
Treatment begins; inattention remains apparent.
Ruth: What was I supposed to be doing?
Panel 4: Day 5
The initial physiological disturbance has corrected.
Ward doctor Amira: Her blood tests are better, but we must assess her thinking directly.
Panel 5: Day 5
Low mood and withdrawal raise another concern.
Ruth: I feel useless here.
Panel 6: Day 5
Mood and acute cognitive symptoms are assessed together.
Liaison psychiatrist Clare: Her attention still fluctuates. We need to retain delirium in the formulation.
Panel 7: Evening
Evening disorientation differs from her morning conversation.
Nurse Tom: She knew where she was earlier; now she cannot keep track.
Panel 8: Day 6
Collateral history clarifies the scale and timing of change.
Ben: This is unlike her previous episodes of depression.
Panel 9: Day 7
A low score during illness does not establish permanent decline.
Ward doctor Amira: We need the course over time, not one result.
Page 2
Panel 10: Day 8
Familiar activities are supported without overwhelming her.
Nurse Tom: Start with this cloth. We can take a break afterwards.
Panel 11: Day 9
Medicines and other continuing causes are reassessed.
Pharmacist Samir: Let us check what changed before and during this illness.
Panel 12: Day 12
Sustained attention begins to improve.
Ruth: I can understand more when we sit here.
Panel 13: Week 3
Daily tasks reveal both gains and remaining difficulties.
Occupational therapist Ruth: You remembered the first steps. I will help with the rest.
Panel 14: Week 3
Emotional care continues alongside cognitive recovery.
Liaison psychiatrist Clare: How are you feeling now that things are becoming clearer?
Panel 15: Week 4
She participates more fully in decisions.
Ruth: I want to try, with help at first.
Panel 16: Week 5
Attention is improving across repeated assessments.
Ward doctor Amira: We will reconsider further cognitive assessment as recovery progresses.
Panel 17: Week 6
Fatigue and task difficulty still limit independence.
Ruth: I need to stop before I lose track.
Panel 18: Week 6
Recovery is gradual, with continuing attention to mood and function.
Ben: We can see progress without expecting everything at once.
Sources
- [S03] Cao, F., Salem, H., Nagpal, C. and Teixeira, A.L. (2017) ‘Prolonged delirium misdiagnosed as a mood disorder’, Dementia & Neuropsychologia, 11(2), pp. 206–208.
- [S28] Kato, T., Tsujii, T., Kida, H., Mochizuki, D., Nikkuni, S. and Sakuma, K. (2025) ‘A case of late-onset psychosis secondary to traumatic brain injury difficult to differentiate from delirium’, Psychiatry and Clinical Neurosciences Reports, 4(2), e70125.
- [P41] Cole MG. Persistent delirium in older hospital patients. Current Opinion in Psychiatry. 2010;23:250–254.
- [G01] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
Commentary
Ruth has a history of depression, but this episode includes a rapid change in attention, awareness and daily abilities. These difficulties still vary after the initial electrolyte disturbance has been corrected. Reduced speech and activity, and expressions of hopelessness, do not remove the need to assess continuing delirium.
The psychiatrist and medical team assess her together. They consider mood symptoms, repeat assessments of thinking and physical health, and review medicines. She needs both medical and psychiatric care. The cited reports describe how psychiatric and neurological histories can make recent changes in thinking harder to recognise [S03, S28].
A low cognitive test score during illness does not establish permanent dementia. Repeated observations, everyday activities and information from someone who knows Ruth help staff assess her progress. Later cognitive testing may be appropriate, but the results need to be interpreted in relation to the recent delirium and her course since admission [P41, G01].
Ruth gradually manages more familiar tasks but still tires and needs support. Continue care for mood, safety and physical health while assessing her thinking. Do not attribute every depressive symptom to delirium or delay depression care until thinking has fully recovered. Compare this episode with her previous depression and review the explanation as further information becomes available.