Delirium etiology and management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Delirium etiology and management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Delirium etiology and management US Medical PG Question 1: Ten days after starting a new medication, a 60-year-old man is brought to the emergency department after a 3-minute episode of myoclonic jerking movements and urinary incontinence. After regaining consciousness, the patient had no recollection of what happened and seemed confused. He has bipolar disorder, which has been controlled with maintenance therapy for the past 15 years. Physical examination shows dry oral mucosa, muscle fasciculations, and bilateral hand tremors. His speech is slow, and he is disoriented. Which of the following drugs most likely precipitated this patient's current condition?
- A. Valproic acid
- B. Celecoxib (Correct Answer)
- C. Metoprolol
- D. Theophylline
- E. Fluoxetine
Delirium etiology and management Explanation: ***Celecoxib***
- This patient's presentation of **myoclonic jerking, seizure, confusion, dry mucosa, fasciculations, and tremors** is classic for **lithium toxicity**.
- The patient has been on **maintenance therapy for bipolar disorder for 15 years**, most likely lithium, which has a narrow therapeutic index.
- **Celecoxib (COX-2 inhibitor/NSAID)** reduces renal clearance of lithium by decreasing renal prostaglandin synthesis, leading to **increased lithium levels and toxicity**.
- NSAIDs are a well-known precipitant of lithium toxicity in patients on chronic lithium therapy.
*Theophylline*
- Theophylline has a narrow therapeutic index and can cause seizures in toxicity, but this patient's presentation is consistent with **lithium toxicity**, not theophylline toxicity.
- Importantly, **theophylline actually decreases lithium levels** by increasing renal clearance, so it would not precipitate lithium toxicity.
- Theophylline toxicity typically presents with tachycardia and cardiac arrhythmias, which are not described here.
*Valproic acid*
- Valproic acid is used for bipolar disorder and can cause tremor and neurological side effects, but would not precipitate the acute toxicity syndrome seen here.
- Valproic acid toxicity typically involves **hepatotoxicity, pancreatitis, or CNS depression** rather than the hyperexcitable state with fasciculations and myoclonus.
- It does not interact significantly with lithium to cause this presentation.
*Metoprolol*
- Metoprolol is a **beta-blocker** that does not interact with lithium in a clinically significant way.
- Beta-blocker overdose causes **bradycardia, hypotension, and CNS depression**, not the hyperexcitable state with myoclonic jerks and fasciculations seen here.
*Fluoxetine*
- Fluoxetine is an **SSRI** that can increase lithium levels slightly, but is less commonly associated with precipitating lithium toxicity compared to NSAIDs.
- Severe SSRI toxicity or **serotonin syndrome** would present with **hyperthermia, hyperreflexia, clonus, and autonomic instability**, not the specific constellation of dry mucosa and fasciculations characteristic of lithium toxicity.
- The clinical picture better fits lithium toxicity precipitated by an NSAID.
Delirium etiology and management US Medical PG Question 2: A 72-year-old man is brought into clinic by his daughter for increasing confusion. The daughter states that over the past 2 weeks, she has noticed that the patient “seems to stare off into space.” She reports he has multiple episodes a day during which he will walk into a room and forget why. She is also worried about his balance. She endorses that he has had several falls, the worst being 3 weeks ago when he tripped on the sidewalk getting the mail. The patient denies loss of consciousness, pre-syncope, chest pain, palpitations, urinary incontinence, or bowel incontinence. He complains of headache but denies dizziness. He reports nausea and a few episodes of non-bloody emesis but denies abdominal pain, constipation, or diarrhea. The patient’s medical history is significant for atrial fibrillation, diabetes, hypertension, hyperlipidemia, and osteoarthritis. He takes aspirin, warfarin, insulin, lisinopril, simvastatin, and ibuprofen. He drinks a half glass of whisky after dinner every night and smokes a cigar on the weekends. On physical examination, he is oriented to name and place but not to date. He is unable to spell "world" backward. When asked to remember 3 words, he recalls only 2. There are no motor or sensory deficits. Which of the following is the most likely diagnosis?
