PAEDIATRIC DELIRIUM

1. PAEDIATRIC DELIRIUM A Paediatric Consultation-liaison Psychiatry Presentation Rene Nassen Dr Sean Hatherill

2. “A non specific neuropsychiatric disorder that indicates global encephalopathic dysfunction in seriously ill patients” • Frequently seen in ill geriatrics and adults • Clinical picture well known in adults • Associated prognostic implications • Children - occurs commonly - often missed - seriousness underestimated

3. Problems • Confusing Terminology – variety of terms used by different disciplines - ‘delirium’ , ‘acute confusional state’ , ‘acute organic brain syndrome’, ‘encephalopathy’ , ‘ICU psychosis’ , ‘cerebral insufficiency’ • Vague and longwinded psychiatric definitions – using terms like ‘clouding of consciousness’ , ‘reduced clarity of awareness of the environment’ • Unhelpful lay and medical stereotypes • Diagnostic difficulty- Underrecognised and undertreated Commonly misdiagnosed Fluctuating by nature

4. Yet More Problems • Relatively extensive adult delirium literature…..but • Precious little child psych. / paediatric literature • Inherent risks of extrapolating from adultliteratureespecially regarding treatment

5. This presentation • Clinical picture-cases • Diagnostic features • Assessment • Management • Aetiology • Final thoughts

6. The many faces of delirium • The ? Depression Referral • The ? PTSD Referral • The “Psychotic Child” Referral • The HIV+ Child

7. ?Depression Referral • 14yr old girl on PD awaiting renal Tx, temporarily living at St Josephs • Very unhappy with St Josephs placement • Clear history of low mood , anhedonia, ideas of hopelessness and passive suicidality • Seemingly leading to non-compliance with treatment • Admitted in status epilepticus to ICU • On return to ward – withdrawn , apathetic , uncommunicative , ?depressed On MSE • Mood difficult to assess and clinical picture dominated by cognitive deficits • Distractable , difficulty attending to questions, disorientated for time , recent memory recall problems , difficulty focusing and shifting attention and problems with mental flexibility tasks

8. ?Depression Referral cont. • Diagnosis of Delirium • On basis of further investigations and a previous history of autoimmune thyroiditis a further diagnosis of Hashimoto’s Encephalopathy made • Good response to steroids • Now requires the possibility of pre-delirium underlying depression explored. • TAKE HOME… • A DIAGNOSIS OF DELIRIUM IS ONLY THE START OF THE DIAGNOSTIC PROCESS • DELIRIUM CAN BOTH MIMIC AND COMPLICATE DEPRESSION • ANTIDEPRESSANTS CAN WORSEN DELIRIUM

9. The ?PTSD Referral • A 10 yr old girl Day 10 post MVA pedestrian with multiple injuries including significant head injury and # femur , now in traction • Nursing staff at wits end • Pulling off traction , trying to get off the bed • “won’t listen” , clingy , and difficult to console (even by mother) • Repeatedly shouting “I’m going home on Monday!” On MSE • Clearly distressed , agitated , not responding to repeated explanation and reassurance • Completely amnestic for injury itself. Vaguely fearful • No repeated nightmares , intrusive trauma imagery or flashbacks • Understands questions and can give reasonable replies • Lucid intervals interrupted by periods of great distress and inconsolability • Quite subtle deficits on bedside cognitive testing

10. The ?PTSD Referral cont. • Able to give home telephone number , birth date , days of week and months of year forward, but… • Disorientated in time, difficulty with recall of 3 named objects after 2 min, ++problems attempting days of week backwards, or with simple continuous performance task or ‘go-no go’ task. • Collateral from mother that she is definitely “confused” • TAKE HOME… • DELIRIUM IS OFTEN ASSOCIATED WITH FEAR & DISTRESS • PSYCHOTIC SYMPTOMS ARE NOT REQUIRED FOR THE DIAGNOSIS • ATTENTIONAL IMPAIRMENTS MAY BE SUBTLE AND, MOST IMPORTANTLY - FLUCTUATING

11. The ‘Help! Psychotic Child!’ Referral • 10 yr old boy seen Day 8 post MVA pedestrian with extensive pelvic injuries. • Short, relatively abrupt onset of agitation , hurling abuse at nurses , insomnia, messing faeces and drinking his own urine • Intermittently “seeing things”, esp. at night • Nursing staff at wits end • Treated with opiates, benzodiazepines and a traditional antipsychotic On MSE • Very distressed, labile affect , speech progressively more incoherent over course of interview • Clear account of frightening visual hallucinations • Disorientated to time and attentional problems on bedside testing • Diagnosis of Delirium – probably multifactorial

12. Delirium presenting in an HIV+ Child • 9yr old girl, HIV+ recently on HAART • ATN resolved • Very low CD4 count • CNS involvement (CT brain atrophy, abn gait, tremor). • ? PTB ( INH) Background History • Orphaned • Double bereavement ( both parents) • Witnessed mothers death • Placement problem

13. Reason for referral • Persistent, pervasive low mood • ? Depression • ? HIV encephalopathy On MSE • Low reactivity • Marked anhedonia • Tearful, hopeless , apathetic, blunted • Cognitively intact ( orientated, count, name, recall)

14. Diagnostically • Major depressive episode • Complicated bereavement • ??? PTSD • ?? HIV encephalopathy Management • Fluoxetine 5mg daily • EEG • 2x weekly counselling,collateral school, liaise with social worker

