An 84-year-old admitted with a urinary tract infection becomes agitated and is trying to leave the ward at 02:00. How do you manage this?

Question

An 84-year-old woman, day 2 of treatment for a UTI, is pulling at her cannula, shouting and attempting to leave. CFS 6, background of mild cognitive impairment. The nurse in charge asks for something to sedate her.

Accepted Answer

I would go and see her rather than prescribe over the phone, because agitation is a symptom with a differential and sedating her without assessment risks both missing the cause and causing harm. I would start with an A-E assessment and immediately exclude the quickly reversible and dangerous causes: hypoxia, hypoglycaemia, hypotension, urinary retention with a bladder scan, uncontrolled pain, constipation, and any sign of new sepsis or of a subdural haemorrhage if she has fallen. I would diagnose delirium formally with a 4AT and get a collateral history from the family or the care record to establish her true baseline, because the important question is what has changed rather than whether she is confused. Then I would work through the reversible contributors systematically using PINCH ME, review her drug chart for anticholinergics, opioids and recently started agents, and consider alcohol or benzodiazepine withdrawal. Management is non-pharmacological first: reorientation, a well-lit but calm environment, her hearing aids and glasses, moving her nearer the nurses' station, a familiar person present if possible, and one-to-one support if it can be found. I would ask the nurse in charge what has worked earlier in the admission. I would assess capacity for the decision to leave, and if she is being continuously supervised and is not free to leave, I would say explicitly that this amounts to a deprivation of liberty requiring an urgent DoLS authorisation with a standard authorisation requested. Only if she remained at genuine risk to herself or others despite all of that would I consider low-dose haloperidol, at the lowest dose for the shortest time, avoiding it entirely if there is any suggestion of Parkinson's disease or Lewy body dementia, and I would document the rationale and review it daily.

Delirium in a Frail Inpatient

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