A SYNDROME of acute brain dys- function, delirium causes observ- able changes in behavior. A hall- mark of delirium is a disturbance of consciousness and cognition, with inattention that develops acutely and fluctuates over time. (See Understanding diagnostic criteria for delirium.) In critically ill adults, delirium can lead to more ventilator days, more intensive care unit (ICU) days, longer hospital stays, long- term cognitive problems, and an increased mortality risk. Adults have described delirium as a fright- ening experience with periods of confusion and hallucinations, plus a sense that they’re in a horrific dream they can’t escape. In pediatric patients, delirium often goes unrecognized, despite its prevalence. One study found delirium occurs in more than 30% of children ages 2 to 5 and more than 50% of critically ill children younger than age 2. Another study uncovered delirium in 20% of patients from birth to age 21 in the study population. In yet another study, among 515 hospitalized pediatric patients who received psychiatric consultations for various symptoms, only six oc- curred because the medical team identified delirium symptoms. Of the 515 patients, 53 were diagnosed with delirium by psychiatrists, in- cluding the six referred by the med- ical team. That team missed 87% of patients with delirium. Newly available diagnostic tools Like many nurses, you may have witnessed patients with signs or symptoms of delirium or acute brain dysfunction but couldn’t iden- tify the condition because you lacked diagnostic tools. Now that valid, reliable tools are available and delirium is known to signifi- cantly contribute to morbidity and mortality, several practice guide- lines (such as the Society of Critical Care Medicine’s ABCDEF bundle) have been issued to help caregivers diagnose, manage, and preventive delirium in critically ill adults. More recently, diagnostic tools have been developed to diagnose delirium in children, helping care- givers identify the condition early in critically ill children. Easily used at the bedside even by clinicians who aren’t specialists in psychiatry, these tools can detect all three sub- types of delirium—hyperactive, hy- poactive, and mixed. (See Identify- ing delirium subtypes) How to recognize delirium in pediatric patients Pediatric delirium can go unrecognized unless clinicians use a bedside assessment tool to identify it. By Stacey R. Williams, MSN, CPNAP-AC
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A SYNDROME of acute brain dys-function, delirium causes observ-able changes in behavior. A hall-mark of delirium is a disturbanceof consciousness and cognition,with inattention that developsacutely and fluctuates over time.(See Understanding diagnostic criteria for delirium.)
In critically ill adults, deliriumcan lead to more ventilator days,more intensive care unit (ICU)days, longer hospital stays, long-term cognitive problems, and anincreased mortality risk. Adultshave described delirium as a fright-ening experience with periods ofconfusion and hallucinations, plusa sense that they’re in a horrificdream they can’t escape.
In pediatric patients, deliriumoften goes unrecognized, despiteits prevalence. One study founddelirium occurs in more than 30%of children ages 2 to 5 and morethan 50% of critically ill childrenyounger than age 2. Anotherstudy uncovered delirium in 20%
of patients from birth to age 21 inthe study population.
In yet another study, among 515hospitalized pediatric patients whoreceived psychiatric consultationsfor various symptoms, only six oc-curred because the medical teamidentified delirium symptoms. Ofthe 515 patients, 53 were diagnosedwith delirium by psychiatrists, in-cluding the six referred by the med-ical team. That team missed 87% ofpatients with delirium.
Newly available diagnostic tools Like many nurses, you may havewitnessed patients with signs orsymptoms of delirium or acutebrain dysfunction but couldn’t iden-tify the condition because youlacked diagnostic tools. Now thatvalid, reliable tools are availableand delirium is known to signifi-cantly contribute to morbidity andmortality, several practice guide-lines (such as the Society of CriticalCare Medicine’s ABCDEF bundle)have been issued to help caregivers
diagnose, manage, and preventivedelirium in critically ill adults.
More recently, diagnostic toolshave been developed to diagnosedelirium in children, helping care-givers identify the condition earlyin critically ill children. Easily usedat the bedside even by clinicianswho aren’t specialists in psychiatry,these tools can detect all three sub-types of delirium—hyperactive, hy-poactive, and mixed. (See Identify-ing delirium subtypes)
How to recognize deliriumin pediatric patients
Pediatric delirium can go unrecognized unless cliniciansuse a bedside assessment tool to identify it.
By Stacey R. Williams, MSN, CPNAP-AC
www.AmericanNurseToday.com May 2016 American Nurse Today 9
Assessment toolsBrain dysfunction caused by deliri-um leads to certain observable be-haviors. Although the key featuresof delirium pertain to both pedi-atric and adult patients, symptomsin an 8-month-old infant may mani-fest differently than in an adult. Toidentify delirium in pediatric pa-tients, you can use the assessmenttools described below.
