Talk:Delirium

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Redirected from "cognitive dysfunction" and "cognitive impairment"[edit]

Cognitive dysfunction or impairment needn't be severe (which delirium is stated as being in the intro, although this is contradicted later) and can have gradual onset, whereas this article insists on acute onset. There's obvious overlap in some symptoms, maybe occassionally treatment but I have never heard the type of impairments commonly described as "brain fog" for instance, described as delirium, but perhaps I'm wrong. I think either the delirium article needs to be broadened or more likely there should be a separate article for non-acute generally less severe cognitive dysfunction and/or impairment. Speaking as a lay person the impression I get is that delirium is more often associated with generally severe hallucination-inducing disorders such as high fevers whereas cognitive impairment is more often some degree of attentional or intellectual disability such as some loss of circumstantial problem solving (which could be severe but perhaps more commonly isn't). Vespadrun (talk) 20:52, 28 October 2012 (UTC)

"Acute" is defined as "hours to days, but not months or years." Any organic decrease in mentation that develops over years is called "dementia" not delirium. Delirium doesn't have to be severe, and I've corrected that. It can be a "brain fog" like state, and often is. The lay definition that suggests halucination is not correct (or at least, not complete). The medical definition includes all recent-onset cognitive impairments that have an organic cause. Thus, the total spectrum of cognitive impairment is a much broader thing that includes not only delirium, but also many other things that aren't delirium, such as learning and intellectual disabilities (what used to be called mental retardation), various psychiatric problems, effects of dementia, and so on. SBHarris 02:27, 29 October 2012 (UTC)

Proposed major revision[edit]

On behalf of the European Delirium Association and the American Delirium Society, we'd like to contribute to a major revision of this article. None of us are experienced Wikipedia editors, but we hope it will be a worthwhile endeavour given that this is designated 'high importance' but class-C article.

Proposed article structure

Initial (including clinical importance of delirium)

Definition

  • DSM v ICD
  • Why delirium is the preferred term
  • Delirium on the spectrum of acute brain dysfunction

Clinical importance by setting and predictors of outcomes

  • ICU
  • Hospital
  • Post-operative delirium
  • Institutional care
  • Palliative care

Signs and symptoms (Rewritten with contribution from David Meagher, 10.12.12)

  • Inattention and associated cognitive deficits (10.12.12)
  • Higher level thinking processes (10.12.12)
  • Circadian disruption (10.12.12)
  • Prodrome
  • Subsyndromal delirium
  • Persistent delirium (added 06.12.12)
  • Acquired dementia (added 06.12.12)

Pathophysiology

  • Animal models of delirium (added 12.12.12)
  • Insights from clinical studies (CSF, MRI, EEG) (added 31.01.13)

Causes (added 8.2.13)

  • Discussion of the inverse relationship between predisposing and precipitating factors (and the common causes), rather than the rather long list which is ultimately not very informative.

Prognosis (added 20.11.12)

  • Mortality
  • Institutionalisation
  • Dementia
  • Cost

Diagnosis in different care settings

  • ICU (added 06.12.12)
  • Hospital
  • Institutional care

Prevention (covering the major RCTs)

  • Pharmacological
  • Non-pharmacological

Treatment (covering the major RCTs)

  • Pharmacological
  • Non-pharmacological

It's likely that we'll need some support as we do this, but we're keen to contribute to (and maintain) the article. The board members of the EDA and ADS number around 35 persons with a multidisciplinary background and experience in research, clinical practice and education, so I think we should be able to offer a balanced article.

Please leave any suggestions and advice here. Thanks and best wishes, Dhj davis (talk) 07:03, 13 November 2012 (UTC)

