Talk:Delirium/Archive 1

Merge with Mental confusion

RE: Merge with Mental confusion Lee: In addition to the changes you recommend, I also would like the Wikipedia community to consider adding a new category to the general topic of confusion. The new category would be labeled something like "confusion in everyday life," and I would submit an article for the community to review and include if it appears appropriate. I don’t know whether it would fit best as an amplification of the pathological concept of confusion, or as a separate article with cross-links.

I'm a retired psychiatrist with a long interest in the confusion that ordinary people experience when confronted with a dilemma, or when coping with disinformation and other confusion-inducing manipulations of corporations, government employees, presidents, spin doctors, etc. Most people have a lot of trouble tolerating this type of confusion, and try to resolve it using various coping methods. Problem is, many of those coping methods worsen the overall confusion, creating a vicious cycle in which sources and coping attempts amplify each other.

I've written two books on the topic, American Confusion from Vietnam to Kosovo: Coping with Chaos in High Places, and Lethal American Confusion: How Bush and the Pacifists Each Failed in the War on Terrorism. (That one is only an e-book at the moment, but a print copy ought to be out in August. Info’s available at www.AmericanConfusion.com ) One result of this broadening of the topic is a forecasting model using cognitive maps, which predicted more of the adverse outcomes of the Afghanistan and Iraq wars than did the Bush administration.

Thanks for raising this question, Lee. Bill Taylor (William R. Taylor, M.D.) wrbftaylor@comcast.net

Have added to merge list:

Merge Mental confusion into Delirium since the current Mental confusion article mostly describes specifically delirium rather than confusion in general. Create a new article Confusion (clinical) discussing the clinical sign of confusion and the differentiation between its acute cause (Delirium) and its chronic cause (Dementia).

Although 'mental confusion' itself is not synonymous with delirium, the actual current text of the Mental confusion article (symptoms and causes) is actually refering to delirium. There's quite a bit of cleaning up that's needed in all three articles (i.e. this one, Mental confusion and Dementia) but I think the best way to start is to merge most of Mental confusion into here.

As I said above, I then plan to create a new article Confusion (clinical) that discusses the clinical picture of confusion with links to delirium and dementia without duplicating what's in those two articles. I think that would make a lot of sense both for students/clinicians using this as a quick reference and for lay people seeking to understand what they've seen or been told by a heathcare professional.

BTW - I am a junior doctor, but I'm not very experienced with Wikipedia. I hope a merge request is the right way to do this but if someone can correct me or reassure me I'd be grateful! I've used wikipedia a bit revising for exams (with caution!) and come across some very good and very poor information, so I'm doing my bit to clean a few things up and may do a lot more in future. --Lee Collier 07:09, 30 June 2006 (UTC)

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Hi there, I've replaced the original initial sentence of this entry. In the case of this entry the construction "In medicine, delirium is a mental state for which are several definitions exist" (sic) is (grammer aside) an incoherent definition.

Since there are several definitions, the word 'delirium' must be a term. Suggesting that 'delerium is a mental state' is fine in everyday language but in an encyclopedia it is important to describe the fact that it may be used in many different ways and that there are competing theories as to what it is actually refers to. -- Vaughan

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Hmm, as for the disambiguation blurb at the top, I was trying to look up a band called 'Delirium' the other day, and uncovered two punk bands of that name (one from Germany, one from Australia), a band from the Delaware, USA area formed in 1986, and an Italian (?) group that started releasing music in 1971. So, maybe further remarks are needed? Even if some/all of the other Deliriums aren't significant enough to have Wikipedia entries, it might still be helpful to list them... not sure. os 02:59, 24 March 2006 (UTC)

Clearly no reason to merge this with confusion

Confusion and loss of focus are the common-denominator symptoms of ALL brain structural and metabolic disorders that affect thinking. These symptoms may be reversible or permanent, acute or chronic, acquired or congenital, "organic" or without obvious evidence of organic origin (ie, "psychiatric"). When confusion and lack of ability to focus happen acutely in medicine, we call it "delirium." Long term problems are divided into learning disabilities and AD(H)D in younger patients, and various sorts of organic brain syndromes and dementias when acquired at later stages in life. But confusion and delirium, while greatly overlapping, are not the same. There are chronically confused patients who aren't technically delirious (for example: stable demented people). And some delirious people who aren't confused (example: the suddenly-ill person who cannot think or focus, but is perfectly well-oriented and conversant). Go without sleep for 36 or 48 hours and you'll find yourself medically delirius, even if you're not confused. The same goes for somebody who is in great pain, either physical or emotional. SBHarris 02:35, 22 July 2006 (UTC)

Disambiguation

I think there should be a Delirium (disambiguation) page. There's a whole bunch of links at the top of the current page that link to other deliria of various sorts. (And sooner or later, someone will create a page for the album — here — by Capercaillie.) Anyone disagree?  — AnnaKucsma   (Talk to me!) 15:23, 27 July 2006 (UTC)

Done!  — AnnaKucsma   (Talk to me!) 16:28, 28 July 2006 (UTC)

Audrey: Our class is doing a research project and we were wondering who first discovered delirium?