Cornell Assessment of PediatricDelirium (CAPD)Background: Adapted from the Pe-diatric Anesthesia Emergence Delir-ium tool to include screening forhypoactive delirium
Sensitivity/specificity: Overallsensitivity of 94.1% and specificityof 79.2% in diagnosing deliriumcompared to the reference standard(psychiatrist)
Age range: 0-21 years Description: The patient must
have a Richmond Agitation andSedation Scale (RASS) score of -3or higher to warrant use of theCAPD. Two nurses assess the pa-tient over a 24-hour period andanswer eight questions about thepatient’s cognition and mental sta-tus (using a Lickert scale) by an-
swering never, rarely, sometimes,often, or always. Using develop-mental anchor points helps identi-fy normal developmental activitiesfor each question for patientsyounger than age 2. The nurseshould assess the patient duringthe middle of the shift, scoring theanswers to the eight questions.Delirium is present if the score is9 or higher.
Bottom line: This tool doesn’t re-quire direct verbal interaction withthe patient. Also, the patientdoesn’t have to demonstrate inat-tention (a cardinal feature of deliri-um) because this tool doesn’t di-rectly test for it.
Pediatric Confusion AssessmentMethod for the Intensive CareUnit (pCAM-ICU)Background: Developed for chil-dren at least ages 5 and older indevelopmental age; adapted fromthe Confusion Assessment Methodfor the Intensive Care Unit (CAM-ICU) for adults
Sensitivity/specificity: Overallsensitivity of 83% and specificity of99% in diagnosing delirium com-pared to the reference standard(psychiatrist)
Age range: Ages 5 and older (de-velopmental age)
Description: The patient musthave a RASS score of -3 or higher.This tool uses the same four deliri-um features as the CAM-ICU—(1)acute change or fluctuation frombaseline mental status, (2) inatten-tion, (3) acute altered level of con-sciousness, and (4) disorganizedthinking. • Features 1 and 2 must be present
for the patient to have delirium.• If feature 1 isn’t present, stop
the assessment; the patient isnegative for delirium.
• If feature 1 is present, assessfeature 2 by showing a series ofpictures and asking the patientto remember them, or by askingthe patient to squeeze yourhand when he or she hears theletter “A” in a sequence of let-ters spoken aloud. If feature 2isn’t present, stop the assess-ment; the patient is negative fordelirium.
• If both features 1 and 2 arepresent, assess for feature 3—anacute altered level of conscious-ness. If the patient isn’t alert andcalm, stop the assessment; thepatient has delirium.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, lists five di-agnostic criteria for delirium:
A. The patient has disturbances in attention (such as reduced ability to direct, fo-cus, sustain, and shift attention) and in awareness (decreased orientation tothe environment).
B. The disturbance develops over a short period (usually hours to a few days),represents a change from baseline attention and awareness, and fluctuates inseverity over the course of a day.
C. An additional disturbance in cognition (for example, memory deficit, disorien-tation, language, visuospatial ability, or perception) is present.
D. The disturbances in criteria A and C aren’t better explained by a preexisting,established, or evolving neurocognitive disorder and don’t occur in the con-text of a severely reduced arousal level (such as coma).
E. Evidence exists that the delirium is a direct physiologic consequence of anoth-er medical condition, substance intoxication or withdrawal, or toxin expo-sure—or that it stems from multiple etiologies.
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (5th ed.)Arlington, VA: American Psychiatric Publishing; 2013.
Understanding diagnostic criteria for delirium
10 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com
• If the patient is alert and calm,assess for feature 4 (disorga-nized thinking) by asking fivequestions and having the patientcomplete one command. If fea-tures 1, 2, and either 3 or 4 arepresent, the patient has delirium. Bottom line: This objective and
rapid assessment tool requires in-teraction with the patient becauseit assesses for delirium at a specificmoment. It can be performedthroughout the shift if the patientexperiences mental-status changes.
Preschool Confusion AssessmentMethod for the Intensive CareUnit (psCAM-ICU) Background: Developed to assess fordelirium in children 6 ages monthsto 5 years in developmental age
Sensitivity/specificity: Overallsensitivity of 75% and specificity of91% in diagnosing delirium com-pared to the reference standard(psychiatrist).
Age range: Ages 6 months to 5years (developmental age)
Description: This tool wasadapted from the pCAM-ICU tosuit children with developmentalages of 6 months to 5 years. (Fea-tures 2 and 4 in pCAM-ICU aren’t
developmentally appropriate forthis age range.)• For assessment of inattention in
feature 2, show a series of 10pictures and determine howlong the pictures hold the child’sattention. The total possiblescore is 10.
• Feature 4 indirectly evaluates forsystem dysregulation by assess-ing for sleep-wake cycle distur-bances. As with the CAM-ICUseries, the patient must have aRASS score of -3 or higher and
both features 1 and 2 must bepresent, along with either fea-ture 3 or 4, to qualify for the di-agnosis of delirium. Bottom line: This tool is largely
objective and efficient for deliriumscreening.
Nursing actionsBecause nurses are at the patient’sbedside more consistently than oth-er clinicians, we’re likely to noticesubtle changes before anyone elsedoes. Now that we have tools foridentifying delirium in pediatric pa-tients, let’s use them. Keep the fol-lowing in mind when caring forchildren with delirium. • Recognize that delirium is acute
and will resolve. Your patient isnot crazy.
