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Casey MR, Sall S, Parsons G, Raveendran K, Zaheri A. Misdiagnosis in an Autistic Adolescent. Cureus 2024; 16:e68129. [PMID: 39347360 PMCID: PMC11438490 DOI: 10.7759/cureus.68129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2024] [Indexed: 10/01/2024] Open
Abstract
With the increase in autism diagnoses in recent years due to improved public and clinical awareness, the association between autism and mental health has emerged as an important issue for patients and their caregivers. Although many with autism spectrum disorder also have coexisting mental health conditions, there exist differences in the presentation and etiology of these symptoms. This case report explains an interaction with a 17-year-old adolescent autistic male with a history of mild depression who was found non-responsive in the shower at home. Although the emergency medical team interpreted the scene as an attempted suicide, after lengthy interviews with the patient and the patient's family, the psychiatry team revealed a pre-existing condition, subdural empyema, that caused him seizures. This case highlights how autism characteristics can mask other relevant clinical details and delay proper diagnosis and treatment, especially when patients are non-responsive or exhibiting atypical behavior. It also underscores the importance of investigating all relevant clinical diagnoses, including those not related to psychiatric conditions. It is vital that healthcare providers learn how to effectively communicate with autistic patients to ensure proper treatment and improve patient outcomes.
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Affiliation(s)
- Madison R Casey
- Department of Psychiatry, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
| | - Saveen Sall
- Department of Psychiatry, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
| | - Gina Parsons
- Department of Psychiatry, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
| | - Keerthiga Raveendran
- Department of Psychiatry, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
| | - Alexa Zaheri
- Department of Psychiatry, Louisiana State University Health Sciences Center Shreveport, Shreveport, USA
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Cook L, Coffey A, Brown Wilson C, Boland P, Stark P, Graham M, McMahon J, Tuohy D, Barry HE, Murphy J, Birch M, Tierney A, Anderson T, McCurtin A, Cunningham E, Curran GM, Mitchell G. Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol. BMC MEDICAL EDUCATION 2024; 24:475. [PMID: 38689311 PMCID: PMC11061903 DOI: 10.1186/s12909-024-05468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues. METHODS Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource. DISCUSSION Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Lana Cook
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Alice Coffey
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | | | - Pauline Boland
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Patrick Stark
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Margaret Graham
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - James McMahon
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Dympna Tuohy
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | | | - Jill Murphy
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Matt Birch
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Audrey Tierney
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Tara Anderson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Arlene McCurtin
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Emma Cunningham
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Geoffrey M Curran
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gary Mitchell
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK.
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Yaregal Melesse D, Teshale Tesema T, Ayinie Mekonnen Z, Chekol WB, Admass BA, Mengie Workie M. Predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia at Amhara Regional State Tertiary Hospitals: a multicenter prospective study. Front Pediatr 2024; 12:1348789. [PMID: 38523839 PMCID: PMC10957644 DOI: 10.3389/fped.2024.1348789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Postoperative delirium in paediatric patients is a recognised issue. Nevertheless, in low- and middle-income nations, researchers have had luck in determining its extent and predictors. Identifying predictors of postoperative delirium in paediatric patients having general anaesthesia at Tertiary Hospitals in Ethiopia was the aim of this study. Methods A multicenter, prospective follow up study was conducted from April 15 to June 15, 2023 at the study settings. During the study period a total of 424 paediatric surgical patients treated under general anaesthesia in all study locations, ranging in age from birth to sixteen were candidates for this study. Charts and direct observation of patient's with assessment tool [Cornell Assessment of Pediatric Delirium (CAPD)] were used from each available patient. Binary logistic regression analysis was performed to determine predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia. Results Postoperative delirium occurred in 160 of the 404 paediatric patients who underwent surgery under general anaesthesia. Ophthalmic surgery, corticosteroid use, anticholinergic use, severe postoperative pain, and preoperative anxiety were found to be predictors of postoperative delirium; whereas, sedative medication premedication and paracetamol used for analgesia were found to be protective against postoperative delirium. Inference and recommendation The postoperative delirium in paediatric patients undergoing surgery under general anaesthesia was higher compared to developed countries. Ophthalmic surgery, corticosteroids, anticholinergic medications, postoperative pain, and preoperative anxiety were found to be predictors. The impact of postoperative delirium might be lessened by concentrating on its screening and factor control.
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Affiliation(s)
- Debas Yaregal Melesse
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Garofano JS, Nakase-Richardson R, Barnett SD, Yablon SA, Evans C, Zaim N. Delirium following traumatic brain injury in adolescents: Symptomatology and prediction of ability to return to school or employment 1-year post-injury. PM R 2024; 16:122-131. [PMID: 37314306 DOI: 10.1002/pmrj.13025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 03/21/2023] [Accepted: 05/13/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is a limited evidence-base describing clinical features of delirium in youth. What is known is largely extrapolated from studies of adults or samples with heterogeneous etiologies. It is unclear if the symptoms experienced by adolescents differ from those experienced by adults, or the degree to which delirium impacts the ability of adolescents to return to school or work. OBJECTIVE To describe delirium symptomatology among adolescents following a severe traumatic brain injury (TBI). Symptoms were compared by adolescent delirium status and across age groups. Delirium and its relationship with adolescent employability 1 year post-injury was also examined. DESIGN Exploratory secondary analysis of prospectively collected data. SETTING Free-standing rehabilitation hospital. PATIENTS Severely injured TBI Model Systems neurorehabilitation admissions (n = 243; median Glasgow Coma Scale = 7). The sample was divided into three age groups (adolescents, 16-21 years, n = 63; adults 22-49 years, n = 133; older adults ≥50 years, n = 47). INTERVENTIONS Not applicable. MEASURES We assessed patients using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria and the Delirium Rating Scale-Revised 98 (DRS-R-98). The employability item from the Disability Rating Scale was the primary 1-year outcome. RESULTS Most items on the DRS-R-98 differentiated delirious from non-delirious adolescents. Only "delusions" differed among age groups. Among adolescents, delirium status 1 month post-TBI provided acceptable classification of employability prediction 1 year later (area under the curve [AUC]: 0.80, 95% confidence interval [CI]: 0.69-0.91, p < .001). Delirium symptom severity (AUC: 0.86, 95% CI: 0.68-1.03, SE: 0.09; p < .001) and days of post-traumatic amnesia (AUC: 0.85, 95% CI: 0.68-1.01, SE: 0.08; p < .001) provided excellent prediction of outcomes for TBI patients in delirium. CONCLUSIONS Delirium symptomatology was similar among age groups and useful in differentiating the delirium status within the adolescent TBI group. Delirium and symptom severity at 1 month post-TBI were highly predictive of poor outcomes. Findings from this study support the utility of DRS-R-98 at 1 month post-injury to inform treatment and planning.
