Development of the Vanderbilt Assessment for Delirium in Infants and Children to Standardize Pediatric Delirium Assessment By Psychiatrists

Psychological Health of the Adolescent Transplant Recipient

BACKGROUND

Solid organ transplant recipients experience a period of unique vulnerability during adolescence, when normative developmental changes intersect with health-related variables to influence psychological health.

METHODS

This article builds on previous reviews of psychological health in solid organ transplant recipients and proposes opportunities for clinical intervention during adolescence.

RESULTS

Transplant recipients often experience neurocognitive changes, particularly with respect to executive functions, that impact health management tasks and autonomous care. Recipients should be monitored for the development of anxiety, depression, and posttraumatic stress symptoms during adolescence, which in turn can negatively impact adherence to immunosuppression. Recent research in posttraumatic growth and resiliency factors may represent a promising avenue of intervention, leveraging normative developmental processes during this time period.

CONCLUSIONS

As pediatric transplant providers, adolescence represents a developmental period for targeted interventions to foster adjustment and adherence and promote a successful transition to adult care.

Prospective validation of Sophia observation withdrawal symptoms: A paediatric delirium scale in critically ill children in Denmark

BACKGROUND

Paediatric delirium (PD) is increasingly recognised as a common disorder in critically ill children with a reported prevalence ranging from 9% to 66%. We validated the PD component of the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale in a Danish setting to provide increased awareness and reliable identification of this critical condition, thereby paving the way for improved pathways to targeted delirium care.

OBJECTIVE

The objectives of this study were to criterion validate the PD component of the SOS-PD screening tool by comparing blinded psychiatric and nurse assessments and to estimate the prevalence of delirium in critically ill children in a Danish context.

METHODS

A prospective observational study was performed on critically ill children aged between 3 m and 18 y, admitted to an intensive care unit, with a hospital stay of 48 h or more. Assessments took place on a fixed weekday over an 18-month period. To test accuracy and criterion validity, bedside nurses' SOS-PD assessments were compared to the reference standard, a diagnostic assessment performed by a child psychiatrist according to the Diagnostic and Statistical Manual-V criteria by use of the Vanderbilt Assessment of Delirium in Infants and Children.

RESULTS

We included 141 children in the study, 30 (21%) of whom were diagnosed with delirium by the child psychiatrist. The accuracy of the delirium diagnosis was 93.6% (95% confidence interval [CI]: 88.3-97.1) among the nurses' SOS-PD assessments compared to the reference standard. The SOS-PD demonstrated a high sensitivity of 83.3% (95% CI: 65.3-94.4) and a high specificity of 96.4% (95% CI: 91.0-99.0) with five false-negative and four false-positive cases.

CONCLUSION

The PD component of the SOS-PD tool has good accuracy and validity for assessments performed by nurses compared to a child psychiatrist's diagnosis in critically ill children in a Danish setting. We recommend the use of the SOS-PD instrument in clinical practice.

Delirium in the NICU

Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.

Clinical application of 'Sophia Observation withdrawal Symptoms-Paediatric Delirium' screening tool in Danish version: A feasibility study

AIMS AND OBJECTIVES

The aims of the present study were investigating the feasibility of: (1) using the Danish version of Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) screening tool in clinical practice and (2) comparing SOS-PD performance to a child psychiatrist's assessment using the diagnostic criteria as a reference standard.

BACKGROUND

Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection. Systematic screening during and after intensive care is central to manage paediatric delirium.

DESIGN AND METHODS

We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS-PD. Second aim: We compared the SOS-PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years.

RESULTS

Nurses found the Danish version of the SOS-PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS-PD score and the child psychiatrist's assessment (88%). We found three false-negative and three false-positive SOS-PD cases. The false-negative cases could be explained by the differences in time periods for the assessments. SOS-PD assessments covered the past 4 h, whereas the psychiatric assessments covered the past 24 h. We assume the false-positive cases represent an acceptable inconsistency between the two assessment methods.

CONCLUSIONS

The Danish version of the SOS-PD appeared suitable for identifying paediatric delirium. Our results emphasised the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium.

RELEVANCE TO CLINICAL PRACTICE

Implementing the Danish SOS-PD may increase awareness of this critical disorder by improving systematic identification of paediatric delirium in clinical practice paving the way for improved delirium prevention and management.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

Improving Delirium Assessments in Vanderbilt Pediatric and Pediatric Cardiovascular Intensive Care Units

Introduction:

Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments.

Methods:

We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children’s Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool.

Results:

Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022.

Conclusions:

Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.