I am aware of the project and am very pleased that the EDA recognises the need of a high-quality Wikipedia article on the condition. I will post a message on WT:MED so other editors can watchlist this article and provide support when needed. I agree with the basic structure, which is aligned broadly with WP:MEDMOS. However, I would not use the "classification" section to explain why delirium is clinically important - this is something better done in the introduction and in the prognosis sections. As for "delirium is special settings", perhaps this is best integrated with "signs and symptoms", "diagnosis" and "treatment" insofar possible. JFW | T@lk 08:24, 13 November 2012 (UTC)
Thanks JFW. We've taken out the epidemiology section and defined the different settings earlier on, these distinctions can then be referred to in the later sections as you suggest. I'm not sure it's correct procedure to edit back on a talk page, but I thought it would be easier than reproducing the whole outline again. Hope that's OK. Dhj davis (talk) 15:39, 13 November 2012 (UTC)
I've added a section (Adverse Outcomes) to test the process a bit, very happy for comments. I know I haven't done the citations correctly, they seem to repeat themselves, but I'll look into this and learn how to fix it. I'm mainly interested in whether the addition is well-received. I should also point out that I'm an author on one of the (peer-reviewed) articles cited, but I hope that doesn't contravene NPOV. Dhj davis (talk) 19:25, 20 November 2012 (UTC)
Looks good, but please avoid primary sources in favour of reviews and textbooks. Very recent studies do not necessarily need a mention. JFW | T@lk 00:22, 21 November 2012 (UTC)
Thanks JFW, I'll think about the sources. The difficulty is that recent (uncontroversial) studies make the article up to date, but they haven't necessarily filtered through to reviews and textbooks yet. What do you think about actually using 'Uptodate' (the website) as a secondary source?Dhj davis (talk) 12:07, 23 November 2012 (UTC)
Bit more to be added today on ICU delirium, from Wes Ely. Dhj davis (talk) 10:20, 6 December 2012 (UTC)
And some reorganisation of the phenomenology section from David Meagher (more citations to be added)Dhj davis (talk) 22:06, 10 December 2012 (UTC)
I support using UpToDate. Thanks. Sorry I haven't been around to help more. Biosthmors (talk) 22:21, 10 December 2012 (UTC)
Applying WP:MEDREV with wise editorial judgement is another option. Biosthmors (talk) 22:23, 10 December 2012 (UTC)

──────────────────────────────────────────────────────────────────────────────────────────────────── New section on pathophysiology added. I think we'll continue to add some more sections and when all this is complete, I think we could use some help in editing for overall tone and perhaps cutting down the length. One major overhaul I think is necessary is the Causes section. Delirium is a sensitive marker of illness, so it's very non-specific, i.e. probably anything can cause delirium. I think the section needs a discussion on how predisposing factors interact with precipitating factors, perhaps reviewing just the most common processes, e.g. drugs, hypoxia, infection. Thank you again for your guidance throughout. Dhj davis (talk) 10:41, 12 December 2012 (UTC)

Some further additions on clinical pathophysiology studies, summarising information from 3 systematic reviews. Where additional studies have been referred to since the publication of the SRs, these were (systematically) identified by re-running the searches detailed in the original SRs.Dhj davis (talk) 00:06, 1 February 2013 (UTC)

Experienced editors interested in supporting new editors[edit]

Per the proposed revision above, new editors are welcome to contact any editor listed below on their talk page for specific questions about how to edit Wikipedia. Also, the "Teahouse" is designed to be a welcoming place, and the links at {{MedWelcome-reg}} are useful because they contain good links and ways to contact other editors for help.

Comments[edit]

  • Can't we name "Adverse outcomes after delirium" just "Prognosis" per WP:MEDMOS?
yep. done Casliber (talk · contribs) 06:43, 21 November 2012 (UTC)
  • If it is causative, let's specify a mechanism. If it's just a consistently observed association, let's just state that it is associated?
not so easy. can be very difficult in hospital inpatients with complex medical problems to deifinitly assign causes. Casliber (talk · contribs) 06:43, 21 November 2012 (UTC)
These are consistently observed associations from prospective studies. These can't on their own make causative claims. Dhj davis (talk) 12:07, 23 November 2012 (UTC)
  • "It" is "long-term poor outcomes", which is too vague.
  • "Only studies that looked at the independent effect of delirium were included". How can we be certain that methodologically they corrected for all confounding variables? That overstates the source, most likely.
This was a rigorously conducted systematic review and an inclusion criterion was that all associations were adjusted for age, sex, etc, but *also* that predisposing factors (e.g. baseline frailty, dementia) and precipitating factors (e.g. illness severity, physiological and metabolic parameters) were adjusted for. Of course, this is a meta-analysis of observational data, so there is always a risk of residual confounding, but it's the best estimate we have. Dhj davis (talk) 12:07, 23 November 2012 (UTC)
  • We shouldn't be describing studies this much "(i.e., after accounting for other associations with poor outcomes, for example co-morbidity or illness severity)." Encyclopedias just state the facts. Studies have limitations. So then we just state the facts as best we can given those limitations.
Thanks, that was what I was trying to do - show that the systematic review had considered these limitations and accounted for them. (see below about my WP:MEDRS question). Dhj davis (talk) 12:07, 23 November 2012 (UTC)
  • "A systematic review collected all studies that followed-up this population for at least three months after discharge from hospital." Irrelevant. Of course we should be using WP:MEDRS. Let's just state the facts.
For my clarification, is the spirit of WP:MEDRS that because this is a systematic review in JAMA (i.e. reliable), it's not necessary to add detail qualifying the nature of the study (methods etc)? I'll take that out. On the other hand, any tips on how to balance this with overstating the source (as above)? Dhj davis (talk) 12:07, 23 November 2012 (UTC)
A late reply but no, it's not necessary to qualify the nature of the study. Biosthmors (talk) 20:27, 18 January 2013 (UTC)
  • "One study has investigated these same associations in the general population, and found consistent results". How can we be certain this isn't cherry-picked? This is why we use reviews and follow WP:MEDREV
Thanks for pointing this out - it does read like it's cherry picked, but in fact it's the *only* study of delirium outcomes in an unselected, general population. It's the study I'm an author on, but I wouldn't want you to think that compromises WP:NPOV. It's not a controversial finding, and strengthens the results of the systematic review in the population of hospital patients. The reason for it being mentioned it that it overcomes some of the biases that the systematic review is vulnerable to (because that only studies persons in hospital once delirium has developed, without the advantage of prospective, pre-delirium cognitive assessments (i.e. a 'before' and 'after' picture).Dhj davis (talk) 12:07, 23 November 2012 (UTC)
  • Those are my comments just for the first paragraph of that section. I can't say I like anything it says. I'm glad you're here to help out!
  • The rest of the section probably doesn't need any level three subheadings (such as ===Death===) which should probably just be mortality/mortality rate in prose, I imagine.
  • Costs should go under Society and culture per WP:MEDMOS. If enough data exists, an Economics section can stand alone. Biosthmors (talk) 06:14, 21 November 2012 (UTC)