• Work with the pediatric ICU staffand faculty to educate yourselfabout pediatric delirium. Estab-lish a delirium monitoring proto-col using a valid, reliable moni-toring tool.
• Collaborate with child and ado-lescent psychiatrists early andconsistently. They can prove in-valuable not only in diagnosingdelirium but also in managingpatients with the condition.
• If your patient is delirious, firstcheck for common causes (suchas hypoxia, brain hypoperfu-sion, sepsis, electrolyte imbal-ances, trauma, drug withdrawal,and pain). If correcting thecause will take time (as withacute respiratory distress syn-drome), consider limiting iatro-genic causes known to worsendelirium (such as increased ben-zodiazepine use and sleep-wakecycle disturbances.)
• Use a recognized preventivestrategy, such as promotinggood sleep hygiene, managingpain, and recognizing and treat-ing drug withdrawal.
• Know what sedative drugs yourpatient is receiving, and monitorthe target sedation level to en-sure his or her safety. One study
Delirium can be hyperactive, hypoactive, or mixed. Observing your patient’s be-havior is the key to identifying which subtype is present.
• In hyperactive delirium, the patient meets all the criteria for delirium. Behaviorsmay include agitation, restlessness, combativeness, and pulling at I.V. lines oran endotracheal tube. The easiest subtype to recognize, hyperactive deliriumis what most healthcare professionals think of when they hear the word deliri-um. Nonetheless, in a study of children younger than age 5 who tested posi-tive for delirium, only 7% showed hyperactive subtype behaviors.
• In hypoactive delirium, the patient meets the criteria for delirium, seems se-date or apathetic, and appears withdrawn from people or the environment.Typically, these children seem comfortable but with something amiss; theydon’t quite seem like themselves. The most common subtype in childrenyounger than age 5, hypoactive delirium accounts for about 60% of childrendiagnosed with delirium—yet it often goes unrecognized.
• In mixed delirium, the patient meets all the criteria for delirium and displayssome behaviors typical of both hyperactive and hyperactive delirium. Thissubtype is common among children with delirium, and is seen in up to 30% ofchildren younger than age 5 who are diagnosed with delirium.
Identifying delirium subtypes
Although the keyfeatures of delirium
pertain to bothpediatric and adultpatients, symptoms inan 8-month-old infant
may manifestdifferently than in
an adult.
found that as little as 20 mg lorazepam in a 24-hour period can increase the risk of delirium to al-most 100% in critically ill adults. The study is sig-nificant for pediatric clinicians because if thatdosage caused delirium in nearly all critically illadults, it’s almost guaranteed to cause it in a childwho receives the same dosage over the same peri-od. As the link between delirium and benzodi-azepines is investigated further, we may need to re-consider such current practices as benzodiazepineinfusions.
• Realize that pharmacologic management of deliri-um may not always be appropriate. However, if thepatient presents a danger to the self, an antipsy-chotic agent may relieve unwanted behavioralmanifestations until the cause of delirium resolves.Don’t be afraid to use pharmacologic managementif appropriate, but know that drugs aren’t meant tobe used long term. Finally, keep in mind that an awake brain is the
first step toward a healthy brain. A child with anawake brain is one who isn’t receiving sedatingmedication, has adequate perfusion, and doesn’thave sleep-wake cycle disturbances.
Stacey Williams is a nurse practitioner in the pediatric critical care unit at MonroeCarell Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee.
Selected referencesAmerican Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders. (5th ed.) Arlington, VA: American PsychiatricPublishing; 2013.
Edwards S, Simone S, Pustilnik S, Walker LK, Lardieri A. The pedi-atric TEAM (Training Education, Assessment, & Management ofDelirium) program: an interprofessional collaboration in the criticalcare setting. Poster presented at: Interprofessional Care for the 21stCentury: Redefining Education and Practice; Jefferson Center for In-terProfessional Education 2014 Conference, October 10, 2014;Philadelphia, PA: Thomas Jefferson University.
Flaigle MC, Ascenzi J, Kudchadkar SR. Identifying barriers to deliri-um screening and prevention in the pediatric ICU: evaluation ofPICU staff knowledge. J Pediatric Nurs. 2016;31(1):81-4.
Kelly P, Frosch E. Recognition of delirium on pediatric hospital serv-ices. Psychosomatics. 2012;53(5):446-51.
Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an inde-pendent risk factor for transitioning to delirium in intensive care unitpatients. Anesthesiology. 2006;104(1):21-6. http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/931078
Smith HA, Boyd J, Fuchs DC, et al. Diagnosing delirium in criticallyill children: validity and reliability of the Pediatric Confusion Assess-ment Method for the Intensive Care Unit. Crit Care Med. 2011;39(1):150-7.
Smith HA, Gangopadhyay M, Goben CM, et al. The Preschool Con-fusion Assessment Method for the ICU: valid and reliable deliriummonitoring for critically ill infants and children. Crit Care Med. 2016;44(3):592-600.
Traube C, Silver G, Kearney J, et al. Cornell Assessment of PediatricDelirium: a valid, rapid, observational tool for screening delirium inthe PICU. Crit Care Med. 2014;42(3):656-63.
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