# An 84-year-old admitted with pneumonia is acutely confused, fluctuating attention, with a positive CAM screen. He is calm but inattentive (hypoactive delirium). Which intervention is the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375129&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: ROR

## Question

An 84-year-old admitted with pneumonia is acutely confused, fluctuating attention, with a positive CAM screen. He is calm but inattentive (hypoactive delirium). Which intervention is the priority?

## Option

1. Identify and treat reversible causes — review and deprescribe anticholinergic medications, treat the pneumonia, remove the unnecessary Foley **✔ Correct answer**
2. Administer haloperidol around the clock for hypoactive delirium
3. Apply soft restraints to prevent self-harm because of confusion
4. Order a brain MRI as the immediate next step

**Correct answer: 1**

## Explanation

Delirium management is FOUNDATIONAL nonpharmacologic with treatment of reversible causes: deprescribe high-risk medications (anticholinergics like diphenhydramine and oxybutynin, sedatives like zolpidem, dopamine antagonists like reglan), treat infection (pneumonia here), remove unnecessary tethers (Foley contributes to delirium), reorient, mobilize, sleep hygiene. Antipsychotics are REJECTED as routine; reserved for severe agitation harming self/staff with non-pharm failure (and only short term, low dose) — and AVOIDED in pure hypoactive delirium. Restraints worsen delirium. MRI is for focal findings, not initial step in delirium with clear medical precipitant.

## In-depth explanation

Hypoactive delirium has higher mortality and is missed often. Use validated tools (CAM, CAM-ICU, 4AT) for screening. Ages 65+ at hospital admission warrant routine screening.

## Clinical scenario

Reglan, oxybutynin, zolpidem, diphenhydramine on home med list. Sleep poor. Foley in place.

## Key concepts

- **delirium** — Acute fluctuating attention/cognition disturbance; medical emergency.
- **CAM** — Confusion Assessment Method; validated delirium screening tool.
- **deprescribing** — Systematic reduction of medications causing or worsening delirium.

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