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Alasdair MacLullich @amaclullich.bsky.social · 8h

“Months of the year backwards, starting with December?” “December. November. October. September. No. Wait. I’ve lost it.” Thirty seconds, no kit. Inattention is the core feature of delirium, and this is the 4AT's attention item. Her full score: 6 of 12; 4 or more is positive. #delirium #4AT

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Alasdair MacLullich @amaclullich.bsky.social · 15h

"What would make this treatment worth it for you?" The answer is rarely the number we were planning to improve. More often it is getting to the toilet unaided, sleeping through, fewer hospital trips, being at a wedding in May.

Illustration of an older adult speaking with a younger adult across a table at equal eye level. The question reads: “What would make this treatment worthwhile for you?”

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Alasdair MacLullich @amaclullich.bsky.social · 20h

"They told me I'd been 'a bit confused'. That is not what it was like." For the patient, delirium can be terror and certainty of harm. When we call it "a bit confused", we wave away the worst hours of their life. Match your language to their reality. #delirium

Quote card, cream background with a red bar. "They told me I'd been 'a bit confused'. That is not what it was like." Below: "For the patient, delirium can be terror. Match your language to their reality." Footer: "Patient and carer experiences", "@think_delirium".

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Alasdair MacLullich @amaclullich.bsky.social · 01/10/2026

Caring for a family member with dementia? iSupport offers free online learning and support. There are versions for adult carers, young people, rare dementia carers, and South Asian carers. Choose what fits your situation. isupportdementiacarers.co.uk/

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Alasdair MacLullich @amaclullich.bsky.social · 01/10/2026

Fitting a hearing aid and using a hearing aid are different achievements. Can they get it in? Get it out? Clean it? Change or charge the battery? Ask them to show you, rather than asking whether they are managing.

Illustration of an older woman holding a small behind-the-ear hearing aid while a clinician watches attentively. An open hearing-aid case sits on the desk. Text asks “Can it be used at home?” and says “Ask for a demonstration”.

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Alasdair MacLullich @amaclullich.bsky.social · 01/10/2026

The journal Delirium, told backwards. 2026: 60 papers, 412 authors, 25+ countries. 2022: the first journal dedicated to delirium (sudden confusion caused by illness) launches. Antiquity: doctors describe delirium. The next line is your paper. deliriumjournal.com/for-aut...

Card from the journal Delirium: Described for more than two thousand years. No journal of its own until 2022. deliriumjournal.com

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Alasdair MacLullich @amaclullich.bsky.social · 30/09/2026

Delirium comes on in hours and can take weeks to clear. Onset: hours to days. Clearing: days to weeks. Full recovery: sometimes months, and not always complete. Tell families early. Expectation is part of the care. #delirium

Card headed "DELIRIUM", titled "THE TIMELINE". Onset over hours to days; causes treated over days; clears over days to weeks; full recovery sometimes weeks to months, and not always complete. In red: "Tell families early. Expectation is part of the care." Handle @think_delirium.

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Alasdair MacLullich @amaclullich.bsky.social · 30/09/2026

Most invitations ask an older person to attend something. Fewer ask what they would like to contribute. A role someone can shape, or turn down, is a different offer from a chair with their name on it.

Illustration of an older woman demonstrating stitching on a patterned cloth while two adults watch with interest in a community room. An empty chair is in the foreground. The only heading asks “What would you like to contribute?”

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Alasdair MacLullich @amaclullich.bsky.social · 30/09/2026

Study spotlight: older adults given trazodone (a sedating antidepressant) for delirium symptoms after discharge had fewer readmissions and deaths than those given antipsychotics. 41,268 older adults (Yang et al., Lancet Healthy Longevity 2025). Observational (not a randomised trial). #delirium

doi.org

Redirecting

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Alasdair MacLullich @amaclullich.bsky.social · 29/09/2026

Tapering a medicine takes more than a smaller prescription. The person needs to know who to contact, which symptoms to report, and when the next review is booked. Without those three, they stop on their own and stop badly.

Illustrative consultation scene. An older woman in a teal cardigan and a pharmacist sit at the same table, facing each other beside a blank plan sheet. Large text reads ‘A supported medicine taper’ and ‘Agree the plan’.

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Alasdair MacLullich @amaclullich.bsky.social · 29/09/2026

A fall is an event with a sequence. What were they doing before? Any warning? What do they remember? What happened afterwards, and how long were they lying there? Let the story, not a risk score, direct the assessment.