- A. Ischemic stroke
- B. Subdural hematoma (Correct Answer)
- C. Vitamin B12 deficiency
- D. Alzheimer disease
- E. Normal pressure hydrocephalus
Delirium etiology and management Explanation: ***Subdural hematoma***
- The patient's presentation with **gradual onset of confusion**, increasing forgetfulness, and **balance issues with falls** over a couple of weeks, especially after a fall three weeks prior, is highly suggestive of a subdural hematoma.
- His use of **warfarin** and **aspirin** significantly increases his risk for bleeding, and the **headache and nausea/vomiting** are common symptoms of increased intracranial pressure.
*Ischemic stroke*
- An ischemic stroke typically presents with **acute, focal neurological deficits**, which are not described here.
- While the patient has risk factors for stroke (atrial fibrillation, hypertension, diabetes), the **gradual onset** of symptoms over weeks makes it less likely.
*Vitamin B12 deficiency*
- Vitamin B12 deficiency can cause **cognitive impairment** and neurological symptoms, but it usually develops **insidiously over months to years**, not acutely over 2 weeks.
- It is also associated with **peripheral neuropathy and megaloblastic anemia**, which are not reported.
*Alzheimer disease*
- Alzheimer's disease causes **progressive cognitive decline** over many years, starting with memory issues that gradually worsen.
- The **relatively rapid 2-week progression** of symptoms and the clear precipitating factor of a fall make Alzheimer's less likely in this acute context.
*Normal pressure hydrocephalus*
- Normal pressure hydrocephalus (NPH) classically presents with a triad of **gait disturbance, urinary incontinence, and dementia**.
- While the patient has gait issues and cognitive changes, the **absence of urinary incontinence** and the relatively rapid onset after a fall makes NPH less probable.
Delirium etiology and management US Medical PG Question 3: A 70-year-old man with a history of Alzheimer dementia presents to the emergency department with a change in his behavior. The patient has been more confused recently and had a fever. Upon presentation, he is too confused to answer questions. His temperature is 103°F (39.4°C), blood pressure is 102/68 mmHg, pulse is 157/min, respirations are 22/min, and oxygen saturation is 99% on room air. The patient is given 3 liters of IV fluids and acetaminophen and his vitals improve. He is also less confused. The patient is asking where he is and becomes combative and strikes a nurse when he finds out he has to be admitted to the hospital. He is given diphenhydramine for sedation and put in soft restraints. His mental status subsequently worsens and he becomes much more aggressive, spitting at nurses and attempting to bite his restraints. He also complains of abdominal pain. A post void residual volume is notable for a urine volume of 750 mL. Which of the following is the etiology of this patient's recent mental status change?
- A. Diphenhydramine (Correct Answer)
- B. Lorazepam
- C. Haloperidol
- D. Acute infection
- E. Olanzapine
Delirium etiology and management Explanation: ***Diphenhydramine***
- This patient exhibited a **paradoxical reaction** (increased agitation and aggression) to diphenhydramine, which is an **anticholinergic** medication.
- Anticholinergic drugs can worsen confusion and agitation, especially in elderly patients or those with pre-existing **dementia**.
*Lorazepam*
- **Benzodiazepines** like lorazepam primarily work on **GABA receptors** to produce sedative and anxiolytic effects.
- While sometimes used for agitation, it typically causes sedation rather than increased aggression in the elderly; a paradoxical reaction is less common than with anticholinergics.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** used to treat acute agitation and psychosis, primarily by blocking **dopamine D2 receptors**.
- Its typical effect would be to decrease agitation and aggression, not worsen mental status in this manner.
*Acute infection*
- The patient initially presented with signs of an acute infection (fever, increased confusion), which improved after initial treatment with IV fluids and acetaminophen, indicating the initial symptoms were likely due to infection.
- The subsequent worsening after diphenhydramine points to a new etiology for the mental status change, rather than a resurgence of the infection.
*Olanzapine*
- Olanzapine is a **second-generation antipsychotic** that blocks serotonin and dopamine receptors, often used for acute agitation.
- Like haloperidol, it would be expected to reduce agitation and aggression, not exacerbate it, and was not administered to the patient according to the vignette.
