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PAEDIATRIC DELIRIUM

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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
 Clinical picture well known in adults
 Associated prognostic implications
 Children - occurs commonly
             - often missed
             - seriousness underestimated
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
   Relatively extensive adult delirium literature…..but

   Precious little child psych. / paediatric literature


   Inherent risks of extrapolating from adult literature
    especially regarding treatment
This presentation
 Clinical picture-cases
 Diagnostic features
 Assessment
 Management
 Aetiology
 Final thoughts
The many faces of delirium
   The ? Depression Referral

   The ? PTSD Referral

   The “Psychotic Child” Referral

   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 On return to ward – withdrawn , apathetic , uncommunicative , ?depressed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
?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
 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.
   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
   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
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
 Major depressive episode
 Complicated bereavement
 ??? PTSD
 ?? HIV encephalopathy
Management
 Fluoxetine 5mg daily
 EEG
 2x weekly counselling,collateral school,
  liaise with social worker
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)
   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
   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
   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
   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
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
   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.)
   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.)
    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
   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 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
   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
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
Thank you

								
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