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PAEDIATRIC DELIRIUM. A Paediatric Consultation-liaison Psychiatry Presentation Rene Nassen Dr Sean Hatherill. “A non specific neuropsychiatric disorder that indicates global encephalopathic dysfunction in seriously ill patients” Frequently seen in ill geriatrics and adults

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paediatric delirium

PAEDIATRIC DELIRIUM

A Paediatric Consultation-liaison Psychiatry Presentation

Rene Nassen

Dr Sean Hatherill

slide2
“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

problems
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

yet more problems
Yet More Problems
  • Relatively extensive adult delirium literature…..but
  • Precious little child psych. / paediatric literature
  • Inherent risks of extrapolating from adultliteratureespecially regarding treatment
this presentation
This presentation
  • Clinical picture-cases
  • Diagnostic features
  • Assessment
  • Management
  • Aetiology
  • Final thoughts
the many faces of delirium
The many faces of delirium
  • The ? Depression Referral
  • The ? PTSD Referral
  • The “Psychotic Child” Referral
  • The HIV+ Child
depression referral
?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  • On return to ward – withdrawn , apathetic , uncommunicative , ?depressed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
depression referral cont
?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
the ptsd referral
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
the ptsd referral cont
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
the help psychotic child referral
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
delirium presenting in an hiv child
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
reason for referral
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)
diagnostically
Diagnostically
  • Major depressive episode
  • Complicated bereavement
  • ??? PTSD
  • ?? HIV encephalopathy

Management

  • Fluoxetine 5mg daily
  • EEG
  • 2x weekly counselling,collateral school,

liaise with social worker

clinical course
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)
slide16
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

the core of delirium
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
associated features
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
some recent literature
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%
assessment
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
developmentally appropriate and language appropriate bedside cognitive testing
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

management
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
assessment and management cont
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

management cont
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

aetiology the usual suspects
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

i watch death
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
unusual suspects
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)

final take home
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
references
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