MSGM Clinical Case Discussion September 2026

“This Is Not Him”: The Long Road Back to Baseline

Prepared by: Dr Nuur Habibah Ghazali

Supervised by: Dr Nurul Huda Mohd Zambri

Case Summary

Mr A was a 79-year-old gentleman with untreated hypertension and a history of male breast cancer treated with surgery and chemoradiotherapy.

He lived with two of his sons and was previously independent in his basic activities of daily living. He walked without an aid, prepared his own breakfast, bought food and helped at his son’s stall. He also performed his five daily prayers independently and walked to a nearby mosque for Friday prayers.

His family had noticed mild forgetfulness over the preceding year, mainly misplacing his telephone or money, without repetitive questioning or an apparent effect on his daily function. However, he had experienced visual hallucinations for several years. He occasionally saw his late wife or dark figures in the hallway, usually in the evening or at night. These experiences were brief and non-distressing, and he sometimes accepted his son’s reassurance that no one was there. There were no other reported changes in his personality, mood, sleep or mobility, and his vision and hearing were not impaired.

In early 2026, Mr A presented with two days of fever, vomiting, poor oral intake and acute confusion. Within 48 hours of admission, he developed further fever and tested positive for COVID-19. He did not require oxygen or corticosteroids but received antibiotics for suspected superimposed bacterial pneumonia. His infection and inflammatory markers subsequently improved.

CT brain showed chronic lacunar infarcts involving the left centrum semiovale and external capsule, without an acute intracranial abnormality. He had no focal neurological findings. Investigations for potentially reversible contributors to cognitive impairment, including vitamin B12, folate, thyroid function and cortisol, were unremarkable.

About two weeks into his admission, after completing COVID-19 isolation and treatment for the acute infection, he was transferred to the geriatric ward for ongoing delirium management and rehabilitation.

His Delirium Persisted

His 4AT score was 8/12 on transfer and remained between 7 and 8 on most days. He recognised his children but could not sustain a meaningful conversation. His speech was often irrelevant or incoherent, and he sometimes responded only by smiling or saying “yes” or “no.”

His alertness fluctuated. He could be awake when approached but would easily fall asleep when left alone. He remained inattentive and needed repeated instructions during rehabilitation.

At night, he was restless and repeatedly attempted to get out of bed, placing him at risk of falling. He was not aggressive, but intermittent physical restraint was used for safety. His sleep and restlessness improved when his sons stayed with him, but they could not continue doing so after returning to work.

Despite non-pharmacological measures, his nocturnal restlessness and unsafe attempts to mobilise persisted. Risperidone 0.25 mg nightly was started. As he required an additional 0.25 mg at night, the regular dose was increased to 0.5 mg after three days. No apparent adverse effects were observed.

Potential contributors to his ongoing delirium, including pain, constipation, urinary retention, hydration, nutrition, medication exposure and sleep disruption, were repeatedly reviewed and addressed. He received multidisciplinary input from the medical, nursing, physiotherapy, occupational therapy and dietetic teams.

Nevertheless, rehabilitation remained limited by poor attention and difficulty following instructions. He required supervision and occasional assistance during meals and became dependent for personal care. He could not reliably indicate when he needed to pass urine or open his bowels.

He no longer initiated transfers or walking and remained predominantly in bed. When prompted to mobilise, he required one-person assistance and close supervision because he was unsteady and at high risk of falling.

Discharge and Outcome

After approximately six weeks in hospital, Mr A remained delirious and substantially more dependent than before admission. His guarded cognitive and functional prognosis and the possibility that he might not return to his previous baseline were discussed with his sons.

He was discharged home under their care, with his sons taking turns to look after

him. Risperidone 0.5 mg nightly was continued, and a geriatric teleconsultation was arranged two weeks later.

At home, he remained predominantly in bed and dependent on others for his care. Around the time of his planned teleconsultation, he developed fever, reduced oral intake and a choking episode while being fed. He subsequently became less responsive and breathless and was brought to the emergency department in septic shock.

Chest radiography showed right-sided consolidation, and aspiration pneumonia was diagnosed. Despite active medical treatment, his condition deteriorated. Following discussion with his son, a ceiling of care without cardiopulmonary resuscitation or invasive ventilation was agreed. Mr A died the following day.

Questions for Discussion

1. When delirium persists after the acute illness has been treated, how far should we continue searching for another cause?

2. Did Mr A have an underlying neurocognitive disorder, and could this have been assessed while he remained delirious?

3. How should family presence, physical restraint and antipsychotic treatment be balanced?

4. How should feeding safety, discharge readiness and early follow-up be planned when delirium does not resolve?

References:

1. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. NICE Guideline CG103. Updated January 2023. Available from: https://www.nice.org.uk/guidance/cg103

2. Whitby J, Nitchingham A, Caplan G, Davis D, Tsui A. Persistent delirium in older hospital patients: an updated systematic review and meta-analysis. Delirium. 2022;1:36822. doi:10.56392/001c.36822.

3. Kiely DK, Marcantonio ER, Inouye SK, et al. Persistent delirium predicts greater mortality. J Am Geriatr Soc. 2009;57(1):55–61. doi:10.1111/j.1532- 5415.2008.02092.x.

4. McKeith IG, Boeve BF, Dickson DW, et al. Diagnosis and management of dementia with Lewy bodies: fourth consensus report of the DLB Consortium. Neurology. 2017;89(1):88–100. doi:10.1212/WNL.0000000000004058.

5. Burry L, Mehta S, Perreault MM, et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2018;6:CD005594. doi:10.1002/14651858.CD005594.pub3.