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Affiliation(s)
| | | | | | - Stuart A Yablon
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA
| | - Clea Evans
- Methodist Rehabilitation Center, Jackson, Mississippi, USA
| | - Nadia Zaim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Elia J, Pajer K, Prasad R, Pumariega A, Maltenfort M, Utidjian L, Shenkman E, Kelleher K, Rao S, Margolis PA, Christakis DA, Hardan AY, Ballard R, Forrest CB. Electronic health records identify timely trends in childhood mental health conditions. Child Adolesc Psychiatry Ment Health 2023; 17:107. [PMID: 37710303 PMCID: PMC10503059 DOI: 10.1186/s13034-023-00650-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research. METHODS In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms. RESULTS The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories. CONCLUSIONS These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.
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Affiliation(s)
- Josephine Elia
- Department of Pediatrics, Nemours Children's Health Delaware, Sydney Kimmel School of Medicine, Philadelphia, PA, US.
| | - Kathleen Pajer
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Raghuram Prasad
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, US
| | - Andres Pumariega
- Department of Psychiatry, University of Florida College of Medicine, University of Florida Health, Gainesville, FL, US
| | - Mitchell Maltenfort
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, US
| | - Levon Utidjian
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, US
| | - Elizabeth Shenkman
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, US
| | - Kelly Kelleher
- The Research Institute, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Ohio, US
| | - Suchitra Rao
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, US
| | - Peter A Margolis
- James Anderson Center for Health Systems Excellence, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, US
| | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, US
| | - Antonio Y Hardan
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, US
| | - Rachel Ballard
- Department of Psychiatry and Behavioral Sciences and Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, US
| | - Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, US
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Department of Healthcare Management, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, US
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Affiliation(s)
- Joel Kian Boon Lim
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Vicknesan Jeyan Marimuttu
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
- Child and Adolescent Mental Wellness Service, Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
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The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121878. [PMID: 36553324 PMCID: PMC9777172 DOI: 10.3390/children9121878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.
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于 夏, 王 蕾, 高 雅, 谢 朝, 李 鸽. [Risk factors for delirium after sedation in children with convulsion and establishment of a nomogram model for predicting the risk of delirium]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:1238-1245. [PMID: 36398550 PMCID: PMC9678057 DOI: 10.7499/j.issn.1008-8830.2205076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/05/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To investigate the risk factors for delirium after sedation in children with convulsion, and to establish a nomogram model for predicting the risk of delirium. METHODS A total of 373 children with convulsion who were hospitalized in the pediatric ward of the Second Affiliated Hospital of Air Force Medical University from August 2020 to January 2022 were prospectively enrolled. There were 245 children in the modeling group and 128 children in the validation group. A multivariate logistic regression analysis was used to identify independent predictive factors for delirium after sedation and establish a nomogram model for predicting the risk of this disorder based on these factors. The calibration curve, the receiver operating characteristic curve, and the decision curve analysis were used to evaluate the accuracy, discriminatory ability, and clinical application value of this model, respectively. RESULTS The incidence of delirium after sedation was 22.3% (83/373) in the children with convulsion. The multivariate logistic regression analysis showed that age>5 years (OR=0.401, P<0.05) was a protective factor against delirium after sedation in these children, while presence of infection (OR=3.020, P<0.05), admission to the pediatric intensive care unit (OR=3.126, P<0.05), use of benzodiazepines (OR=5.219, P<0.05), history of status convulsion (OR=2.623, P<0.05), and history of delirium episodes (OR=3.119, P<0.05) were risk factors for delirium. The H-L deviation test of the nomogram prediction model showed a good degree of fit (χ2=9.494, P=0.302). Internal and external validation showed that the mean absolute errors between the actual and predicted values of the calibration curve were 0.030 and 0.018, respectively, and the areas under the receiver operating characteristic curve were 0.777 and 0.775, respectively. The decision curve analysis showed that the model provided significant net clinical benefit when the predicted risk threshold was >0.01. CONCLUSIONS Age, presence of infection, admission to the pediatric intensive care unit, use of benzodiazepines, history of status convulsion, and history of delirium episodes are closely associated with the development of delirium after sedation in children with convulsion. The nomogram model for predicting this disorder that is established based on these factors has relatively high accuracy, discriminatory ability, and clinical application value.
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Shah SA, Gautam R, Lowder R, Mauer EA, Carullo RB, Parlatore DE, Gerber LM, Schiff ND, Traube C. Quantitative Electroencephalographic Markers of Delirium in the Pediatric Intensive Care Unit: Insights From a Heterogenous Convenience Sample. J Neuropsychiatry Clin Neurosci 2022; 33:219-224. [PMID: 33757305 DOI: 10.1176/appi.neuropsych.20070184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Little is known about the underlying neurophysiology of pediatric delirium. In adult patients, the sensitivity of EEG to clinical symptoms of delirium has been noted, with a slowing of background activity (alpha) and an increase in slow-wave activity (delta-theta). In this pilot study, the authors extended this investigation to a pediatric cohort. METHODS In a convenience sample, 23 critically ill children were screened for delirium, using the Cornell Assessment for Pediatric Delirium (CAPD), every 12 hours throughout their pediatric intensive care unit stay as part of standard intensive care unit procedure, and EEGs were performed as part of their clinical care. After hospital discharge, EEGs were reviewed using quantitative analysis, and the maximum delta-alpha ratio (DAR; eyes closed) was derived for each 12-hour period. DAR values were compared between delirious and nondelirious episodes, and the linear relationship between DAR and CAPD was assessed. RESULTS Higher DARs were associated with episodes of delirium. The DAR also positively correlated with CAPD assessments, with higher DARs relating to higher delirium scores. CONCLUSIONS Future prospective studies may further investigate this relationship in a more homogeneous and larger sample, and the DAR should be considered to track delirium and assess the effectiveness of therapeutic interventions.