The heading “During the fall” appears above one large empty teal speech bubble on a warm white background, introducing discussion of what the person remembers.

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Alasdair MacLullich @amaclullich.bsky.social · 29/09/2026

The 4AT (a delirium test) needs no family informant. Mr Williams is markedly drowsy, yet last week he collected his prescription in person: evidence of acute change. Alertness 4, questions 2, attention 2, acute change 4: 12/12, possible delirium. Score item 4 from the evidence. #Delirium #4AT

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Alasdair MacLullich @amaclullich.bsky.social · 28/09/2026

Student nurse, 3 am, told 'he's always like this'. Checks the notes anyway. He was gardening on Saturday.

Baby Yoda looking surprised. Top band: 'Student nurse, 3 am, told he's always like this.' Bottom band: 'Checks the notes. He was gardening on Saturday.'

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Alasdair MacLullich @amaclullich.bsky.social · 28/09/2026

Two clocks count at discharge. The one on the ward, showing when the person leaves. And the one at home, showing when the first care visit arrives. The gap between them is somebody sitting in a cold house.

Graphic headed “Two times to check”. An unnumbered clock outline with no hands appears above each of two empty doorways, labelled “Leaving hospital” and “Support available at home”. A short line with a gap links the doorways.

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Alasdair MacLullich @amaclullich.bsky.social · 28/09/2026

In older adults, serious illness often has none of the textbook signs. Sepsis without fever. Heart attack without chest pain. What shows instead is new confusion. Delirium can be the only visible sign of an emergency. Work it up. #delirium

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

In dementia, rehabilitation aims at something the person wants to keep doing: making the tea, managing the post, getting to the shop. Start from the task, not the deficit.

Illustration of an older woman seated at a home table with a rehabilitation professional. She points to keys in a bowl beside an organiser and an unnumbered calendar. Text says “Start with a task that matters” and “Dementia rehabilitation”.

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

Goya, "Self-Portrait with Dr Arrieta" (1820): the painter, half-collapsed after a fever that nearly took his reason, is held up by his doctor. One of art's great images of dangerous illness, and the one steadying figure a frightened patient needs. #delirium #art

Oil painting. A grey faced elderly man slumps back in bed, clutching the sheet; a younger man in a green coat supports him and holds a glass of medicine to his lips. Three shadowy faces watch from the dark. Spanish inscription at the foot: Goya thanks his friend Arrieta for the skill and care with which he saved his life in the acute and dangerous illness he suffered at the end of 1819, at seventy three years of age; painted in 1820.

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

"I should have realised sooner." Carers carry that for years. Delirium is missed daily by trained professionals. A relative who noticed something was wrong at all has often outperformed the system. Raising the alarm was the job. #delirium

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

"You've lost weight!" is not a compliment until you know whether it was on purpose. When did it start? What changed then? Has eating become harder, or shopping, or cooking?

Illustration of an older woman and a clinician seated at a desk, talking face to face, with an unnumbered line on a sheet of paper. Large text asks, “Was the weight loss intended?” and says, “Ask about the change”.

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

Mr Smith is awake and answering questions. His daughter says: “He was much clearer yesterday.” His 4AT score is 7/12: possible delirium. A two-minute animated case on recognising delirium: alasdairmaclullich.substack.com/p/awake-and-...

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

The Clinical Frailty Scale is quick, familiar, and not suitable for everyone. Its developers say it has not been shown to work in people under 65, or in those with a single, stable, lifelong disability. Check the fit before asking for the number.

dal.ca

Clinical Frailty Scale

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Alasdair MacLullich @amaclullich.bsky.social · 27/09/2026

Major surgery places stress on the whole body and can be followed by delirium. New confusion after an operation needs assessment.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

Denosumab is not a fire-and-forget injection. Missing or stopping it without a plan can be followed by rapid bone loss and spine fractures. Whoever gives the first dose owns the question of who gives the next one.

