Delirium
Contributing Author: Yu Kawai, M.D.
Definition
DSM V
Acutely develops
Fluctuating course
Delirium can improve or get worse, so just because patient looks good at one point in time does not rule out underlying delirium
Inattention and lack of environmental awareness
Disturbance of cognition
Not explained by preexisting neurocognitive disorder or reduced level of arousal
Triggered by medical condition(s)
Manifestation of CNS organ dysfunction, much like oliguria is a manifestation of AKI
Subtypes
Hyperactive: Agitation, purposeless actions, inconsolability, hallucinations, autonomic dysregulation,
Hypoactive: Low response, apathy, withdrawal, hallucinations
Mixed: Hyperactive + Hypoactive
Prevalence
10-30% of ICU infants and children
Hypoactive delirium 3 times as common as hyperactive
Symptoms manifest around 5th day of hospitalization but case reports of developing delirium within 24 hours of admission also exist
Risk Factors
Younger age, especially 2-5 year olds
Use of mechanical ventilation
Developmental delay
Higher severity of illness
Longer length of hospitalization
Use of opiates/benzodiazepenes >2 days
Admitted for neurological disorder (TBI, meningitis, encephalitis, status epilepticus)
Preexisting emotional, behavioral, psychological disorders
Causes
Lack of oxygen delivery to the brain (hypoxemia, anemia, decreased cardiac output)
New infection, worsening organ dysfunction, electrolyte and acid/base disturbances
Uncomfortable and unfamiliar environment
Unnecessary restraints/tubes/lines/absent family, lack of hearing aid/glasses
Untreated pain, agitation, medication/substance withdrawal
Deliriogenic medications (benzodiazepenes, anti-cholinergics, polypharmacy)
Immobility (lack of PT/OT involvement or inability to participate)
Poor sleep quality (excessive noise/light, frequent nursing care, lack of sleep protocol)
Clinical Outcomes
Increased post-traumatic symptoms
Increased maladaptive behavior
anxiety, eating disorders, aggression, apathy
Increased length of PICU stay
Increase of direct medical costs
Possible association with increased mortality
Diagnosis
Gold standard= psychiatric evaluation using DSM V criteria
Bedside tools available for non-psychiatric care providers
Pediatric Confusion Assessment Method (PCAM) for ICU (Smith, et al, CCM 2011)
Diagnostic Test
Can only be used in patients 5-17 years of age (hence, misses the younger population with the higher risk of developing delirium)
Cornell Assessment of Pediatric Delirium (CAPD)- See figure below. (Traube et al, CCM 2014).
Screening Test
Can be used in neonates and up to age 21 years
Development anchor points help screeners answer the questions on CAPD accurately by age group (see below)
Scores range 0-32 and ≥9 means the patient is at risk of developing delirium (positive predictive value ~50% based on previous studies although this will depend on ICU specific prevalence)
The higher the score, the more severe the delirium symptoms
In order to use either of the tools above, the Richmond Agitation Sedation Scale (RASS) needs to be performed (see below)
Richmond Agitation Sedation Scale (RASS)
Cornell Assessment of Pediatric Delirium (CAPD)
Treatment & Prevention
Manage acute medical conditions (hypoxia, anemia, electrolyte disturbances etc)
Assess need for lines/tubes/drains daily
Encourage parental involvement in care
Frequent reorientation
Clear communication
Prevent sensory deprivation (hearing aids, glasses)
Consult child life
Manage pain, agitation and withdrawal
Minimize sedation as able (particularly judicious use of benzodiazpenes)
PT/OT involvement early as able
Sleep protocol as able
Consult psychiatry and discuss possible use of atypical antipsychotic agents (risperdal, seroquel, olanzapine, etc)
REDUCE Study did not find benefit with the use of prophylactic haldol for prevention of delirium in adult patients at high risk of delirium
An adult study demonstrated reduced rates of delirium in the group treated with low dose nocturnal dexmedetomidine (Skrobik Y et al, AJRCCM 2018)
Clinical Scenarios