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Affiliation(s)
- Sudhin A Shah
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Richa Gautam
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Ryan Lowder
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Elizabeth A Mauer
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Renata B Carullo
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Dorin E Parlatore
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Linda M Gerber
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Nicholas D Schiff
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
| | - Chani Traube
- Departments of Rehabilitation Medicine (Shah, Lowder), Pediatrics (Traube), and Population Health Sciences (Mauer, Gerber), Cornell University Joan and Sanford I Weill Medical College, New York; Clinical and Translational Science Center, Cornell University Joan and Sanford I Weill Medical College, New York (Gautam); Department of Pediatrics, New York-Presbyterian Hospital, New York (Carullo, Parlatore, Traube); Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (Shah, Schiff); Department of Neurology, Weill Cornell Medicine, New York (Schiff); and Rockefeller University Hospital, New York (Schiff)
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Michel J, Schepan E, Hofbeck M, Engel J, Simma A, Neunhoeffer F. Implementation of a Delirium Bundle for Pediatric Intensive Care Patients. Front Pediatr 2022; 10:826259. [PMID: 35198518 PMCID: PMC8859429 DOI: 10.3389/fped.2022.826259] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Delirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures. MATERIAL AND METHODS This is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics. RESULTS A total of 792 critically ill children aged 0-18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium. CONCLUSIONS Based on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care-toward a comprehensive approach to prevent delirium in critically ill children as best as possible.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Elena Schepan
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Alexander Simma
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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Ubeda Tikkanen A, Kudchadkar SR, Goldberg SW, Suskauer SJ. Acquired Brain Injury in the Pediatric Intensive Care Unit: Special Considerations for Delirium Protocols. J Pediatr Intensive Care 2021; 10:243-247. [PMID: 34745696 DOI: 10.1055/s-0040-1719045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022] Open
Abstract
The goal of this article was to highlight the overlapping nature of symptoms of delirium and acquired brain injury (ABI) in children and similarities and differences in treatment, with a focus on literature supporting an adverse effect of antipsychotic medications on recovery from brain injury. An interdisciplinary approach to education regarding overlap between symptoms of delirium and ABI is important for pediatric intensive care settings, particularly at this time when standardized procedures for delirium screening and management are being increasingly employed. Development of treatment protocols specific to children with ABI that combine both nonpharmacologic and pharmacologic strategies will reduce the risk of reliance on treatment strategies that are less preferred and optimize care for this population.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, United States.,Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, United States
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sarah W Goldberg
- Division of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Stacy J Suskauer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Kennedy Krieger Institute, Baltimore, Maryland, United States
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12
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Liviskie C, McPherson C, Luecke C. Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review. J Pediatr Intensive Care 2021; 12:94-105. [PMID: 37082469 PMCID: PMC10113017 DOI: 10.1055/s-0041-1730918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractMany critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.
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Affiliation(s)
- Caren Liviskie
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
| | - Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Caitlyn Luecke
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
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13
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Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
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Abstract
Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.
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15
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Yontem A, Yildizdas D, Horoz OO, Ekinci F, Misirlioglu M. Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2021; 25:715-719. [PMID: 34316155 PMCID: PMC8286413 DOI: 10.5005/jp-journals-10071-23857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The number of studies evaluating delirium and its frequency in critically ill infants, children, and adolescents is increasing day by day. The primary objective of this study was to evaluate all patients hospitalized in our pediatric intensive care unit (PICU) in terms of pediatric delirium, to determine the frequency and risk factors of pediatric delirium. Patients and methods The patients included in this study had been hospitalized in the PICU between November 1, 2018, and August 31, 2019, and were followed up for more than 48 hours. Results Delirium was detected in 14 patients (9.9%) through regular evaluations. The Pediatric Index of Mortality 2 (PIM2) scores and the length of stay in the PICU were higher in patients with delirium (p = 0.03 and p = 0.01, respectively). The use of respiratory support, sedation-analgesia, vasoactive and corticosteroid treatments, and physical restraints were higher in patients with delirium and were statistically significant (p <0.05). Following admission to the PICU, psychosocial interventions were implemented for 76.1% of the whole cohort. Delirium developed in only five (4.5%) of the 108 patients who underwent psychosocial interventions, while it was detected in nine (26.5%) of the 34 patients who did not receive psychosocial interventions (p = 0.001). The psychosocial intervention was associated with a lower likelihood of delirium (odds ratio [OR], 0.237; p = 0.044). An increasing number of days in the PICU was independently associated with increasing odds of delirium (OR, 1.095; p = 0.037 for each day). Conclusions We observed that the risk factors associated with delirium were similar to previous studies. Additionally, psychosocial intervention before delirium symptoms developed was associated with a lower risk of developing delirium. However, multicenter randomized controlled trials are needed on this subject. How to cite this article Yontem A, Yildizdas D, Horoz OO, et al. Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2021;25(6):715-719.
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Affiliation(s)
- Ahmet Yontem
- Department of Pediatric Intensive Care, Cukurova University Medicine Faculty, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Cukurova University Medicine Faculty, Adana, Turkey
| | - Ozden O Horoz
- Department of Pediatric Intensive Care, Cukurova University Medicine Faculty, Adana, Turkey
| | - Faruk Ekinci
- Department of Pediatric Intensive Care, Cukurova University Medicine Faculty, Adana, Turkey
| | - Merve Misirlioglu
- Department of Pediatric Intensive Care, Cukurova University Medicine Faculty, Adana, Turkey
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16
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Kalvas LB, Harrison TM. State of the science in pediatric ICU delirium: An integrative review. Res Nurs Health 2020; 43:341-355. [PMID: 32632985 PMCID: PMC8006059 DOI: 10.1002/nur.22054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/23/2020] [Indexed: 11/08/2022]
Abstract
Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.
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Affiliation(s)
- Laura Beth Kalvas
- Graduate Fellow at The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- Associate Professor at The Ohio State University College of Nursing, Columbus, OH
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17
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Not just to survive but to thrive: delirium in the pediatric cardiac ICU. Curr Opin Cardiol 2019; 35:70-75. [PMID: 31592787 DOI: 10.1097/hco.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Pediatric delirium has recently been recognized to occur frequently in the pediatric general and cardiac ICU. The purpose of this review is to highlight recent data on the prevalence, prevention, and management of this condition. RECENT FINDINGS Pediatric delirium occurs in the pediatric cardiac ICU (PCICU) in as many as 67% of patients. Validated screening tools are now available to assist clinicians in the diagnosis of this condition. Research has shown a growing relationship between benzodiazepines, mainstays in the realm of sedation, and delirium. The full spectrum of risk factors has yet to be clearly elucidated. After normalization of the ICU environment, antipsychotics are infrequently required for treatment. While pediatric delirium has been associated with increased length of stay and cost, long-term morbidities are unknown at this time. SUMMARY Application of bundles to normalize the PCICU environment may lead to decreased incidence of pediatric delirium. Multiinstitutional studies are indicated to further delineate optimal bundles, stratify treatment strategies, and investigate long-term morbidity in pediatric delirium.
