Commentary: The Diagnosis of Delirium in Pediatric Patients

Abstract

Delirium is characterized by an acute onset and fluctuating course, impairment in attention, disorientation, deficits in language and visuospatial skills, and a deterioration in cognition not explained by an underlying dementia (Murphy, 2000). The disorder appears as a consequence of an illness or its treatment. In adult patients, delirium is considered an independent predictor of higher 6-month mortality and longer hospital stays (Ely et al., 2004). Pediatric patients seem to be especially vulnerable to toxic, metabolic, or traumatic CNS insults and are at greater risk of delirium with fever regardless of the etiology. Developmental limitations, in the areas of communication and cognition, prevent a thorough evaluation of the young patient for delirium. Only the most severe cases are identified, and the remainder is either ignored or mismanaged under incorrect diagnoses. Despite the importance of the diagnosis in the care of medically ill patients, few studies examine delirium in pediatric patients. Schieveld and Leentjens take on this task through the case reports of two young children. They describe the profound effects of delirium on the care of these patients and the emotional stability of both the child and caregiver. Delirium presents diagnostic challenges that are particularly relevant when attempting to evaluate a pediatric population. Physicians rarely conduct objective screening for the disorder, in part because of ambiguous diagnostic terminology. The effect of the diagnosis on medical care is poorly understood. Physicians are, therefore, less motivated to identify or treat delirium. The hypoactive subtype of the disorder is either infrequently recognized or misdiagnosed as depression. This is more likely in children who volunteer little information and, without obvious behavioral problems, may be ignored. These patients may also be perceived as calm and somnolent by the medical staff. Patients with paranoia, hallucinations, and aggressive behaviors are considered oppositional, defiant and difficult and demand immediate attention. Delirium symptoms fluctuate throughout the day with lucid intervals alternating with periods of confusion and agitation. Making the correct diagnosis may depend on the time of the assessment. Cases can also be very complicated with multifactorial causes of delirium that include aspects of treatment as well as illness (Lawlor and Bruera, 2002). Determining the cognitive status of the patient requires baseline information that existed before the hospitalization. Adults recognize declines in memory, orientation, writing, or mathematical skills. Children are either not aware of the deterioration from their previous level of functioning or are terrified of the circumstances and possible consequences. They may not actively participate in their treatment because they are unable to effectively communicate their needs and wants to medical staff and family members. Medical staff members may interpret distress secondary to mental status change as an indication of inadequate analgesic coverage. For example, the 28month-old child in the first case was given a variety of medications including opioids and benzodiazepines in an effort to comfort her. These drugs may also be an inappropriate treatment for a missed diagnosis of delirium. Recent adult studies of delirious patients discovered a circadian distribution to analgesic coverage. Patient with delirium are more likely to receive rescue medications for breakthrough pain in the evening and through the night, whereas patients without delirium receive most of their pain medication during the day. Accepted November 16, 2004. Dr. Martini is with the Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital, and the Departments of Psychiatry and Behavioral Sciences and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago. Correspondence to Dr. D. Richard Martini, Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital, 2300 Children’s Plaza, #10, Chicago, IL 60614; e-mail: d-martini@nwu.edu. 0890-8567/05/4404–0395 2005 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000153716.52154.cf