It may not always be obvious whether your patient is in pain, agitated, withdrawing, or delirious. Fortunately, we have several scores to help triangulate the cause of your patient's change in mental status. They include FLACC (pain), RASS (agitation), WAT (withdrawal), and CAPD (delirium). See the following scenarios:
To be able to distinguish the cause(s), here are the tools you have:
FLACC (pain; 0 to 10)
RASS (agitation/sedation; -5 to +4)
WAT-1 (withdrawal; 0 to 12)
CAPD (delirium; 0 to 32)
Case 1
-- FLACC = 7
-- RASS = +2
-- WAT-1 = 0
-- CAPD = 4
*** agitation due to pain --> may need an opioid ***
Case 2
-- FLACC = 0
-- RASS = +3
-- WAT-1 = 6
-- CAPD = 4
*** agitation due to withdrawal --> may need a benzo/opioid ***
Case 3
-- FLACC = 0
-- RASS = +3
-- WAT-1 = 1
-- CAPD = 15
*** agitation due to hyperactive delirium --> may need to avoid benzos and initiate sleep protocol ***
Case 4
-- FLACC = 0
-- RASS = -3
-- WAT-1 = 1
-- CAPD = 15
*** agitation due to hypoactive delirium --> may need to avoid benzos and initiate sleep protocol ***
Case 5
-- FLACC = 0
-- RASS = +3
-- WAT-1 = 6
-- CAPD = 15
*** agitation due to withdrawal that is leading to hyperactive delirium --> may need a benzo/opioid for the withdrawal --> as withdrawal improves, delirium should improve (this is why WAT-1 needs to be scored when CAPD ≥9) ***
Current Pediatric Delirium QI Initiative in the Mott PICU
Goals/Timeline
Develop a Pediatric Delirium Team for CS Mott Children's Hospital
Completed: Yu Kawai (PCCM Fellow, chair), Matthew Niedner (faculty advisor)
Implement RASS q4 hours in all patients admitted to the PICU- completed.
Implement CAPD q12 hours in all patients admitted to the PICU-completed.
Create an educational family brochure to be given to families of patients with positive CAPD screen- completed and available here: http://www.med.umich.edu/i/pteducation/docs/PediatricICU/PICU-DeliriumParentEd.pdf
Implement Bundle to Eliminate Delirium (BED) in all patients admitted ot the PICU
Checklists for care providers to reduce known risk factors for delirium and help manage it once it is diagnosed
Piloting on 2 patients currently
Develop a clinical practice guideline
Develop mLearning education module for bedside nurses to be completed annually
Project supported by Fostering Innovation Grant (FIG)
Installed sound and light monitors in all patient rooms and hallways to measure noise and light pollution at night time
Tablets with noise alert app to be mounted in all patient rooms for live feedback of noise level
Bedside portable LED lights that can be clipped to patient bed rail to avoid turning on main patient room light in an effort to promote sleep
Digital clocks with date/year displayed to promote orientation
Communication boards for all patients to be used for nonverbal communication
References
1) Traube C, Silver G, Kearney J, Patel A, Atkinson TM, Yoon MJ, Halpert S,Augenstein J, Sickles LE, Li C, Greenwald B. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*. Crit Care Med. 2014 Mar;42(3):656-63.
2) Smith HA, Boyd J, Fuchs DC, Melvin K, Berry P, Shintani A, Eden SK, TerrellMK, Boswell T, Wolfram K, Sopfe J, Barr FE, Pandharipande PP, Ely EW. Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit. Crit Care Med. 2011 Jan;39(1):150-7.
3) Schieveld JN, Leentjens AF. Delirium in severely ill young children in the pediatric intensive care unit (PICU). J Am Acad Child Adolesc Psychiatry. 2005;44:392–394
4) Creten C, Van Der Zwaan S, Blankespoor RJ, et al. Pediatric delirium in the pediatric intensive care unit: A systematic review and an update on key issues and research questions. Minerva Anestesiol. 2011;77:1099–1107
5) Neto AS, Nassar AP Jr, Cardoso SO, et al. Delirium screening in critically ill patients: A systematic review and meta-analysis. Crit Care Med. 2012;40:1946–1951
6) Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30–39
7) Schieveld JN, Lousberg R, Berghmans E, et al. Pediatric illness severity measures predict delirium in a pediatric intensive care unit. Crit Care Med. 2008;36:1933–1936