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Editor’s Note
While it may be true that a rose by another name would still smell as sweet, there is value to calling things by their correct names. What is a good word to describe the agitated and confused patient? There are many possible terms, more than 25 by one count, but let us consider the term delirium. The word has been in use since the mid-16th century. It was derived from two Latin words, de (“away”) and lira (“ridge between furrows”). The combination “delirare” literally means to “deviate from the furrow.” As used, it meant to deviate or be deranged. Use of the word peaked in the second half of the 19th century and declined in the 20th century as descriptive terms, such as altered mental status, acute confusional state, or encephalopathy, came into common use. This is partly a shame. The word delirium packs a wallop’s worth of meaning into just eight characters. Fortunately, it never went away completely, being established in 1966 within the Medical Subject Heading structure developed by the National Library of Medicine. The word is undergoing something of a rebirth as clinical investigators are rediscovering its utility. The European Delirium Association, the American Delirium Society, and the Australasian Delirium Association, professional organizations formed to study this syndrome, have embraced the term delirium.
Delirium and encephalopathy often are used interchangeably in the clinical setting as well as in the research and literature. Unfortunately, medical diagnosis coding using either ICD-9 or ICD-10 has not kept up with modern understanding of this syndrome. Instructions for medical diagnosis coders often direct using delirium when the symptoms result from psychiatric origin and reserve the use of encephalopathy for a brain malfunction that is a result of an acute or chronic medical disease state. This should not be of importance, but the Centers for Medicare & Medicaid Services gives the nonspecific behavioral diagnosis of delirium a lower severity than the pathophysiological diagnosis of encephalopathy. Doing this often enough can begin to affect things like risk adjustment, hospital profiling, and payment. How many of you have been advised by your coders to use the diagnosis of “acute toxic encephalopathy” as a diagnosis for the agitated and confused patient? I have.
So back to the beginning. Delirium...