15. Clinical course • Fluoxetine stopped, imipramine started. • Deterioration- labile mood, agitated - Hallucinations - Thought disordered • Fluctuating picture ( worse at night) On MSE: • Agitated, tearful, actively hallucinating, speech incoherent • Cognitively impaired (orientation, attention,memory, calculation)

16. Assessment: Delirium • ? Cause- Fluoxetine vs Imipramine - INH psychosis - initial presentation hypoactive delirium? - ??? Immune reconstitution syndrome? • Management: low dose haloperidol * Settled after 10 days Placed at St Josephs Home

17. The ‘core’ of delirium • An attentional disturbance with reduced ability to focus, maintain and shift attention • An altered level of consciousness with reduced clarity of awareness of the environment (often subtle) • Diffuse cognitive deficits – attention, orientation, memory, visuoconstructive problems and frontal executive deficits • Acute or subacute in onset • Fluctuating in nature *Often associated with sleep-wake disturbance and worsening at night • More often than not of multiple aetiologies

18. Associated Features • Motoric disturbance – Hyperactive, Hypoactive, Mixed • Affective changes – lability of mood, tearfulness, fear, irritability, anxiety • Hallucinations and delusions • Regression in acquired skills • Aggression and uncooperativeness • Thought disorder • Word-finding difficulties and perseveration • Difficulty consoling – even by parent

19. Some recent literature • Turkel et al (2003) Retrospective study of 84 pt’s between ages of 18mo and 16yrs identified from 1027 consecutive psychiatric consultations. • Psychosis and disorientation less common than in adult delirium • Impaired attention 100% • Sleep disturbance 98% • Irritability 86% • Exacerbation at night 82% • Impaired orientation 77% • Agitation 69% • Apathy 68% • Impaired memory 52% • Hallucinations 43%

20. Assessment • The patient:Serial Interviewand observation (fluctuating with lucid intervals) Observing child interacting with parent • Collateral: From nursing staff – esp. nightshift reports, prn analgesics at night, fluctuating cognitive problems • Interview of parent: Time course of onset , baseline cognitive level, fluctuation

21. Developmentally appropriate and language-appropriate bedside cognitive testing • Testing orientation – esp. time • Testing attention - days of week backwards, a simple continuous performance task, ‘go-no go’ • Testing recent memory recall – 3 objects after a delay • Drawing and calculation (need baseline!) • Looking for associated features eg. Visual hallucinations *Delirium is a clinical diagnosis Often , but not invariably associated with generalised slowing on EEG

22. Management • Recognition and early intervention • Find and reverse contributory factors …Search & Destroy • Review prescription chart for the Usual Suspects • Ensure patient safety • Environmental manipulation and orientating techniques - appropriate level of stimulation cf. ICU - familiar toys and objects from home - night-light - familiar faces - consistent staff • Encourage frequent visits from family and friends • Good nursing care – safety , orientation , reassurance and explanation

23. Assessment and Management (cont.) • Monitor hydration (esp. in hypoactive delirium) • Control fever • Pain control • USE AS FEW MEDICATIONS AS POSSIBLE • PSYCHOTROPIC MEDICATION - No placebo-controlled trial data available - No FDA-approved medication specifically for delirium - Limited data to a great extent extrapolated from adults - May themselves worsen or cause delirium - Significant risks and side-effects - Cautious individualised risk – benefit analysis

24. Management (cont.) • Haloperidol – good track record in delirium - IV route available - less anticholinergic than other traditional antipsychotics - significant risk of extrapyramidal side-effects and QT prolongation (esp. with IV route) - LOW DOSE eg. 0,5mg • Risperidone – theoretical benefits with less EPSE’s with short term use - little evidence-base in paediatric delirium - LOW DOSE eg. 0,25mg bd Ideally AVOID benzodiazepines

25. Aetiology:the usual suspects • Stress-vulnerability threshold model of delirium • Vulnerabilities relating to age, neurological disorder, learning disability (cognitive reserve), sensory deficits, immobility, social isolation • Common precipitants - fever / sepsis - trauma - polypharmacy - certain medications esp. anticholinergic , opiates , antihistamines, benzodiazepines - low serum albumin - hypoxia - perioperative - burns

26. I WATCH DEATH • Infection • W ithdrawal • A cute metabolic • T rauma & burns • C NS pathology • H ypoxia • D eficiency eg. Thiamine • E ndocrine • A cute vascular • T oxins and drugs • H eavy metals

27. Unusual suspects • Tune et al , American J of Psychiatry 149 , 1393 – 1394, 1992 Measures of anticholinergic activity in ‘atropine-equivalents’ Digoxin Cimetedine Codeine Nifedipine (And obviously the tricyclic antidepressants)

28. Final take home • Delirium contributes to significantly increased morbidity • The literature suggests we are missing it a lot of the time • Our prescribing practice can have a significant impact • Delirium comes in many shades and forms • Delirium can mimic most psychiatric diagnoses • It’s main mode of treatment is reversal of cause • Multiple aetiology is most common

29. References • Schieveld et al , (2005) Delirium in Severely Ill Children in the Pediatric Intensive Care Unit. J. Am. Acad. Child Adolesc. Psychiatry , 44:4, April 2005 • Turkel et al , (2003) Delirium in Children and Adolescents ,J. Neuropsychiatry Clin. Neuroscience 15:4, 2003 • Turkel et al , (2003) The Delirium Rating Scale in Children and Adolescents. Psychosomatics 44:2 2003 • Martini RD, (2005) The Diagnosis of Delirium in Pediatric Patients . J. Am. Acad. Child Adolesc. Psychiatry 44:4 2005 • Tune et al (1992) Am. J. Psychiatry 149, 1393 - 1394

30. Thank you