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McGetrick ME, Lach C, Mullen JE, Munoz-Pareja JC. Assessing Nursing and Pediatric Resident Understanding of Delirium in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2019; 31:481-488. [PMID: 31685114 DOI: 10.1016/j.cnc.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Delirium is a common disease process in the pediatric critical care unit, yet practices for screening and prevention vary drastically between institutions. The authors hypothesized that surveying pediatric residents and nurses who care for patients in the intensive care setting would expose misunderstandings about delirium. They brought to light common incorrect beliefs that benzodiazepines are appropriate therapy for delirium and that children who are delirious will not have memories of the experience. Many nurses and residents listed that they were not comfortable or were extremely uncomfortable identifying delirious patients. Findings demonstrate an opportunity to improve on nursing and resident knowledge.
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Affiliation(s)
- Molly E McGetrick
- Division of Pediatrics, University of Florida, Gainesville, FL, USA; Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA.
| | - Caitlin Lach
- University of Florida, Shands Children's Hospital, 1600 Southwest Archer Road, Gainesville, FL 32608, USA; College of Nursing, University of Florida, Gainesville, FL, USA
| | - Jodi E Mullen
- University of Florida, Shands Children's Hospital, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Jennifer C Munoz-Pareja
- Division of Pediatric Critical Care, Department of Pediatrics, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
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19
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Winsnes K, Sochacki P, Eriksson C, Shereck E, Recht M, Johnson K, Loret De Mola R, Stork L. Delirium in the pediatric hematology, oncology, and bone marrow transplant population. Pediatr Blood Cancer 2019; 66:e27640. [PMID: 30697919 DOI: 10.1002/pbc.27640] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Delirium affects 10% to 30% of patients in pediatric intensive care units (PICU) and is associated with increased length of stay and prolonged late sequela. There are no prospective trials evaluating delirium in the pediatric hematology, oncology, and bone marrow transplant (PHO) population. Hypothesizing that delirium is underrecognized in this population, our study aimed to identify the prevalence of delirium in hospitalized PHO patients and associated risk factors. PROCEDURE PHO and PICU nurses were trained to use the Cornell Assessment for Pediatric Delirium and to record scores once every 12-hour shift. Predetermined demographic and clinical variables were collected daily on all hospitalized PHO patients during the year-long prospective study. RESULTS Prior to initiating routine delirium screening, 1.1% of PHO admissions and 2.4% of unique patients had delirium mentioned in a progress note. This study included 807 consecutive admissions: 671 oncology, 49 hematology, and 87 bone marrow transplant (BMT) hospitalizations among 223 unique PHO patients. The prevalence of delirium among hospitalizations was 5% and among unique patients was 13%. Among BMT hospitalizations, the prevalence was 23%. Multiple logistic regression identified significant association of delirium with increased length of stay, admission to the BMT service, patient location (PICU vs PHO unit), benzodiazepine, opioid, and anticholinergic administration. CONCLUSIONS Before routine screening, delirium was underrecognized in this PHO-hospitalized population. Patients at highest risk had prolonged hospital stays, PICU admissions, BMT, and/or frequent use of benzodiazepines, opioids, or anticholinergics. Routine screening is feasible and may improve our recognition of delirium.
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Affiliation(s)
- Katrina Winsnes
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | | | - Carl Eriksson
- Division of Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Evan Shereck
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Michael Recht
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Kyle Johnson
- Division of Pediatric Psychiatry, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Rebecca Loret De Mola
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Linda Stork
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
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Kınay D, Soyata AZ. Biperiden-Induced Delirium In A Five-Years Old Child. Curr Drug Saf 2019; 14:48-50. [PMID: 30370855 DOI: 10.2174/1574886313666181029101830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Extrapyramidal adverse effects of antipsychotic drugs are more reported in children. Biperiden is an anticholinergic agent to treat the adverse effects of antipsychotic drugs. The drug has the potential to induce delirium at toxic doses. However, data are scarce about delirium associated with biperiden in children. Thus far, a case of delirium has been associated with biperiden in an adolescent patient. We report the first case of delirium associated with the use of biperiden in a preadolescent patient. CASE REPORT A boy aged five years and weighing 20 kilograms had been diagnosed as having oppositional defiant disorder and separation anxiety disorder in the previous treatment center. Ten milligrams fluoxetine and 0.25 milligrams risperidone had been initiated. On the third day of treatment, dystonia developed and he was administered with biperiden. An hour later, he was brought to our emergency clinic due to disorganized speech and behavior. His vital signs were stable. There were no findings in blood and urine tests. No electrolyte imbalance, liver, kidney, and thyroid dysfunction have been observed. His neurologic examination was unremarkable and no abnormal findings were shown on cranial magnetic resonance imaging. No other system findings or findings pointing out to infectious diseases have been observed. One milligram physostigmine was administered with intravenous infusion. However, symptoms did not resolve and he was diagnosed with delirium. Naranjo Adverse Drug Reaction Probability Scale score was seven, indicating a "Probable" Adverse Drug Reaction. Half milligram haloperidol was administered bid for three days and he was discharged with complete recovery. CONCLUSION Clinicians must be aware of the risk of delirium when using non-toxic doses of biperiden in young children.
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Affiliation(s)
- Duygu Kınay
- Department of Child and Adolescent Psychiatry, Bilecik State Hospital, Bilecik, Turkey
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Franken A, Sebbens D, Mensik J. Pediatric Delirium: Early Identification of Barriers to Optimize Success of Screening and Prevention. J Pediatr Health Care 2019; 33:228-233. [PMID: 30449648 DOI: 10.1016/j.pedhc.2018.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/30/2018] [Accepted: 08/03/2018] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pediatric delirium has a 25% prevalence rate in the pediatric intensive care unit. The purpose of this project was to evaluate the impact/effect of implementing nonpharmacologic nursing bundles on the incidence of pediatric delirium. It is not yet known whether or not bundles consistently reduce the incidence of delirium. METHOD A nonpharmacologic nursing bundle was implemented for pediatric intensive care unit patients, 2 to 18years of age, admitted to an Arizona metropolitan children's hospital. Data were collected using the Cornell Assessment of Pediatric Delirium (CAP-D) screening tool. RESULTS Control group scores and post-bundle CAP-D scores (mean = 5.57, standard deviation = 5.78 and mean = 7.10, standard deviation = 5.61, respectively) did not differ among the participants. Control participants required an intervention 26.7% of the time for delirium compared with 31.6% in the post-bundle population. No statistical significance was seen between the control group and the post-bundle CAP-D scores t(59) = 7.46; t(205) = 18.17 (p = .08, Fisher exact test). DISCUSSION The use of nonpharmacologic bundles for delirium prevention have shown some promising results in helping with delirium reduction. Whether they consistently reduce the incidence has yet to be fully proven. This project shows that significant barriers exist when implementing them in a complex pediatric intensive care environment.