A prospective cohort study of emergence delirium and its clinical correlates in a pediatric intensive care unit in North India

BACKGROUND

Delirium is a common occurrence in medically compromised adults, but, research is limited in the pediatric population especially from low- and middle-income countries such as India.

AIMS

This study aimed to evaluate the emergence of delirium in children aged 5-18 years admitted to a pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Other objectives included delineating the clinical characteristics of delirium and its clinical correlates.

METHODOLOGY

It was a prospective cohort study in which all admitted children during a calendar year were assessed and those fulfilling the inclusion criteria were enrolled for study. The Pediatric Confusion Assessment Method Intensive Care Unit (p-CAM-ICU) scale was used to diagnose delirium.

RESULTS

ut of 305 total admissions to the PICU, 105 children were included. More than two third were male (68.6%) with a median age of 11 years. The incidence of delirium was 11.4% and median duration of delirium was 2 days. Majority of the children had hypoactive delirium (58.3%), followed by hyperactive (25%) and mixed type (16.7%). Metabolic or respiratory acidosis at baseline was significantly associated with delirium (p = 0.030). Presence of delirium led to significant prolongation of PICU stay (p < 0.001).

CONCLUSION

The emergence of delirium elicited in this study is on the lower side incomparison to previous studies. Several etiological factors for delirium are preventable and hence protocols and guidelines for management are required.

Prospective Validation of the Preschool Confusion Assessment Method for the ICU to Screen for Delirium in Infants Less Than 6 Months Old

OBJECTIVES

ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population.

DESIGN

Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry.

SETTING

Tertiary medical center PICU, including medical, surgical, and cardiac patients.

PARTICIPANTS

Infants less than 6 months old admitted to the PICU regardless of admission diagnosis.

MEASUREMENTS AND MAIN RESULTS

We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7-4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89-100%), specificity of 81% (68-90%), "negative and positive predictive values" of 97% (94-100%) and 69% (55-79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1-6 months old.

CONCLUSIONS

The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.

The diagnostic threshold of Cornell assessment of pediatric delirium in detection of postoperative delirium in pediatric surgical patients

Background

Cornell assessment of pediatric delirium (CAPD) showed advantage in diagnosis of pediatric delirium in Chinese critically ill patients. But its performance in surgical patients is still unclear. The present study was designed to validate the diagnostic performance of CAPD in surgical pediatric patients.

Methods

This is a prospective validation study. Pediatric patients who underwent selective surgery and general anesthesia were enrolled. Primary outcome was the incidence of delirium within postoperative three days. CAPD Chinese version was used to evaluate if the patient had delirium one time per day. At the meantime, a psychiatrist employed Diagnostic and Statistical Manual of Mental Disorders fifth edition to diagnose delirium, which was the “gold standard”, and the result was considered as reference standard. Sensitivity, specificity and area under receiver operating characteristic (ROC) curve were calculated to investigate the performance of CAPD.

Results

A total of 170 patients were enrolled. Median age was 4 years old. As diagnosed by psychiatrist, 23 (13.5 %) patients experienced at least one episode of delirium during the follow-up period. When diagnostic threshold was set at 9, CAPD showed the optimal sensitivity (87.0 %, 95 %CI 65.3 %-96.6 %) and specificity (98.0 %, 95 %CI 93.7 %-99.5 %) in comparison with other diagnostic thresholds. ROC analysis showed that CAPD was a good delirium assessment instrument with area under curve of 0.911 (95 % CI 0.812 to 1.000, P < 0.001). Agreement between CAPD and reference standard was 0.849 (Kappa coefficient, P < 0.001).

Conclusions

This study found that Cornell assessment of pediatric delirium could be used as an effective instrument in diagnosis of delirium in pediatric surgical patients.

Trial registration

www.chictr.org.cn Identifier: ChiCTR-DDD-17,012,231, August 3, 2017.

Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care

OBJECTIVES

The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity.

DESIGN

This is a prospective observational study.

SETTING

The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital.

PATIENTS

The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h.

INTERVENTIONS

No interventions were provided in the study.

MEASUREMENTS AND MAIN RESULTS

Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01).

CONCLUSIONS

Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.

