PAEDIATRIC DELIRIUM

A Paediatric Consultation-liaison Psychiatry Presentation

Rene NassenDr 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Seemingly leading to non-compliance with treatment Admitted in status epilepticus to ICU On return to ward – withdrawn , apathetic , uncommunicative , ?depressed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 encephalopathyManagement 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