Addition 6 Dec[edit]

The following sentence was added:

It is not as important which tool is used as that the patient gets monitored. Without using one of these tools, 75% of ICU delirium is missed by the practicing team, which leaves the patient without any likely active interventions to help reduce the duration of his/her delirium.

This requires a source, particularly because a numerical claim is made, and gives the suggestion of passing judgement. JFW | T@lk 20:29, 6 December 2012 (UTC)

Thanks JFD. The primary study where the 75% figure comes from is this one: PMID 21514176, but I've gone for a secondary source that also mentions it. Dhj davis (talk) 21:26, 6 December 2012 (UTC)
Fantastic. JFW | T@lk 23:21, 6 December 2012 (UTC)

Drugs versus Medication[edit]

In the section Delirium#Causes, there are separate sub-sections for "Medication" and "Drugs". Should these not be combined, particularly as medication is also referred to as a pharmaceutical drug? Also, the sub-section "Substance withdrawal" should be merged into "Drugs" (where it is already discussed). I don't want to do this myself as this is not my area of expertise. HairyWombat 23:15, 21 January 2013 (UTC)

Agree, and we will address this when the 'Causes' section is overhauled. Dhj davis (talk) 00:06, 1 February 2013 (UTC)
Just started the causes section, but called away before adding references etc. Will return to this shortly. Dhj davis (talk) 17:06, 8 February 2013 (UTC)
Admittedly more to do with the references, but I've run out of time for now....Dhj davis (talk) 20:31, 8 February 2013 (UTC)
Thanks for your edits! Biosthmors (talk) 20:51, 8 February 2013 (UTC)
The list looks good. Could I recommend that nested lists of causes are converted to tables? See WP:EMBED. You could grab the code from hypopituitarism or pneumothorax where I used this approach. JFW | T@lk 23:50, 9 February 2013 (UTC)

Good Article aspirations[edit]

Just to point out that Delirium is on this list: Wikipedia:WikiProject Medicine/Good article goals for 2013, and that the European Delirium Association and the American Delirium Society will be helping with edits here over the next few months.Dhj davis (talk) 00:06, 1 February 2013 (UTC)

Emergency medicine[edit]

Delirium in the Emergency Department - doi:10.1136/emermed-2011-200586 JFW | T@lk 20:48, 21 March 2013 (UTC)

Delirium should be contrasted with dementia[edit]

Hence dementia is "chronic" loss of cognition, whereas delirium is "acute" loss of cognition. PS: Delirium and confusion are distinct (from a psychiatric perspective)-since confusion occurs to everyone, and delirium - does not. 129.180.175.45 (talk) 09:05, 25 October 2013 (UTC)

I've read through it more thoroughly, and it just is really badly written. For example, in the opening paragraph, essentially, it is NECESSARY to refer to the DSM diagnostic criteria. Not just what "somebody thinks" 129.180.175.45 (talk) 23:29, 25 October 2013 (UTC)

Merger proposal[edit]

CLOSED:

Consensus rejects merging of Mental confusion article(s) as per wp:Snow. Non-Administrative closure-- GenQuest "Talk to Me" 22:40, 22 January 2014 (UTC)