Assessment of delirium in children admitted into the Intensive Care Unit: psCAM-ICU Tool

Background: Delirium has been identified as a risk factor for the mortality of critically ill patients, generating great social and economic impacts, since patients require more days of mechanical ventilation and a prolonged hospital stay in the intensive care unit (ICU), thus increasing medical costs. Objective: To describe the prevalence and characteristics of delirium episodes in a sample of 6-month to 5-year-old children who are critically ill. Methods: Cohort study at a Pediatric Intensive Care Unit (PICU) in Bogotá (Colombia). Participants were assessed by the Preschool Confusion Assessment Method for the ICU (psCAM-ICU) within the first twenty-four hours of hospitalization. Results: One quarter of the participants (25.8%) presented some type of delirium. Among them, two sub-types of delirium were observed: 62.5% of the cases were hypoactive and 37.5% hyperactive. Moreover, from them, six were male (75%) and 2 female (25%). Primary diagnosis was respiratory tract infection in 62.55% of the patients, while respiratory failure was diagnosed in the remaining 37.5%. Conclusions: The implementation of delirium monitoring tools in critically ill children provides a better understanding of the clinical manifestation of this phenomenon and associated risk factors in order to contribute to the design of efficient intervention strategies.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

Delirium in hospitalised children

Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).

Delirium in patients with dementia and in children: Overlap of symptoms profile and possible role for future diagnosis

BACKGROUND

Delirium in the extremes of the age spectrum may show similarities in presentations, and these similarities may provide information to develop tools for the diagnosis of delirium superimposed on dementia (DSD). We sought to investigate the symptom profile and subtypes of delirium in patients with dementia, and in infants and preschool children.

METHODS

This was an exploratory analysis of previous prospective cohort studies that evaluated delirium with the DSM-IV criteria in patients with dementia, and in critically ill infants (< 2 years of age) and preschool children (2-5 years of age), respectively. Delirium subtypes were defined based on the Richmond Agitation-Sedation Scale.

RESULTS

We included 147 patients, 35 adult patients with delirium DSD, 80 infants, and 32 preschool children with delirium. Hypokinesia and apathy were common among both DSD (72%), infants (74%) and preschool children (75%) with delirium, whereas hallucinations and anxiety were less common in both adults with DSD (26%) and infants (10%) and preschool children (14%). Hypoactive delirium was most common delirium subtype among infants (68%) and preschoolers (76%), whereas RASS = 0 (alert) delirium was the most common among adult patients with DSD (55%).

CONCLUSIONS

The study reports similarities in the symptoms profile of delirium in a cohort of patients with dementia and delirium, and in infants and preschool-aged children with delirium. These preliminary findings might be informative to design future studies adapting delirium assessments used in in infants and preschool-aged children to patients with dementia, especially in the moderate to severe stages.

Verifying the Japanese version of the Preschool Confusion Assessment Method for the ICU (psCAM-ICU)

Aim

Pediatric delirium has been well investigated and its prevalence is reported to be from 20% to 44%. For pediatric intensive care settings, several validated assessment tools for diagnosing delirium, including the Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM‐ICU), are available in English. However, validated assessment tools for identifying pediatric delirium are unavailable in Japanese. Therefore, the aim of this study is to verify the Japanese translation of the psCAM‐ICU.

Methods

We enrolled patients at the Pediatric ICU at University of Tsukuba Hospital (Tsukuba, Japan) from May 2017 to February 2019. Enrollment criteria included patients aged 6 months to 5 years, and we excluded coma patients scoring under −4 on the Richmond Agitation–Sedation Scale or suffering from stroke. Pediatric patient delirium was simultaneously evaluated by three medical workers (pediatric intensivist and researchers). Psychiatrists then verified these findings against criteria of the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition. We evaluated criterion validity (sensitivity and specificity) and reliability using Cohen's κ coefficient.

Results

We made a total of 56 independent assessments of 19 patients (42% female) with an average age of 18 (±15) weeks. Mechanical ventilation was used at least once in 73% of patients and the positive rate of delirium was 54% in total observation. Overall, the psCAM‐ICU showed high sensitivity, specificity (sensitivity, 0.90 [95% confidence interval [CI], 0.80–0.94]; specificity, 0.93 [95% CI, 0.83–0.97]), and high reliability within the researcher assessments (κ = 0.92; 95% CI, 0.82–1.0).

Conclusion

We verified the psCAM‐ICU and it shows high validity and reliability.

Pediatric Delirium: Recognition, Management, and Outcome

PURPOSE OF REVIEW

This review seeks to provide an update on the diagnosis, management, and outcome of pediatric delirium.

RECENT FINDINGS

Care of patients with delirium depends on correct diagnosis and treatment of its underlying cause. A variety of instruments are available to aid diagnosis. Management of delirium currently depends on atypical antipsychotics, while avoiding agents that may precipitate or exacerbate it. While most critically ill children survive delirium, many children die or have worsening function after their illness. The longer the duration of delirium, the more severe its subsequent problems including postintensive care syndrome and posttraumatic stress disorder. Possible serious long-term consequences emphasize the importance of efforts to improve diagnosis and outcome in critically ill children suffering from delirium.