Delirium etiology and management US Medical PG Question 4: An 82-year-old woman comes to the physician because of difficulty sleeping and increasing fatigue. Over the past 3 months she has been waking up early and having trouble falling asleep at night. During this period, she has had a decreased appetite and a 3.2-kg (7-lb) weight loss. Since the death of her husband one year ago, she has been living with her son and his wife. She is worried and feels guilty because she does not want to impose on them. She has stopped going to meetings at the senior center because she does not enjoy them anymore and also because she feels uncomfortable asking her son to give her a ride, especially since her son has had a great deal of stress lately. She is 155 cm (5 ft 1 in) tall and weighs 51 kg (110 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she is tired and has a flattened affect. Cognition is intact. Which of the following is the most appropriate initial step in management?
- A. Begin mirtazapine therapy
- B. Begin cognitive-behavioral therapy
- C. Notify adult protective services
- D. Assess for suicidal ideation (Correct Answer)
- E. Recommend relocation to a nursing home
Delirium etiology and management Explanation: ***Assess for suicidal ideation***
- The patient exhibits several **risk factors for depression**, including **insomnia**, **early morning awakening**, **anorexia**, **weight loss**, and significant **anhedonia** (lack of enjoyment in activities).
- Given her age, recent loss of her husband, social withdrawal, feelings of guilt, and significant emotional distress, it is crucial to first assess for **suicidal ideation** before initiating other treatments.
- **Elderly patients with depression have elevated suicide risk**, especially with recent bereavement and social isolation. Safety assessment is the **mandatory first step** in managing any patient with major depressive symptoms.
*Begin mirtazapine therapy*
- While **mirtazapine** is an effective antidepressant that could address several of her symptoms (insomnia, poor appetite, depression), it should only be considered after a **thorough safety assessment**, particularly for suicide risk.
- Starting medication without assessing for immediate danger may overlook critical safety concerns.
*Begin cognitive-behavioral therapy*
- **Cognitive-behavioral therapy (CBT)** is an effective treatment for depression and could be beneficial for this patient.
- However, similar to medication, it is a subsequent treatment step. The immediate priority is to rule out **suicidal intent** given the severity of her depressive symptoms.
*Notify adult protective services*
- There is no direct evidence of **abuse or neglect** in the provided information that would warrant involving adult protective services.
- Her feelings of guilt and worry about burdening her family, while contributing to her depression, do not indicate that her son or daughter-in-law are harming her.
*Recommend relocation to a nursing home*
- While the patient is elderly and potentially depressed, there is no medical or social necessity presented that indicates she requires or would benefit from a **nursing home** at this stage.
- This step would be premature and does not address the immediate mental health concerns or potential safety issues.
Delirium etiology and management US Medical PG Question 5: A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows:
Alcohol positive
Amphetamine negative
Benzodiazepine negative
Cocaine positive
GHB negative
Ketamine negative
LSD negative
Marijuana negative
Opioids negative
PCP negative
Which of the following is the most likely diagnosis in this patient?
- A. Delusion
- B. Alcohol withdrawal
- C. Visual hallucination
- D. Cocaine intoxication
- E. Illusion (Correct Answer)
Delirium etiology and management Explanation: ***Illusion***
- The patient is seeing **animal shapes in the clouds**, which is a misinterpretation of a real external stimulus. This is the definition of an **illusion**.
- Unlike hallucinations, illusions involve a distorted perception of an existing object, rather than perceiving something that is not present.
*Delusion*
- A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence, and it is not what is being described here.
- The patient is experiencing a perceptual distortion, not a false belief system.
*Alcohol withdrawal*
- While the patient tests positive for alcohol, the symptoms described are **perceptual distortions** (misinterpretation of clouds), not typical signs of alcohol withdrawal which include tremors, seizures, and delirium tremens.
- The timeline of "more than 2 weeks" also makes acute alcohol withdrawal less likely, as withdrawal symptoms typically peak within days.
*Visual hallucination*
- A **hallucination** is a perception in the absence of an external stimulus; the patient would be seeing animals when no clouds (or other visual stimuli) are present.
- The patient is seeing animal shapes *in the clouds*, indicating an existing external stimulus that is being misinterpreted.
*Cocaine intoxication*
- While cocaine intoxication can cause psychiatric symptoms like paranoia and hallucinations, the specific description of **seeing animal shapes in clouds** (misinterpretation of a real stimulus) points more directly to an illusion rather than a primary effect of cocaine use.