The following discussion is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Received request to merge the Mental confusion (edit|talk|history|protect|delete|links|watch|logs|views) article into the Delirium (edit|talk|history|protect|delete|links|watch|logs|views) article on 14 November 2013. Discuss it here. GenQuest "Talk to Me" 02:21, 15 November 2013 (UTC)

  • Disagree, I believe these have different social and cultural connotations and shouldn't be merged. --LT910001 (talk) 03:02, 16 November 2013 (UTC)
  • Disagree Indeed they overlap but are different. A person with dementia, for example, may have permanent mental confusion, but is not delirious. And some set of delirious people are not actually confused (disoriented, etc) but simply have an inability to focus (like temporary ADD, or even ADHD). And of course some delirious people are simply drowsy, but again not confused. Anybody who hasn't slept in 48 hours or more will be clinically delirious. How confused they are, depends on the person. SBHarris 03:01, 23 December 2013 (UTC)
  • Disagree for reasons stated. JFW | T@lk 14:52, 23 December 2013 (UTC)

The discussion above is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Age as predictor[edit]

The article was changed by QuintBy (talk · contribs):

It is a syndrome which occurs more frequently in people in their later years although it is unclear whether it is in fact a function of age per se or whether it is simply a reflection of the fact that older people tend to develop critical illness more frequently.

I would like to see the source before this sentence can be allowed to stand. In daily practice it is exceedingly common for elderly people to develop delirium in the context of really very mild acute illness, while in younger people you need to be critically ill before that happens. For the moment I've taken out the entire sentence. JFW | T@lk 07:35, 19 January 2014 (UTC)

Thank you JFW and I agree with you! However, since there seems to be no controversy about "It is a syndrome which occurs more frequently in people in their later years" I put that sentence back in. Lova Falk talk 19:55, 19 January 2014 (UTC)
I don't mind having it put back, but QuintBy seemed to be challenging it. JFW | T@lk 20:18, 19 January 2014 (UTC)
I cannot see that QuintBy challenges the higher prevalence, which is exactly what we say in this sentence. Lova Falk talk 20:34, 19 January 2014 (UTC)
The obvious conclusion which the original author intended to convey was that older people are more susceptible to ICU delirium. What I suggested is that it is "unclear" whether the more frequent occurrence in older people is a function of their being old or whether it is simply a function of their being present in ICUs more often. If there is in fact research which establishes that what I called "unclear" is in fact "clear" then I believe it is incumbent upon the reverter to cite a reference which reached that conclusion. I don't think there is any such research. On the other hand, the October 2 (or 3), 2013 edition of the New England Journal of Medicine includes a research paper which either explicitly or implicitly states that ICU delirium occurs at approximately the same rate in all age groups, genders, etc. Unfortunately, NEJM current maintains an embargo on this article. I will probably reinstate with general reference to the article. But before I do I want to give the reverter a chance to include the research he/she claims makes it "clear".QuintBy (talk) 22:16, 19 January 2014 (UTC)
QuintBy, when you add text you also need to add a source for your text - even when stating something is unclear. It is not up to the reverter to find a source that supports the revert, it is up to the author of the added text to find a source that supports the addition. Lova Falk talk 08:53, 20 January 2014 (UTC)
We need a secondary source for your claim, as outlined in WP:MEDRS. It bears remembering that delirium is exceedingly common in hospitalised (and even community-dwelling) people, predominantly the elderly. ICU cares for only a small proportion of those people. You might be right that on ICU everyone is so unwell as to carry a roughly equivalent risk of delirium, but this does not apply to other groups. JFW | T@lk 20:29, 20 January 2014 (UTC)
You will note that 'ICU delirium' redirects to "Delirium", meaning that the article is supposed to refer to BOTH conditions. I believe I was quite careful to note that what I was referring to is ICU delirium. It is indeed a shame that some misguided editor decided that everything to do with delirium should be contained in one article, but there it is. I can certainly see how someone who works only in a nursing home environment would come to believe that only older people develop delirium. There are, after all, no younger patients there with rare exception. — Preceding unsigned comment added by QuintBy (talkcontribs) 20:43, 22 January 2014 (UTC)

(undent) QuintBy Sorry, I cannot let that go unchallenged. Your edit suggested that age was not a predictor of delirium risk,[1] which is amply contradicted both by experience and by data. You noted the distinction only in your edit summary, which is not visible to readers who are simply perusing the article.

I don't think the decision to discuss all forms of delirium in a single article is "misguided", nor was it the decision of a single editor. Much of what we know about delirium in the frail elderly comes from studies in ICU delirium, and the pathophysiology is one and the same. The management strategies, too, are very similar (e.g. reorientation, low-stimulus nursing, pharmacotherapy). JFW | T@lk 21:39, 22 January 2014 (UTC)