An 80-year-old man develops acute confusion, disorientation, and auditory hallucinations following hip replacement surgery. His serum sodium is 125 mEq/L. The MOST appropriate immediate intervention is:

• A Start haloperidol 5 mg IM for agitation immediately
• B Give lorazepam 2 mg IV and order brain MRI
• C Sedate the patient and reassess in 24 hours
• D Correct the underlying hyponatraemia and address contributing medical factors; use low-dose antipsychotics only if behavioural disturbance cannot be managed otherwise ✓

Explanation

Delirium management prioritises identifying and treating the underlying cause — in this case, hyponatraemia (sodium 125 mEq/L) is a likely precipitant requiring careful correction. Non-pharmacological measures (reorientation, adequate lighting, family presence, maintaining sleep-wake cycle) are first-line. Antipsychotics (low-dose haloperidol or quetiapine) are used only for severe agitation posing safety risks, and their routine use in delirium is not evidence-based for improving outcomes. Lorazepam can worsen delirium and is contraindicated except in specific situations (alcohol/benzodiazepine withdrawal delirium).

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.