- The patient's presentation does not include other common symptoms of acute cocaine intoxication like severe agitation, dilated pupils, or hyperthermia beyond a rapid heart rate.
Delirium etiology and management US Medical PG Question 6: An 87-year-old woman is brought to the emergency department from her nursing home because of increasing confusion and lethargy for 12 hours. The nursing home aide says she did not want to get out of bed this morning and seemed less responsive than usual. She has Alzheimer's disease, hypertension, and a history of nephrolithiasis. She has chronic, intractable urinary incontinence, for which she has an indwelling urinary catheter. Current medications include galantamine, memantine, and ramipril. Her temperature is 38.5°C (101.3°F), pulse is 112/min, respiratory rate is 16/min, and blood pressure is 108/76 mm Hg. Physical examination shows mild tenderness to palpation of the lower abdomen. On mental status examination, she is oriented only to person. Laboratory studies show:
Hemoglobin 12.4 g/dL
Leukocyte count 9,000/mm3
Platelet count 355,000/mm3
Urine
pH 8.2
Glucose 1+
Protein 2+
Ketones negative
RBC 5/hpf
WBC 35/hpf
Bacteria moderate
Nitrites positive
Which of the following is the most likely causal organism?
- A. Enterococcus faecalis
- B. Klebsiella pneumoniae
- C. Staphylococcus saprophyticus
- D. Escherichia coli
- E. Proteus mirabilis (Correct Answer)
Delirium etiology and management Explanation: ***Proteus mirabilis***
- The high urine pH (8.2), positive nitrites, and moderate bacteria, along with signs of infection in an elderly catheterized patient, are highly suggestive of a **urea-splitting organism**.
- **Proteus mirabilis** is a common cause of catheter-associated UTIs and produces urease, leading to alkaline urine and the formation of struvite stones, consistent with the patient's history of nephrolithiasis.
*Enterococcus faecalis*
- While *Enterococcus faecalis* can cause UTIs, it typically does not produce urease and therefore would not cause such a **markedly elevated urine pH** (above 7.5).
- Although it can cause positive nitrites, the absence of a strong alkali pH makes it less likely than *Proteus mirabilis*.
*Klebsiella pneumoniae*
- *Klebsiella pneumoniae* can cause UTIs and produce nitrites, but it is not typically a strong **urease producer** to the extent that would cause an alkaline urine pH of 8.2.
- It is more commonly associated with nosocomial infections, but the highly alkaline urine points away from it as the most likely cause here.
*Staphylococcus saprophyticus*
- *Staphylococcus saprophyticus* is a common cause of UTIs in young, sexually active women, but it is **rare in elderly, catheterized patients**.
- It is also not typically associated with such a high urine pH as seen in this case.
*Escherichia coli*
- *Escherichia coli* is the most common cause of UTIs, but it is a **non-urease-producing** bacterium and would typically result in acidic urine, or at least a less alkaline pH than 8.2.
- While it would cause positive nitrites and moderate bacteria, the elevated pH makes it less likely than *Proteus mirabilis* in this context.
Delirium etiology and management US Medical PG Question 7: A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?
- A. Second opinion from a neurologist
- B. Withdraw ventilation support and mark time of death
- C. Electroencephalogram
- D. Repeat examination in several hours
- E. Apnea test (Correct Answer)
Delirium etiology and management Explanation: ***Apnea test***
- The patient exhibits classic signs of **brain death**, including a **coma**, fixed and dilated pupils, and absent brainstem reflexes (corneal, gag, cough). The next step is to perform an apnea test to confirm the absence of spontaneous respiratory drive.
- An apnea test confirms brain death by demonstrating the **absence of respiratory effort** despite a rising pCO2, provided that spinal cord reflexes are not mistaken for respiratory efforts.
*Second opinion from a neurologist*
- While consulting a neurologist is often helpful in complex neurological cases, the current clinical picture presents such clear signs of brain death that **further confirmatory testing** for brain death (like the apnea test) is more immediately indicated before seeking additional opinions on diagnosis.
- A second opinion would typically be sought to confirm the diagnosis or guide management, but establishing brain death requires a specific protocol which is incomplete without the apnea test.