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Kishk OA, Simone S, Lardieri AB, Graciano AL, Tumulty J, Edwards S. Antipsychotic Treatment of Delirium in Critically Ill Children: A Retrospective Matched Cohort Study. J Pediatr Pharmacol Ther 2019; 24:204-213. [PMID: 31093019 PMCID: PMC6510524 DOI: 10.5863/1551-6776-24.3.204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically. METHODS> The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium. RESULTS Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported. CONCLUSIONS No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.
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Abstract
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.
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Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse 2018; 37:e9-e18. [PMID: 28572112 DOI: 10.4037/ccn2017692] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Delirium in children is an often underrecognized but serious complication of hospitalization. Delirium in this age group has been described as behaviors such as refractory agitation and restlessness, visual or auditory hallucinations, children being "not themselves," and a lethargic state. Often, children with delirium are at risk for harming themselves by dislodging tubes, falling, or refusing care. Pediatric nurses must recognize and intervene to prevent and treat delirium in hospitalized children because the delirium may be an indicator of worsening clinical status and is associated with high mortality and morbidity in children of all ages and with posttraumatic stress disorder. Pediatric nurses are uniquely positioned to design care interventions to both reduce risk for delirium and treat active delirium. Many treatment recommendations are nonpharmacological and are part of excellent nursing care.
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Affiliation(s)
- Amanda Bettencourt
- Amanda Bettencourt is a pediatric clinical nurse specialist at UF Health Shands Children's Hospital, Gainesville, Florida.,Jodi E. Mullen is a clinical leader, pediatric intensive care unit, UF Health Shands Children's Hospital
| | - Jodi E Mullen
- Amanda Bettencourt is a pediatric clinical nurse specialist at UF Health Shands Children's Hospital, Gainesville, Florida. .,Jodi E. Mullen is a clinical leader, pediatric intensive care unit, UF Health Shands Children's Hospital.
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Alvarez RV, Palmer C, Czaja AS, Peyton C, Silver G, Traube C, Mourani PM, Kaufman J. Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit. J Pediatr 2018; 195:206-212. [PMID: 29395177 DOI: 10.1016/j.jpeds.2017.11.064] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 11/08/2017] [Accepted: 11/29/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. STUDY DESIGN Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. RESULTS Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) days; P < .0001). A multivariable generalized linear mixed model showed a significant association between delirium and younger age (OR 0.35 for each additional month, 95% CI 0.19, 0.64), need for mechanical ventilation (OR 4.1, 95% CI 1.7, 9.89), and receipt of benzodiazepines (OR 3.78, 95% CI 1.46, 9.79). CONCLUSIONS Delirium is common in patients in the pediatric CICU and is associated with longer length of stay. There may be opportunities for prevention of delirium by targeting modifiable risk factors, such as use of benzodiazepines.
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Affiliation(s)
- Rita V Alvarez
- Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, WI.
| | - Claire Palmer
- Research Institute Biostatistics Core, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Angela S Czaja
- Section of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Chris Peyton
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Gabrielle Silver
- Department of Child Psychiatry, Weill Cornell Medical College, New York, NY
| | - Chani Traube
- Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Jon Kaufman
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO
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Cano Londoño EM, Mejía Gil IC, Uribe Hernández K, Alexandra Ricardo Ramírez C, Álvarez Gómez ML, Consuegra Peña RA, Agudelo Vélez CA, Zuluaga Penagos S, Elorza Parra M, Franco Vásquez JG. Delirium during the first evaluation of children aged five to 14 years admitted to a paediatric critical care unit. Intensive Crit Care Nurs 2018; 45:37-43. [PMID: 29428252 DOI: 10.1016/j.iccn.2017.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 12/24/2017] [Accepted: 12/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the prevalence and characteristics of delirium during the initial evaluation of critically ill patients aged 5-14 years. METHOD/DESIGN This is a cross-sectional descriptive study in a critical care unit. For six months, all patients were evaluated within the first 24-72 hours or when sedation permitted the use of the paediatric confusion assessment method for the intensive care unit (PCAM-ICU) and the Delirium Rating Scale-Revised-98 items #7 and #8 to determine motor type. We report the characteristics of PCAM-ICU delirium (at least three of the required items scored positive) and of subthreshold score cases (two positive items). RESULTS Of 77 admissions, 15 (19.5%) had delirium, and 11 (14.2%) were subthreshold. A total of 53.3% of delirium and 45.5% of subthreshold cases were hypoactive. The prevalence of delirium and subthreshold PCAM-ICU was 83.3% and 16.7% in mechanically ventilated children. The most frequent combination of PCAM-ICU alterations in subthreshold cases was acute onset-fluctuation with altered alertness. The main nursing diagnoses were related to reduced cellular respiration. CONCLUSIONS Delirium is common in critically ill children. It is necessary to assess whether certain nursing diagnoses imply an increase in delirium. Longitudinal studies of subthreshold PCAM-ICU cases are needed to understand their importance better.
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Affiliation(s)
- Eliana María Cano Londoño
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Isabel Cristina Mejía Gil
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Katerine Uribe Hernández
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia; Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Carmenza Alexandra Ricardo Ramírez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Matilde Ligia Álvarez Gómez
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Ricardo Antonio Consuegra Peña
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Camilo Andrés Agudelo Vélez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Susana Zuluaga Penagos
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | | | - José G Franco Vásquez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
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Bellelli G, Morandi A, Trabucchi M, Caironi G, Coen D, Fraticelli C, Paolillo C, Prevaldi C, Riccardi A, Cervellin G, Carabellese C, Putignano S, Maggi S, Cherubini A, Gnerre P, Fontanella A, Latronico N, Tommasino C, Corcione A, Ricevuti G, Ferrara N, De Filippi F, Ferrari A, Guarino M, Ruggieri MP, Modesti PA, Locatelli C, Hrelia P, Toscano MO, Bondi E, Tarasconi A, Ansaloni L, Perticone F. Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons. Intern Emerg Med 2018; 13:113-121. [PMID: 28741278 DOI: 10.1007/s11739-017-1705-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delirium in elderly hospitalized patients, (2) to focus the attention of health care personnel on prevention, diagnosis, and therapy of patients suffering from delirium, and (3) to make the health services research community and policy-makers more aware of the potential risks of this condition providing a reference for training activities and data collection.