Another cause for delirium?

Last night my mother and I fell sick from what was believed to be food poisoning due to bacterial toxins from the cupcakes that I had made earlier that evening. When I left my bed to go get a cold cloth to put on my forehead, I turned on the light of the bathroom, but I was very confused because the light didn't seem to be on (even though it actually was). I left the room, unconciously leaving the water on and the cloth behind. I stumbled back, and turned the water off, now just leaving the cloth behind. I finally went back to bed and told my mom to go get it, since my attempts were clearly in vain. But the strange thing happened when I was walking over to the side of the bed that I slept on. I looked towards the corner of the room and there were these triangular-like figures (like an image depicting the center of an equilateral triangle and the vertices connected from one line that is branching out from the middle, remove the perimeter of the triangle and there it is) of a bluish-purple color all clustered together. I do not know what this is, and I was hoping that one of you guys could help? Thanks. —Preceding unsigned comment added by CorpseJester (talk • contribs) 15:42, 7 December 2007 (UTC)

Hmm, you must have had a dangerously high fever to be in such a delirious state. Sounds interestingly similar to an anticholinergic-induced delirium also, see Deliriant.--Metalhead94 ^{T C} 15:40, 21 December 2008 (UTC)

Merger proposal

How do we feel about a merge as OBS is delirium by another name...Cheers, Casliber (talk · contribs) 23:25, 19 April 2008 (UTC)

No! They aren't the same. Both are organic syndromes (caused by physical factors not mental illness without known physical cause), but OBS is the more general and inclusive term. OBS includes not only recent and secondarily-caused organic syndomes like delirium, but also all the other permanent and long-term primary physical causes of mental dysfunction, such as trauma, all of the various dementing brain diseases (Alzheimer's disease, etc), dementing stroke, and so on. In short, anything that causes new cognitive dysfunction that is NOT mental illness, is OBS. But delirium, by definition, must be a sort of OBS which is both new and of recent onsent, and is therefore often temporary, and often caused by something that is (in theory) reversible. Delirium is a subset of OBS, but it is generally used very specifically to indicate a different prognosis and approach, so that in practice the two are rarely used interchangably. Even though some patients could (by strict definition) be said to have both syndromes. Perhaps a Venn diagram is needed :) SBHarris 06:16, 20 April 2008 (UTC)

Yeah, I 'spose. In Oz we do occasionally talk about chronic delirium but it is pretty rare, it'd then be some form of dementia really, or if some post-traumatic injury it might be a frontal lobe-type syndrome. Hmmm. Cheers, Casliber (talk · contribs) 06:24, 20 April 2008 (UTC)

"Chronic delirium" is a bad term-- technically an oxymoron. It should never be used. When any congitive dysfunction becomes chronic, it's something else and not delirium. Dementias aren't deliriums, though demented people can become temporarily delirious on top of their dementia, and often do (when infected, ill in other ways, etc, etc). SBHarris 06:29, 20 April 2008 (UTC)

The above will very soon become an obsolute analysis based upon the research that has been conducted at Vanderbilt University. Stay tuned.67.161.162.197 (talk) 05:06, 20 May 2013 (UTC)

I'm an MD - organic brain syndrome is most definitely NOT delirium at all. Should not be merged, and furthermore I think this article has major errors. —Preceding unsigned comment added by 142.83.138.14 (talk) 18:57, 27 May 2008 (UTC)

I came here and was about to say the same thing that organic brain syndrome is not delerium or at least not necessarily delerium. Organic brain syndrome is just a brain condition usually showing psychiatric symptomatology but has a physical cause eg drug or alcohol or toxin induced or some other medical cause. It is basically a medical malfunction of brain function inducing a wide range of somatic and neurological symptoms, which can present itself as depression, anxiety, personality issues and the like. It has a wide field of definition. I am going to remove the merge tag on the organic brain syndrome page unless the definition of organic brain syndrome changes to delerium.--Literaturegeek | T@1k? 19:00, 22 December 2008 (UTC)

