Delirium and numbers

 

I been meaning to write this for a couple of years; the relationship between numbers and delirium… Let me explain.

You see, there is at times an incredible focus on the numbers associated with people who find themselves in hospital; I’ll give you an example –

Sodium 141

Potassium 4

Urea 7

Creatinine 98

Glucose 5.4

CRP 0.6

I could go-on. The bottom line, is, that these numbers are all within the normal range.

The normal range relates to something statisticians describe as being the numbers which are most common in a certain population. In other words, the normal might not be that normal if the population is odd.

If you take running speed.

For a class of 13 year olds, this might be a certain ‘x’ mph, whereas for 80 year olds the normal speed might be ‘y’ mph. The numbers don’t specifically matter.

Outside this normal distribution, you will have someone like Flying Philip Rabinowitz who, before he died in 2008 held the 100m record for a 100-year-old (30.86 seconds).

You see, normal is as Hemingway says, a Moveable Feast.

Back to the numbers.

There are within certain branches of medicine a fixation with numbers – usually this is when those without an adequately deep understanding of sickness and health, where too high or too low a number isn’t normal, and is interpreted as not right.

This is medicalese for ‘the computer says no’

Translating all of this to the world of delirium –

One of the challenges we sometimes encounter in hospital is determining whether an individual’s behaviour relates to delirium or dementia.

This is important to establish, as I have previously described – those experiencing delirium often, given great care and support, are able to fully recover, whereas, for those who have dementia, the prognosis is different.

In most situations, you can compare this with a standard reference chart found in text-books which differentiate delirium from dementia:

 

In a hospital setting, this is complicated, as the entire experience is delirioigenic – (a word I have invented, meaning ‘inducing or leading to delirium’) – the changes of staff, the light, the bed-moves, medicines, doctors, therapists, nurses; cardiac arrests, or shift-changes; phlebotomists, radiographers, coordinators or social workers, all passing in and out of your experience, unpredictably, erratically, inconsistently.

Were you to seek a recipe for delirium – admission to hospital would be the primary ingredient.

Therefore, trying to determine whether an individual’s confusion is because of delirium or dementia can be difficult.

My most frequent management plan in these situations is to advise discharge – get the person home and allow normality to sort them out.

Sometimes, this is not straightforward.

A complication relates to the situations where the clinical team needs to decide… delirium or dementia…

This is when the numbers game is played.

Sodium or urea too high > dehydration > delirium > > >

For certain mental-health teams, this is a point of disconnection, where the psychiatrists say – physical and the physicians who asked for help from the psychiatrists are left floundering (I met someone like this today – hence the blog) (aka diagnostic/therapeutic tug-of-war)

This goes to the core of the mental and physical health divide.

Most might not realise this exists; you see, some conditions are considered physical (at times called organic), others functional;

Here is a list of the medical and physical conditions:

Physical (organic)

Pneumonia, Diabetes, Epilepsy, Schizophrenia, Dementia, Bipolar Disorder; delirium

Psychological (functional)

Depression, anxiety, Irritable Bowel Syndrome, Fibromyalgia, Chronic Fatigue.

I don’t know that much about the pathogenesis of either – physical or psychological; my understanding however is that in this modern age of genomics & men on the moon, everything is organic.

If I feel fed-up – this is organic; there are strands of RNA inside cells in my brain replicating and sub-dividing, secreting chemicals and hormones that make me feel or perceive the situation a certain way; if, I have septic-shock because my immune system is overwhelmed by the meningococcus, different cells will be replicating, dividing, responding.

It is all cells & chemicals.

Yet, when it comes to the way health is interpreted, dementia is considered a mental health condition (with various causes – Alzheimer’s, Vascular, Alcohol, etc) and delirium, a physical health condition (like, Pneumonia, Epilepsy, Stroke).

I appreciate this is confusing. I often find myself struggling.

I think what I am trying to express is my exasperation at the divide between physical and mental health, functional and organic disease.

You see, everyone who is in a state of dis-ease or ill-health needs the same things;

For those conditions which respond to treatments or remedies, we need tablets and love; for those without the tablets, whether in the form of placebo or not, we need at the very least, love.

Love – this is care, support, attention and a sensitive ear.

And back to the numbers – those which are sometimes used to define a pathway or an individual;

You are my patient because your CRP (C-Reactive Protein – a marker of infection or inflammation which often increases in situations of physiological stress or distress) is elevated – this is something medical; I can’t help you because your CRP is normal – this must be within the sphere of the head-shrinker.

No, no, no.

Let us all come together and acknowledge what is self-evident; what is before our eyes.

People are more than their numbers.

Sure; you can tell a lot from the numbers:

T 39, P120, BP 80/50, Sat 88, BM 2, GCS 13… All say something to those doctors and nurses out there who can recognise critical illness, yet when the numbers are normal, this does not necessarily mean all is well. Numbers are just statistical aberrations.

I began writing about numbers and here I will end.

Let us not make enemies of the numbers.

Let us remember that they have brought us wonderful things;

At the same time, let’s not be limited by them, let us not obsess or forget where the numbers have come-from.

Numbers are relative, people are absolute.