The heading “Denosumab needs a long-term plan” sits above a calendar with blank cells. Linked circular illustrations show a clinician and an older woman in conversation. The prominent sentence below reads “Discuss any delay or stopping with the treating clinician”.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

A representative case, details changed for anonymity: "It wasn't until a geriatrician reviewed my mother's medications that we found the cause of her sudden confusion. A new sleeping pill... Within two days of stopping it, she was back to her old self." #delirium

An older person's hand rests on a hospital bed table next to a small clear plastic medicine pot holding five pills: two white capsules, two blue ones and a small orange tablet. Pale blue bedding behind.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

Free dementia courses for families and carers: The Empowered Caregiver, Alzheimer's Association. Topics include communication, independence, and behaviour changes. Account required; services information is US-based. www.alz.org/help-support/re...

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

Someone can look settled in bed and still have pain that makes the next movement impossible. After a hip fracture, ask about pain on turning, on washing, on standing. Asking only about pain at rest misses the pain that stops them moving.

Illustration of an older grey-haired man seated calmly in a stable teal armchair, with his feet on the floor. A plant stands beside the chair. The large heading asks “Pain at rest?”.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

The word "delirium" comes from the Latin "de lira": off the furrow, or off the track. Celsus (25 BCE-50 CE) first used it to describe acute mental disturbances with fever. 2000 years later we're still very much on a learning curve to get the basics right.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

Palliative care can start long before the last weeks. It can run alongside treatment that is still aimed at the illness, and it covers symptoms, practical worries, and what the person wants from the time. Start it when the need is there, whatever the prognosis.

Illustration headed “Care can run alongside care”. Two parallel arrows are labelled “Treatment of the illness” and “Support for living with it”, with an older adult, a consultation and everyday activities.

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Alasdair MacLullich @amaclullich.bsky.social · 26/09/2026

Replace ‘pleasantly confused’ with a clinical description. A cheerful appearance does not show whether the person is safe or free from distress.

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

A continence problem has a setting as well as a cause. The door that is hard to open. The clothing that takes two minutes. The call bell answered in five. Time the whole journey before calling it incontinence.

Illustrative room with an armchair and a call bell on its arm. A dotted route leads to a visible toilet, with a trolley narrowing the approach. Text says “Continence care includes access” and “The route. The clothing. The help.”

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

Give the family a job. Watching someone you love be confused, with nothing to do, is its own suffering. Hand them a role: bring the glasses, a photo, sit, talk about ordinary things, tell us when he seems himself. #delirium

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

A good seated blood pressure is no reassurance in someone who is dizzy on standing. A reading means more when you know how it was taken. If the symptom happens on standing, measure on standing.

Illustrative scene of the same older woman now standing beside a clinician, with a stable chair nearby. They talk face to face. Text reads ‘Symptoms on standing’ and ‘Assess the change’. No blood-pressure values are shown.

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

'Our delirium rate is 2 per cent.' Your screening rate is 2 per cent. Those are different numbers and only one of them is being reported.

Business Cat wearing a shirt and tie. Top: 'Our delirium rate is 2 per cent'. Bottom: 'Your screening rate is 2 per cent. Those are different numbers.'

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

A glucose monitor can work perfectly and still be unusable by the person holding it. Can they see the display? Manage the buttons? Hear the alarm? Know what to do about the number? Watch them use it once.

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Alasdair MacLullich @amaclullich.bsky.social · 25/09/2026

Families should hear the same core explanation from each part of the team. Conflicting messages add avoidable anxiety.

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

An old study can appear under a brand new headline. Check the date of the original peer-reviewed paper, not the date it was posted or the date the webpage says it was updated. Old is not the same as wrong. Mislabelled is a different problem.

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

Missed #delirium = longer stays, more complications, higher mortality, massive costs. But hey, at least we saved 2 minutes by not doing a 4AT (the delirium test) in the emergency department.

A young woman with long wavy auburn hair in a red knitted jumper stands against an orange background. She holds her fingers in an L shape against her forehead, the loser sign, and looks at the camera with a dismayed expression.

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

A pain score of 7 out of 10 tells you one thing. What the pain is stopping someone doing tells you more. Holding a cup. Getting dressed. Making a meal. Reaching the bus stop. Pick the one they want back, and measure that.

Illustrative consultation scene of the older man in a navy jumper discussing a plan with a physiotherapist. His teal mug and a blank plan sheet sit on the table. The heading reads ‘Agree the plan’.

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

For delirium researchers: Publishing delirium research should not require a four-figure fee. Delirium is open access: €20 to submit and a €280 publishing charge (APC) on acceptance. Peer review normally takes an estimated 4 to 6 weeks. deliriumjournal.com/for-aut... #Delirium

deliriumjournal.com

For Authors | Delirium

The open-access home for delirium research, quality improvement, reviews, protocols, and case reports.