Occurrence in hospitals

This sentence from the "Occurrence in hospitals" is incomplete. Could a person knowledgable on the subject complete it or rephrase the paragraph appropriately:

Since the advent of validated and easy to implement delirium instruments for ICU patients such as the Confusion Assessment Method for the ICU (CAM-ICU)[7] and the Intensive Care Delirium Screening Checkllist (IC-DSC)[8]

(John User:Jwy talk) 05:26, 20 October 2008 (UTC)

Bickerstaff

Who??
87.55.201.154 (talk) 02:14, 7 August 2009 (UTC)

Aperently the Bickerstaff mentioned here is 'Edwin R. Bickerstaff' a British physician and author. It seems his area of expertise is neurology. Someone who knows how should add a "who?" tag as I'm sure most have never heard of him.

Dustie (talk) 02:43, 7 August 2009 (UTC)

There's a Bickerstaff who described a variety of encephalitis, but the symptoms of this are not necessarily a typical delirium. Since the description here has no reference and is at odds with the standard DSM definition (in fact it sounds more like the popular definition) I'm going to remove it to here until somebody gives us a cite and a quote. Then we can talk about whether this guy intended his definition to be general, and if his colleges agree with him. Here it is:

Bickerstaff defines delirium as a state in which the patient appears out of touch with his surroundings and is spontaneously producing evidence of his confusion and disorientation by muttering, rambling, shouting (often offensively and continuously), with evidence of delusion and hallucination, and often with so much associated motor activity that physical exhaustion overcomes him.

SBHarris 07:24, 25 October 2009 (UTC)

Edits

I've had a quick scan of the article. I think there's lots more content that could be sourced to secondary sources. A number are available, and are indeed cited in this article. doi:10.1056/NEJMra052321 is a recent NEJM review on the same.

The question is whether to discuss "sepsis-induced encephalopathy" here also. I have the feeling that we should, because the overlap with delirium is near-enough perfect. At the same time, the terminology may need broadening.

NICE has published a guideline National Institute for Health and Clinical Excellence. Clinical guideline 103: Delirium. London, 2010. - this places more emphasis on good quality nursing and less reliance on "chemical cosh" in the management of delirium. We probably should be quoting that. JFW | T@lk 11:33, 11 April 2011 (UTC)

I am just browsing through the pharmacological treatment bit - I groan when I see atypical antipsychotics classified as a homogeneous group (amisulpride is not an atypical by some definitions anyway). I find the idea of using an agent with anticholinergic activity (such as olanzapine) in treating delirium somewhat counterintuitive. Casliber (talk · contribs) 13:46, 11 April 2011 (UTC)

I've only put in what the sources say, but I understand your misgivings... JFW | T@lk 08:52, 12 April 2011 (UTC)

Next stop Cochrane and/or review articles I guess...Casliber (talk · contribs) 09:51, 12 April 2011 (UTC)

Of course "sepsis induced encephalopathy" is a type of delirium. When elderly females with an indwelling urinary catheter are hospitalized, and suddenly become disoriented and delusional after being initially oriented and mentally intact, sepsis heads the list of presumptive causes, even in the absense of fever. Nosocomial sepsis and poor use of neuroleptic psychoactives are probably the two most common causes of new-delirium on the non post-op hospital ward. I've seen a few cases of sepsis delirium blithely dismissed as "ICU psychosis" and "post-op fever", too. Making me wish the latter terms had never been invented (or every intern or resident threatened with extra on-call hours for using either of them except as a tenative diagnosis of strict exclusion).

I share misgivings of using neuroleptics (even the newer fancier ones with the glossy ads) in the treatment of delirium also. It probably comes from their routine use in treating paraphrenic paranoia in the elderly, but new paranoid delusions in a hospitalized patient are not the same thing as long, ongoing paraphrenia as a baseline in dementia. Delusions are very common in delirium, especially septic delirium, and what component of paranoia there is will likely depend on the patient's underlying psychology, level of anxiety, and discomfort. That means if you remove the discomfort and anxiety with opioids and benzodiazepines, you can often reduce paranoid delusions to comfortable and harmless delusions. That's sometimes very, very useful in a patient who has no baseline delusions, since it can be used to track treatment effectiveness in sepsis. I can't give you an immediate reference, but I've generally found that a new decrease in mental state as a result of sepsis in the elderly, is a far more sensitive and rapid test of the progress of the infection than fever, tachycardia, or even bandemia. Here's a paper looking at 65,000 ER admissions of which 10% had bacteremia, finding that altered mental status was the most sensitive of any of the immediate clinical or lab tests for finding bacteremia, though nothing was very sensitive [1]. However, if you've already determined the patient IS septic (thus you don't care about positive predictive value), I can tell you that it's a very sensitive way to tell that they're getting better. If the patient is smothered under a new antipsychotic, you can lose some of that.

