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)

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 ***

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