*Withdraw ventilation support and mark time of death*
- It is **premature to withdraw ventilation** before brain death is unequivocally confirmed by all necessary clinical and confirmatory tests, including the apnea test.
- Withdrawing support without full confirmation could lead to ethical and legal issues, as the patient might still have residual brainstem function, however minimal.
*Electroencephalogram*
- An **EEG** can show absent electrical activity, supporting brain death, but it is **not a mandatory part of the core brain death criteria** in many protocols, especially when clinical signs are clear and an apnea test can be performed.
- The primary diagnostic criteria for brain death usually prioritize clinical examination and the apnea test for proving irreversible cessation of all brain functions.
*Repeat examination in several hours*
- Repeating the examination in several hours is typically done if there are **confounding factors** (e.g., severe hypothermia, drug intoxication) that might mimic brain death, or if the initial assessment is incomplete.
- In this case, there are no mentioned confounding factors, and the immediate priority is to complete the brain death protocol with an apnea test, given the current clear clinical picture.
Delirium etiology and management US Medical PG Question 8: A 56-year-old man presents with constipation and trouble urinating for the past day. He says that he tried drinking a lot of water but that did not help. He also says that he has been tired all the time recently. Past medical history is significant for schizophrenia, diagnosed 3 months ago, and being managed on chlorpromazine. Current medications also include sildenafil. The vital signs include blood pressure 80/45 mm Hg, respiratory rate 23/min, heart rate 86/min and temperature 38.7°C (101.7°F). On physical examination, the patient appears agitated and confused. Which of the following medications is the most likely cause of this patient's presentation?
- A. Chlorpromazine (Correct Answer)
- B. Ziprasidone
- C. Haloperidol
- D. Aripiprazole
- E. Lithium
Delirium etiology and management Explanation: ***Chlorpromazine***
- The patient's presentation with **constipation**, **trouble urinating**, **fever**, **tachycardia**, **hypotension**, **agitation**, and **confusion** is highly suggestive of **anticholinergic toxicity**.
- **Chlorpromazine**, a low-potency first-generation antipsychotic, has significant **anticholinergic side effects** due to its potent blockade of muscarinic receptors, making it the most likely cause.
*Ziprasidone*
- Ziprasidone is a **second-generation antipsychotic** known for a lower propensity for anticholinergic side effects compared to first-generation agents like chlorpromazine.
- While it can cause side effects, severe anticholinergic toxicity is less common and less pronounced with ziprasidone.
*Haloperidol*
- Haloperidol is a **high-potency first-generation antipsychotic** with relatively weak anticholinergic properties compared to chlorpromazine.
- It is more commonly associated with **extrapyramidal symptoms** rather than the severe anticholinergic syndrome described.
*Aripiprazole*
- Aripiprazole is a **second-generation antipsychotic** with **dopamine partial agonist** properties and very low anticholinergic activity.
- It would be an unlikely cause of the profound anticholinergic toxicity observed in this patient.
*Lithium*
- Lithium is a **mood stabilizer** used in bipolar disorder and does not possess significant anticholinergic properties.
- Lithium toxicity typically presents with **tremor**, **nausea**, **vomiting**, **diarrhea**, and **neurological symptoms** like ataxia, rather than the specific constellation of anticholinergic symptoms seen here.
Delirium etiology and management US Medical PG Question 9: An 83-year-old man is being seen in the hospital for confusion. The patient was admitted 4 days ago for pneumonia. He has been improving on ceftriaxone and azithromycin. Then 2 nights ago he had an episode of confusion. He was unsure where he was and attempted to leave. He was calmed down by nurses with redirection. He had a chest radiograph that was stable from admission, a normal EKG, and a normal urinalysis. This morning he was alert and oriented. Then this evening he became confused and agitated again. The patient has a history of benign prostatic hyperplasia, severe dementia, and osteoarthritis. He takes tamsulosin in addition to the newly started antibiotics. Upon physical examination, the patient is alert but orientated only to name. He tries to get up, falls back onto the bed, and grabs his right knee. He states, “I need to get to work. My boss is waiting, but my knee hurts.” He tries to walk again, threatens the nurse who stops him, and throws a plate at the wall. In addition to reorientation, which of the following is the next best step in management?