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Affiliation(s)
| | | | | | - Guido Caironi
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | - Daniele Coen
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | - Ciro Paolillo
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | - Angela Riccardi
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | | | | | - Stefania Maggi
- EUGMS (European Union Geriatric Medicine Society), Venice Lido, Italy
| | - Antonio Cherubini
- EUGMS (European Union Geriatric Medicine Society), Venice Lido, Italy
| | - Paola Gnerre
- FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti), Rome, Italy
| | - Andrea Fontanella
- FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti), Rome, Italy
| | - Nicola Latronico
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Concezione Tommasino
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Antonio Corcione
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Giovanni Ricevuti
- SIGG (Società Italiana di Geriatria e Gerontologia), Florence, Italy
| | - Nicola Ferrara
- SIGG (Società Italiana di Geriatria e Gerontologia), Florence, Italy
| | | | - Alberto Ferrari
- SIGOT (Società Italiana di Geriatria Ospedale e Territorio), Rome, Italy
| | - Mario Guarino
- SIMEU (Società Italiana di Medicina di Emergenza e Urgenza), Milan, Italy
| | - Maria Pia Ruggieri
- SIMEU (Società Italiana di Medicina di Emergenza e Urgenza), Milan, Italy
| | - Pietro Amedeo Modesti
- SIMI (Società Italiana di Medicina Interna), Rome, Italy.
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | | | | | - Marco Otto Toscano
- CNI-SPDC (Coordinamento Nazionale Servizi Psichiatrici di Diagnosi e Cura), Bergamo, Italy
| | - Emi Bondi
- CNI-SPDC (Coordinamento Nazionale Servizi Psichiatrici di Diagnosi e Cura), Bergamo, Italy
| | | | - Luca Ansaloni
- WSES (World Society of Emergency Surgery), Bologna, Italy
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Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Malas N, Brahmbhatt K, McDermott C, Smith A, Ortiz-Aguayo R, Turkel S. Pediatric Delirium: Evaluation, Management, and Special Considerations. Curr Psychiatry Rep 2017; 19:65. [PMID: 28801871 DOI: 10.1007/s11920-017-0817-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Delirium describes a syndrome of acute brain dysfunction with severe consequences on patient outcomes, medical cost, morbidity, and mortality. It represents a final common pathway of numerous pathophysiologic disturbances disrupting cerebral homeostasis. The diagnosis is predicated on recognition of the clinical features of the syndrome through ongoing clinical assessment. Early identification can be aided by routine screening, particularly in high-risk populations. Evaluation and management are continuous and simultaneous processes involving a multidisciplinary care team including child psychiatry consultation. Prevention, early identification and management are critical in alleviating symptoms, improving outcomes, and reducing distress for patients, families, and care teams. This review highlights our current understanding regarding pediatric delirium, its mechanisms, clinical manifestations, detection and management.
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Affiliation(s)
- Nasuh Malas
- Department of Psychiatry and Pediatrics, University of Michigan Medical School, 1500 East Medical Center Drive, L5023, SPC 5277, Ann Arbor, MI, 48109, USA.
| | - Khyati Brahmbhatt
- Department of Psychiatry, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Cristin McDermott
- Department of Psychiatry and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Allanceson Smith
- Department of Psychiatry, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Roberto Ortiz-Aguayo
- Department of Psychiatry and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Susan Turkel
- Department of Psychiatry and Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital of Los Angeles, CA, Los Angeles, USA
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Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU. Pediatr Crit Care Med 2017; 18:531-540. [PMID: 28410275 DOI: 10.1097/pcc.0000000000001127] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases. DESIGN Quality improvement project with prospective observational analysis. SETTING Nineteen-bed PICU in an urban academic medical center. PATIENTS All consecutive patients admitted from December 1, 2013, to September 30, 2015. INTERVENTIONS A multidisciplinary team implemented an ICU bundle consisting of three clinical protocols: delirium, sedation, and early mobilization using the Plan-Do-Study-Act cycles as part of a quality improvement project. The delirium protocol implemented in December 2013 consisted of universal screening with the Cornell Assessment of Pediatric Delirium revised instrument, prevention and treatment strategies, and case conferences. The sedation protocol and early mobilization protocol were implemented in October 2014 and June 2015, respectively. MEASUREMENTS AND MAIN RESULTS One thousand eight hundred seventy-five patients were screened using the Cornell Assessment of Pediatric Delirium revised tool. One hundred forty patients (17%) had delirium (having Cornell Assessment of Pediatric Delirium revised scores ≥ 9 for 48 hr or longer). Seventy-four percent of delirium positive patients were mechanically ventilated of which 46% were younger than 12 months and 59% had baseline developmental delays. Forty-one patients had emerging delirium (having one Cornell Assessment of Pediatric Delirium revised score ≥ 9). Statistical process control was used to evaluate the impact of three ICU bundle process changes on monthly delirium rates over a 22-month period. The delirium rate decreased with the implementation of each phase of the ICU bundle. Ten months after the delirium protocol was implemented, the mean delirium rate was 19.3%; after the sedation protocol and early mobilization protocols were implemented, the mean delirium rate was 11.84%. CONCLUSIONS Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.
