Transcript paediatric delirium

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
 Clinical picture well known in adults
 Associated prognostic implications
 Children - occurs commonly
- often missed
- seriousness underestimated
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Problems
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Confusing Terminology – variety of terms used by different
disciplines - ‘delirium’ , ‘acute confusional state’ , ‘acute organic brain
syndrome’, ‘encephalopathy’ , ‘ICU psychosis’ , ‘cerebral insufficiency’
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Vague and longwinded psychiatric definitions – using terms
like ‘clouding of consciousness’ , ‘reduced clarity of awareness of the
environment’
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Unhelpful lay and medical stereotypes
Diagnostic difficulty- Underrecognised and undertreated
Commonly misdiagnosed
Fluctuating by nature
Yet More Problems
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Relatively extensive adult delirium literature…..but
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Precious little child psych. / paediatric literature
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Inherent risks of extrapolating from adult literature
especially regarding treatment
This presentation
Clinical picture-cases
 Diagnostic features
 Assessment
 Management
 Aetiology
 Final thoughts
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The many faces of delirium
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The ? Depression Referral
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The ? PTSD Referral
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The “Psychotic Child” Referral
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The HIV+ Child
?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 On return to ward – withdrawn , apathetic , uncommunicative , ?depressed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
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?Depression Referral cont.
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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.
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TAKE HOME…
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A DIAGNOSIS OF DELIRIUM IS ONLY THE START OF THE
DIAGNOSTIC PROCESS
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DELIRIUM CAN BOTH MIMIC AND COMPLICATE DEPRESSION
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ANTIDEPRESSANTS CAN WORSEN DELIRIUM
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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
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The ?PTSD Referral cont.
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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”
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TAKE HOME…
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DELIRIUM IS OFTEN ASSOCIATED WITH FEAR & DISTRESS
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PSYCHOTIC SYMPTOMS ARE NOT REQUIRED FOR THE DIAGNOSIS
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ATTENTIONAL IMPAIRMENTS MAY BE SUBTLE AND, MOST
IMPORTANTLY - FLUCTUATING
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The ‘Help! Psychotic Child!’
Referral
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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
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
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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)
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Diagnostically
Major depressive episode
 Complicated bereavement
 ??? PTSD
 ?? HIV encephalopathy
Management
 Fluoxetine 5mg daily
 EEG
 2x weekly counselling,collateral school,
liaise with social worker
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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)
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Assessment: Delirium
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? Cause- Fluoxetine vs Imipramine
- INH psychosis
- initial presentation hypoactive delirium?
- ??? Immune reconstitution syndrome?
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Management: low dose haloperidol
* Settled after 10 days
Placed at St Josephs Home
The ‘core’ of delirium
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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
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More often than not of multiple aetiologies
Associated Features
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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
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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
The patient:Serial Interview and 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
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Developmentally appropriate and language-appropriate
bedside cognitive testing
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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
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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.)
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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.)
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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
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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
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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
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I nfection
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
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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
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
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References
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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
Thank you