- A. Morphine
- B. Lorazepam
- C. Haloperidol (Correct Answer)
- D. Rivastigmine
- E. Physical restraints
Delirium etiology and management Explanation: ***Haloperidol***
- The patient exhibits **delirium** with acute agitation, threatening behavior, and violent actions (throwing objects), representing an **imminent safety risk** to himself and staff.
- After **non-pharmacological interventions** (reorientation) have failed, **low-dose haloperidol** is appropriate for managing **severe agitation** in delirium when there is risk of harm.
- While antipsychotics have an FDA black box warning for increased mortality in elderly patients with dementia and recent evidence questions their efficacy in delirium, they remain indicated for **acute agitation with safety concerns** as a short-term intervention.
- Haloperidol is preferred over atypical antipsychotics in acute hospital settings due to availability in parenteral forms and lower anticholinergic burden.
*Morphine*
- While the patient mentions knee pain (likely from osteoarthritis), his **primary issue** is acute agitation and delirium, not pain management.
- **Opioids** can worsen delirium and confusion in elderly patients through anticholinergic effects and sedation.
- Pain should be addressed, but not as the primary intervention for violent, agitated behavior.
*Lorazepam*
- **Benzodiazepines** are generally **contraindicated in delirium** as they worsen confusion, increase fall risk, and can cause paradoxical agitation in elderly patients.
- The **only exceptions** are delirium from alcohol or benzodiazepine withdrawal, or seizures—none of which apply to this patient.
- Lorazepam would likely exacerbate rather than improve this patient's mental status.
*Rivastigmine*
- **Rivastigmine** is an acetylcholinesterase inhibitor for chronic management of **dementia symptoms**, not acute delirium.
- It has **no role** in managing acute behavioral disturbances and takes weeks to show any effect.
- Studies have not shown benefit of cholinesterase inhibitors in preventing or treating delirium.
*Physical restraints*
- Physical restraints should be used only as a **last resort** when pharmacological and non-pharmacological interventions have failed and there is immediate, serious risk of harm.
- Restraints can **increase agitation**, cause injuries, lead to delirium worsening, and are associated with increased morbidity and mortality.
- They do not address the underlying cause and should be avoided when other options are available.
Delirium etiology and management US Medical PG Question 10: A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. The patient’s temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% O2 on room air. During the physical exam, the patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the best initial therapy?
- A. Electroconvulsive therapy
- B. Lorazepam (Correct Answer)
- C. Haloperidol
- D. Cyproheptadine
- E. Benztropine
Delirium etiology and management Explanation: **Lorazepam**
- The patient presents with classic symptoms of **catatonia**, including **mutism**, **waxy flexibility**, and **posturing**, following a medication change from phenelzine (MAOI) to fluoxetine (SSRI), which could potentially precipitate catatonia or serotonin syndrome.
- **Benzodiazepines**, particularly lorazepam, are the **first-line treatment** for catatonia, often showing a rapid and dramatic response.
*Electroconvulsive therapy*
- While **ECT** is a highly effective treatment for severe catatonia, especially when unresponsive to benzodiazepines, it is typically considered a **second-line intervention** or for cases involving medical instability.
- Given the strong initial efficacy and safety profile of benzodiazepines, they are preferred as the first step before proceeding to ECT.
*Haloperidol*
- **Antipsychotics** like haloperidol are generally **contraindicated** in catatonia, as they can sometimes worsen the symptoms or even induce **neuroleptic malignant syndrome (NMS)**, which shares some features with severe catatonia.
- NMS is a serious condition with high mortality, and introducing an antipsychotic in a catatonic patient could be dangerous.
*Cyproheptadine*
- **Cyproheptadine** is a **serotonin antagonist** used primarily in the treatment of **serotonin syndrome**, which involves symptoms like hyperthermia, agitation, and hyperreflexia.
- While the medication change could raise suspicion for serotonin syndrome, the clinical picture of **waxy flexibility, mutism, and posturing** is much more indicative of catatonia, for which cyproheptadine is not an effective treatment.
*Benztropine*
- **Benztropine** is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** caused by antipsychotics, such as **dystonia** or **parkinsonism**.
- The patient's symptoms are not indicative of EPS, and benztropine has no role in the treatment of catatonia.
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