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

Waking from anaesthesia into blur and silence is disorientation by design. Glasses and hearing aids should travel to theatre with the patient and go back on as they wake. Cheap, kind, protective. #periop #delirium

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

The 4AT (a bedside delirium test scored 0 to 12) does not need a family informant. Mr Williams is markedly drowsy. Evidence of recent independent activity supports an acute change: alertness 4, questions 2, attention 2, acute change 4: 12 out of 12. Score item 4 from the evidence. #Delirium #4AT

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Alasdair MacLullich @amaclullich.bsky.social · 24/09/2026

"They've tried the non-drug approach" can mean two very different things. A leaflet of sleep hygiene tips is not cognitive behavioural therapy for insomnia. CBT-I is a structured course of treatment, and NICE puts it first for long-term insomnia.

Illustrative consultation scene of an older woman in a teal blouse speaking with an attentive female clinician at the same table. A blank notebook sits between them. Text reads ‘Persistent insomnia’ and ‘Assessment’.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

A digital front door makes care easier for most people. It still needs an answer for the person who is unable to use it, and that answer should be a real route rather than a sentence in a policy. Who picks up the phone?

Graphic headed “A usable route to care”. One older adult uses a smartphone under “Digital access”; another speaks on a telephone under “Support and alternatives”. Equally prominent paths lead to the same clinic entrance.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

Robert-Fleury's painting of Pinel striking the chains from asylum patients (1876) commemorates a radical idea: the confused are ill, not dangerous, and care beats restraint. Modern delirium practice is the same argument in modern dress. #delirium #history

Nineteenth-century painting. In the stone courtyard of an asylum a young woman in a white gown stands with her arms out while a restraint is unbuckled from her wrist. A man in a dark coat and a crowd of onlookers watch from the left. Women in ragged clothes sit and lie along the wall on the right, one being unchained on the ground, with discarded irons on the flagstones.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

A walking plan needs somewhere to happen. Look at the route from the person's chair. Is it clear? Is the frame within reach? Is there anywhere to sit halfway? A plan with no usable route is not a plan.

Illustration of a clear hospital corridor with wall handrails. A stable rest chair and unoccupied walking frame stand to the side, outside the main route. Text reads “Where will the activity happen?”, “Route • Equipment • Support” and “Illustrative setting”.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

"Denies pain" means little from a patient who is unable to say where it hurts. In dementia and delirium, pain hides as agitation or silence. Use an observational pain tool, treat, reassess. Painkillers before tranquillisers. #delirium

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

Overnight confusion and agitation, clearer this morning. The 4AT (a delirium test) includes the recent course: new restlessness and disorientation reported by night staff score 4 on item 4. Alertness 0, questions 1, attention 1, acute change 4: 6 out of 12. Possible delirium. #Delirium #4AT

Six-panel 4AT comic: Mr Hassan, 70, had a 4AT of 0 on admission with a chest infection. He was restless and disorientated overnight. This morning he is alert, makes one AMT4 error and skips July in months backwards. Night staff confirm the change was new. Scores 0, 1, 1, 4; total 6/12. The overnight change still counts.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

Every treatment has a timetable as well as a benefit. Appointments, blood tests, transport, and the work at home. "What would this add to your week?" is a question for before starting, not after.

Illustration of an older adult considering a blank desk calendar. Large text asks: “What would this add to your week?”

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

Delirium aftercare: name it in the discharge letter, teach the early signs of recurrence, expect gradual recovery, talk about frightening memories, book cognitive follow-up. The episode ends before the caring should. #delirium

Card headed 'Aftercare: after delirium'. Five points: name it in the discharge letter; teach the early signs of recurrence; expect gradual recovery over weeks to months; talk about frightening memories; book a cognitive follow-up. Footnote: the episode ends before the caring should.

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Alasdair MacLullich @amaclullich.bsky.social · 23/09/2026

Hearing aids in, glasses on, curtains open, a cup of tea, a familiar voice. Most of what helps in delirium is ordinary care, and it is done by the people with the least protected time.

The Hulk handing over a taco. Top: 'The night nurse at 6 am'. Bottom: 'Hearing aids in, glasses on, curtains open, a cup of tea. Before anyone wrote a plan.'

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