Doctors who often give their non-schizophrenic/paraphrenic patients amisulpride or any other new-generation neuroleptics as temporary-symptom treating drugs, should try those drugs on themselves. Go ahead: take a weekend off, and experiment. You'll not only learn why these drugs are not DEA controlled-substances, and you'll learn something viscerally that you can't get from reading journals. SBHarris 17:29, 12 April 2011 (UTC)

Pain control is an accepted modality, as is clear from Inouye and NICE. What seems to be problematic is the treatment with benzodiazepines. Unless you can find a source supporting your argument, this will be hard to represent in the article.

I really wonder what your weekend on amisulpiride felt like! JFW | T@lk 20:03, 12 April 2011 (UTC)

Like crap! Only it was respiridone-- I actually have yet to try amisulpride, but don't expect much difference. They all feel much like haloperidol to me (so far). If I ever find one that makes the world more pleasant instead of dysphoric, colorless, and anhedonic, I'll know they've finally come up with a neuroleptic that HAS abuse potential. But until then, you know the lion by its paw print, and so long as none of these drugs are abused, you can infer (even if you refuse to try them youself) that there's a very good reason for the fact that they're not street drugs. And I've won a few bets with those I got to try them, who said they're not that bad. They are bad. If they didn't suck, people would take them to feel good, which they do not.

The last argument I get from my shrink friends is a somewhat elitist one: "They don't make you and me feel better (of course, of course, old man!), but they DO make psychotic people feel more comfortable ". But if you ask psychotic people, they tell you that the only comfort these things provide is to stop intrusive voices and thoughts, but the price you pay for that is anhedonia.

There are no good trials of benzos in delirium on the ward, and of the two you find in Cochrane PMID 19821364 one shows no (overt) difference between benzo and neuroleptic, for treating "aggitation" (type delirium) whereas a similar one showed that benzos are worse for treating "confusion" (type delirium). Well, sure-- that's expected. If the main component of your patient's delirium is not terror or fear, there's no point in using a drug that resolves anxiety but may well contribute to simple and non-distressful confusion (as of course do opiates, but we all give them a pass since we fear for our patients pain more than their anxiety-- even though anxiety is at least half of subjective pain). However, talking about neuroleptics, it were YOU lying there in that hospital bed with paranoid delusions, calling for HELP!, you'd probably want somebody to fix your fear, not turn you into a pliable zombie. That might look okay on the outside (it certainly cuts nurse staffing needs), but if you ask non-demented people later what that experience was like, after neuroleptics (or after getting nothing), they report very negative things.

In summary, the studies on this are not that good, and not that well thought-out or controlled. In part because the drug companies don't come out with newer and more expensive and (supposedly) side-effect free benzodiazepines every few years, which generate money for new trials. Of course that DOES happen for neuroleptics, now supposedly in their "4th generation". Bleh. Beware the bias of drug company money. Let me know if you find a recent study looking at ICU delirium and (say) haloperidol. "Use the new drugs quickly, young man, before they lose their effectiveness." And patent protection, and become ordinary nonexciting generics. SBHarris 20:51, 12 April 2011 (UTC)

ITU agitation

On intensive care, lots of other modalities are used that I've not included in the "treatment" section yet. If my memory serves, morphine, midazolam, fentanyl, and sometimes clonidine are used here. Interestingly, a recent critical care-based review of sepsis-induced encephalopathy (doi:10.1097/CCM.0b013e3181b6ed58) doesn't mention any of these modalities but chats about disease-modifying treatment only. Will need to have a better look. JFW | T@lk 08:52, 12 April 2011 (UTC)

doi:10.1093/bja/aep291 (Br J Anaesth 2009 - postoperative delirium and cognitive impairment)

doi:10.1378/chest.10-0466 (Chest 2010 - reducing iatrogenic risks: ICU-acquired delirium and weakness)

There's a lot about. JFW | T@lk 09:03, 12 April 2011 (UTC)