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Coyle MA, Burns P, Traynor V. Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study. J Gerontol Nurs 2017; 43:29-37. [DOI: 10.3928/00989134-20170111-02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/18/2016] [Indexed: 11/20/2022]
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Brahmbhatt K, Whitgob E. Diagnosis and Management of Delirium in Critically Ill Infants: Case Report and Review. Pediatrics 2016; 137:e20151940. [PMID: 26908691 DOI: 10.1542/peds.2015-1940] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/24/2022] Open
Abstract
Delirium in children is common but not widely understood by pediatric practitioners, often leading to underdiagnosis and lack of treatment. This presents a significant challenge in the young patients in the PICU who are most at risk for delirium and in whom the core features of delirium are difficult to assess and treat. However, because of the potential increased morbidity and mortality associated with untreated delirium in adults and children, it remains important to address it promptly. The literature for delirium in this age group is limited. Here we present the case of an infant with multiple underlying medical risk factors who exhibited waxing and waning motor restlessness with disrupted sleep-wake cycles contributing significantly to destabilization of vital parameters. Making a diagnosis of delirium was key to guiding further treatment. After appropriate environmental interventions are implemented and underlying medical causes are addressed, antipsychotic medications, although not Food and Drug Administration-approved in infants, are the mainstay of pharmacotherapy for delirium in older age groups. They may lengthen corrected QT interval (QTc) intervals, presenting a challenge in infants who frequently have other coexisting risks for QTc prolongation, as in our case. The risk from QTc prolongation needs to be balanced against that from untreated delirium. Low doses of risperidone were successfully used in this patient and without side effects or worsening of QTc interval. This case illustrates the importance of increased recognition of delirium in children, including infants, and the role for cautious consideration of atypical antipsychotics in the very young.
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Affiliation(s)
- Khyati Brahmbhatt
- Department of Psychiatry, University of California, San Francisco, San Francisco, California; and
| | - Emily Whitgob
- Fellow in Developmental-Behavioral Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital
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Silver G, Traube C, Gerber LM, Sun X, Kearney J, Patel A, Greenwald B. Pediatric delirium and associated risk factors: a single-center prospective observational study. Pediatr Crit Care Med 2015; 16:303-309. [PMID: 25647240 PMCID: PMC5031497 DOI: 10.1097/pcc.0000000000000356] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe a single-institution pilot study regarding prevalence and risk factors for delirium in critically ill children. DESIGN A prospective observational study, with secondary analysis of data collected during the validation of a pediatric delirium screening tool, the Cornell Assessment of Pediatric Delirium. SETTING This study took place in the PICU at an urban academic medical center. PATIENTS Ninety-nine consecutive patients, ages newborn to 21 years. INTERVENTION Subjects underwent a psychiatric evaluation for delirium based on the Diagnostic and Statistical Manual IV criteria. MEASUREMENTS AND MAIN RESULTS Prevalence of delirium in this sample was 21%. In multivariate analysis, risk factors associated with the diagnosis of delirium were presence of developmental delay, need for mechanical ventilation, and age 2-5 years. CONCLUSIONS In our institution, pediatric delirium is a prevalent problem, with identifiable risk factors. Further large-scale prospective studies are required to explore multi-institutional prevalence, modifiable risk factors, therapeutic interventions, and effect on long-term outcomes.
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Paddick SM, Kalaria RN, Mukaetova-Ladinska EB. The prevalence and clinical manifestations of delirium in sub-Saharan Africa: a systematic review with inferences. J Neurol Sci 2014; 348:6-17. [PMID: 25466692 DOI: 10.1016/j.jns.2014.10.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/30/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In high-income countries with ageing populations, delirium is most prevalent in older adults and in palliative and intensive care settings. The prevalence and aetiology of delirium are likely to differ in low income countries, including sub-Saharan Africa (SSA), due to different population demographics, disease burden and exposure to pathogens. We reviewed published literature relating to the prevalence, clinical features and underlying causes of delirium in SSA and compare this with that published in high-income countries in order to identify knowledge and clinical service gaps, and priorities for further research. METHODS We performed a narrative review by comprehensively searching the following databases: Medline, PsychInfo, Embase and PubMed. Studies published between January 1 1975 and December 31 2013 in all languages, including the terms 'delirium', 'acute brain syndrome', 'organic brain syndrome', or 'acute confusion' originating from SSA were included. In addition, reference lists of included articles and online databases of African medical literature were hand-searched. We also included case series and case reports due to paucity of published studies. RESULTS We identified a total of 46 relevant studies. Delirium was the main focus of only one cross-sectional study, whereas most included delirium in studies on neuropsychiatric conditions. Only two studies reported prevalence in older adults. Most studies reported very low (<2%) delirium prevalence, whereas delirium in psychiatric inpatient and outpatient settings was higher than expected (18.2%-29.9%). Descriptive studies of 'bouffee delirante' from psychiatry settings were often describing delirium. Infection and HIV seropositivity were common associations of delirium throughout these studies. There were no studies of intensive, critical or surgical care settings or of management strategies. CONCLUSIONS We currently know very little about the prevalence, presentation and aetiology of delirium in developing countries. This knowledge gap should be tackled with some urgency, in order to address questions of screening, diagnosis, prevention and management in this setting.
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Affiliation(s)
- S-M Paddick
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK; Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - R N Kalaria
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK.
| | - E B Mukaetova-Ladinska
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK
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Daoud A, Duff JP, Joffe AR. Diagnostic accuracy of delirium diagnosis in pediatric intensive care: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:489. [PMID: 25672219 PMCID: PMC4207322 DOI: 10.1186/s13054-014-0489-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 08/05/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Delirium is common in adult intensive care, with validated tools for measurement, known risk factors and adverse neurocognitive outcomes. We aimed to determine what is known about pediatric delirium in the pediatric intensive care unit (PICU). METHODS We conducted a systematic search for and review of studies of the accuracy of delirium diagnosis in children in the PICU. Secondary aims were to determine the prevalence, risk factors and outcomes associated with pediatric delirium. We created screening and data collection tools based on published recommendations. RESULTS After screening 145 titles and abstracts, followed by 35 full-text publications and reference lists of included publications, 9 reports of 5 studies were included. Each of the five included studies was on a single index test: (1) the Pediatric Anesthesia Emergence Delirium Scale (PAED; for ages 1 to 17 years), (2) the Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU; for ages ≥ 5 years), (3) the Cornell Assessment of Pediatric Delirium (CAP-D; a modification of the PAED designed to detect hypoactive delirium), (4) the revised Cornell Assessment of Pediatric Delirium (CAP-D(R)) and (5) clinical suspicion. We found that all five studies had a high risk of bias on at least one domain in the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Sample size, sensitivity, specificity, and effectiveness (correct classification divided by total tests done) were: PAED 144, 91%, 98%, <91% (>16% of scores required imputation for missing data); p-CAM 68, 78%, 98%, 96%; CAP-D 50, 91%, 100%, 89%; CAP-D (R) 111, and of assessments 94%, 79%, <82% (it is not clear if any assessments were not included); and clinical suspicion 877, N/A (only positive predictive value calculable, 66%). Prevalence of delirium was 17%, 13%, 28%, 21%, and 5% respectively. Only the clinical suspicion study researchers statistically determined any risk factors for delirium (pediatric risk of mortality, pediatric index of mortality, ventilation, age) or outcomes of delirium (length of stay and mortality). CONCLUSION High-quality research to determine the accuracy of delirium screening tools in the PICU are required before prevalence, risk factors and outcomes can be determined and before a routine screening tool can be recommended. Direct comparisons of the p-CAM-ICU and CAP-D(R) should be performed.
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Adverse events of haloperidol for the treatment of delirium in critically ill children. Intensive Care Med 2014; 40:1602-3. [PMID: 25183567 DOI: 10.1007/s00134-014-3446-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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Abstract
Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.
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Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*. Crit Care Med 2014; 42:656-63. [PMID: 24145848 DOI: 10.1097/ccm.0b013e3182a66b76] [Citation(s) in RCA: 314] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. DESIGN Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. SETTING Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012. PATIENTS One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. INTERVENTION Two hundred forty-eight paired assessments completed. MEASUREMENTS AND MAIN RESULTS The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. CONCLUSIONS With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.
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Abstract
Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.
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Affiliation(s)
- Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| | - Rudi G J Westendorp
- Leiden University Medical Center, Leiden, Netherlands; Leyden Academy on Vitality and Ageing, Leiden, Netherlands
| | - Jane S Saczynski
- Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
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Benjamin S, Lauterbach MD, Stanislawski AL. Congenital and acquired disorders presenting as psychosis in children and young adults. Child Adolesc Psychiatr Clin N Am 2013; 22:581-608. [PMID: 24012075 DOI: 10.1016/j.chc.2013.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A review of the published literature found 60 congenital and acquired disorders with symptoms that include psychosis in youth. The prevalence, workup, genetics, and associated neuropsychiatric features of each disorder are described. Eighteen disorders (30%) have distinct phenotypes (doorway diagnoses); 18 disorders (30%) are associated with intellectual disability; and 43 disorders (72%) have prominent neurologic signs. Thirty-one disorders (52%) can present without such distinct characteristics, and are thus more easily overlooked. A systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs is recommended.
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Affiliation(s)
- Sheldon Benjamin
- Departments of Psychiatry and Neurology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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Symptom profile of delirium in children and adolescent--does it differ from adults and elderly? Gen Hosp Psychiatry 2012; 34:626-32. [PMID: 22516219 DOI: 10.1016/j.genhosppsych.2012.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/03/2012] [Accepted: 03/06/2012] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The objective was to evaluate the phenomenology, etiology and outcome of delirium in children and adolescents (8-18 years of age) seen in a consultation-liaison psychiatric service in India. Additionally, an attempt was made to compare the phenomenology with adult and elderly patients with delirium. METHOD Thirty children and adolescents (age 8-18 years) diagnosed with delirium by the consultation-liaison psychiatry team were rated on the Delirium Rating Scale-Revised-98 (DRS-R-98) and compared with DRS-R-98 data on 120 adults and 109 elderly patients. RESULTS The commonly observed symptoms in children and adolescents with delirium were disturbance in attention, orientation, sleep-wake cycle disturbances, fluctuation of symptoms, disturbance of short-term memory and motor agitation. The least commonly seen symptoms included delusions and motor retardation. Compared to adults, children and adolescents had lower frequency of long-term memory and visuospatial disturbances. Compared to the elderly, children and adolescents had higher frequency of lability of affect. For severity of symptoms, compared to adults, the children and adolescents had lower severity of sleep-wake disturbances, abnormality of thought, motor agitation, orientation, attention, short-term memory, long-term memory and visuospatial abilities. When compared to elderly patients, children and adolescents had higher severity of lability of affect and lower severity of language disturbances, short-term memory and visuospatial abilities. CONCLUSIONS In general, phenomenology, of delirium in children and adolescents (age 8-18 years) is similar to that seen in adults and elderly patients.
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Detecting pediatric delirium: development of a rapid observational assessment tool. Intensive Care Med 2012; 38:1025-31. [PMID: 22407142 DOI: 10.1007/s00134-012-2518-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 01/23/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Development of a novel screening tool for the detection of delirium in pediatric intensive care unit (PICU) patients of all ages by comparison with psychiatric assessment based on the reference standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. METHODS This was a prospective blinded pilot study investigating the feasibility of the Cornell Assessment of Pediatric Delirium (CAP-D) performed in a PICU at a university hospital. Fifty patients, ages 3 months to 21 years, admitted to the PICU over a 6-week period were included. No interventions were performed. RESULTS After informed consent was obtained, two study teams independently assessed for delirium by completing the CAP-D and by conducting psychiatric evaluation based on the DSM-IV criteria. Concordance between the CAP-D and DSM-IV criteria was excellent, at 97%. Prevalence of delirium in this sample was 29%. CONCLUSION The CAP-D may be a valid screen for identification of delirium in PICU patients of all ages. Further studies are required to explore its validity, inter-rater reliability, and feasibility of use as a nursing screen.
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Wang LJ, Sun CL, Huang YL. Biperiden-induced delirium in an adolescent patient. J Child Adolesc Psychopharmacol 2011; 21:499-500. [PMID: 22040198 DOI: 10.1089/cap.2011.0050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Liang-Jen Wang
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
- Chang Gung University School of Medicine, Taoyuan, Taiwan
| | - Chia-Ling Sun
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Yu-Lin Huang
- Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
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Management of nonpsychiatric medical conditions presenting with psychiatric manifestations. Pediatr Clin North Am 2011; 58:219-41, xii. [PMID: 21281858 DOI: 10.1016/j.pcl.2010.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is a significant dilemma when underlying medical disorders present as psychiatric conditions. It is important to identify the medical condition because treatment and management strategies need to be directed to the presenting symptoms and also to the underlying medical condition for successful treatment of the patient. Some systemic disorders present with psychiatric manifestations more often than others. The pattern of psychiatric disturbance seen may be specific for a particular medical disorder but may also be varied. Many drug formulations and medications also may produce psychiatric presentations. This article considers the management of nonpsychiatric medical conditions presenting with psychiatric manifestations.
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Hindley P. Pediatric consultation-liaison psychiatry. J Psychosom Res 2010; 68:325-7. [PMID: 20307698 DOI: 10.1016/j.jpsychores.2010.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 03/01/2010] [Accepted: 03/04/2010] [Indexed: 11/16/2022]
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