Continuing Education ORIGINAL RE SEARCH Recognizing ...

24 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com

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ORIGINAL RESEARCHContinuing EducationCE

Delirium is a frequent, underrecognized, com-plex neuropsychiatric syndrome. It is an acute state that is believed to be organically based.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disor-ders, Fifth Edition (DSM-5), characteristics of de-lirium include rapid onset; fluctuating course; and disturbances of attention, memory, thought, per-ception, and behavior that “do not occur within the context of a severely reduced level of arousal such as coma.”1, 2 While delirium in hospitalized adults, and particularly older adults, is well documented, affect-ing between 42% and 80% of this population,3 its occurrence among hospitalized children is less clear. A recent literature review found the reported prev-alence of delirium among hospitalized children to range from 13% to 28%; one study, which used “clinical suspicion” as its index, reported just 5%.4 Yet one retrospective study of children ages seven to 17 years who had been hospitalized found that more than 30% recalled having hallucinatory expe-riences during their stay.5 In almost all cases (94%), these delusional memories were “highly disturbing,”

The findings can facilitate earlier recognition and prevention of pediatric delirium.

with persistent and threatening content. Except in two cases, the location associated with these mem-ories was the pediatric ICU (PICU).

Delirium in adults has been associated with longer hospital stays, poorer functional outcomes, and high mortality rates.6 Although there have been fewer stud-ies among children, one study of pediatric psychiatric patients found that delirium was associated with pro-longed hospital stays and high mortality rates.7 Factors that increase the likelihood of delirium in hospitalized patients include disturbed sleep, discomfort, dehydra-tion, limited access to food and fluids, isolation, and immobility.8 In other words, the acute care hospital environment itself may be a precipitating factor. The specific pathophysiology of delirium remains largely unknown. That said, research in traumatic brain in-jury indicates that the immature, developing brain has different responses to oxygen deprivation and cytokine release than the adult brain, making children poten-tially more susceptible to occurrences of delirium.9, 10

In children, acute delirium can present in one of three subtypes: hypoactive, hyperactive, or mixed (also known as emerging or veiled) delirium.11 Hypoactive

1.5

Recognizing Delirium in Hospitalized Children: A Systematic Review of the Evidence on Risk Factors and Characteristics

[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 25

ABSTRACTPurpose: The purpose of this study was to examine the evidence regarding the risk factors for and charac-teristics of acute pediatric delirium in hospitalized children.

Methods: The systematic review method within an epidemiological framework of person, place, and time was used. Fifty-two studies were selected for initial retrieval. Of these, after assessment for method-ological quality, 21 studies involving 2,616 subjects were included in the review.

Results: Findings revealed five primary characteristics seen in children experiencing delirium: agitation, disorientation, hallucinations, inattention, and sleep–wake cycle disturbances. Children who were more se-riously ill, such as those in a pediatric ICU (PICU) and those with a high Pediatric Risk of Mortality II (PRISM II) score, and children who were mechanically ventilated were at greater risk for development of delirium. Those with a developmental delay or a preexisting anxiety disorder were also more prone to delirium. Although delirium symptoms fluctuate, most episodes occurred at night. Boys were slightly more susceptible than girls, though this difference was not significant. A key finding of this review was that delirium is multifactorial, re-lated to treatment (mechanical ventilation, for example) and to a hospital environment (such as a PICU) that deprives patients of normal sleep–wake cycles and familiar routines.

Conclusion: These findings will be useful in efforts to achieve earlier recognition and better management or prevention of pediatric delirium. This may also help to prevent unnecessary laboratory testing and imag-ing studies, which can cause children and parents unnecessary pain and anxiety and increase hospital costs.

Keywords: acute care, pediatric delirium, pediatric intensive care unit, risk factors, systematic review

delirium, thought to be related to the poorest out-comes, is characterized by inattention and lethargy. Hyperactive delirium is characterized by heightened psychomotor activity (such as agitation and pulling out catheters) and hallucinations. In mixed delirium, the patient fluctuates between the hyperactive and hypoactive subtypes. The patient may present with disturbed cognition or attention (or both) and severe anxiety “often accompanied with moaning and rest-lessness,” yet without clear agitation or lethargy.11

Estimates of the economic burden of delirium vary. One U.S. study conducted among elderly pa-tients found that delirium accounted for added health care costs of between $16,303 and $64,421 per pa-tient annually, resulting in an overall annual burden of $38 billion to $152 billion.12 A study in the Nether-lands by Smeets and colleagues found that pediatric delirium increased the duration of PICU stay by an average of 2.39 days, which corresponded to an in-crease of 1.5% in direct medical costs.13 And in a study of costs associated with pediatric delirium, Traube and colleagues found that median total PICU costs were almost four times higher for patients with delir-ium than for those without ($18,832 versus $4,803, respectively).14 After controlling for age, sex, illness severity, and PICU length of stay, delirium was as-sociated with an 85% increase in PICU costs.

It’s likely that a better understanding of the risk factors and characteristics of pediatric delirium would lead to earlier identification, referrals to psychiatric consultation when appropriate, and the development of delirium reduction and prevention programs. These

approaches have been shown to improve outcomes,12 and thus might also reduce costs.

Nurses, particularly pediatric nurses, are well posi-tioned to recognize the risk factors for and characteris-tics of pediatric delirium and to address ways to reduce such risk. Thus, we framed the research question as, “How do nurses recognize the risk factors and char-acteristics of delirium in children?” The purpose of this study was to examine the evidence regarding the risk factors for and characteristics of acute pediatric delir-ium in hospitalized children.

METHODSDesign. A descriptive epidemiological systematic re-view method was used. Descriptive epidemiological studies examine the distribution of a disease or con-dition for the purposes of establishing prevention or management programs (or both) and informing their planning and evaluation.15 Such studies do so by de-scribing the characteristics of people (race, age, and sex, for example), place (geographic location), and time (a specific year or span of time), rather than by examining the effects of an intervention. For this review, epidemiological study designs—including prospective and retrospective cohort studies with or without control groups, and cross-sectional and case–control studies that addressed nonemergent delirium (delirium unrelated to the administration of anesthe-sia, for example)—were sought.

The target population was hospitalized children, from birth through 21 years, who had been diagnosed with delirium. Studies were selected for inclusion if

By Cheryl Holly, EdD, RN, Sallie Porter, PhD, DNP, APN, RN-BC, CPNP, Mercedes Echevarria, DNP, APRN, Margaret Dreker, MLS, MPA, and Sevara Ruzehaji, BS, RN


they involved this target population, used a delirium screening method, described risk factors for or char-acteristics of delirium episodes (or both), and were published in English. Single case studies, intervention studies, and qualitative studies, as well as non-English publications, were excluded.

Selection of studies for inclusion. A four-step search strategy for articles published in English from 1990 through 2015 was used. First, we searched MEDLINE and CINAHL using an initial list of key-words generated from a concept map based on the research question; this method also allowed us to iden-tify additional keywords. Second, in consultation with a health sciences librarian, we used the expanded list of keywords to search 20 databases (see Electronic Databases Searched). Third, the reference lists of all identified articles were searched to identify additional studies. Lastly, we searched the selected Web of Sci-ence articles by author names to determine if any other relevant publications existed.

Two reviewers (CH and SP) screened all articles that were identified by title and abstract, using the in-clusion criteria. The resulting list was then reviewed by the entire review team. Each article selected for re-trieval was assessed independently by teams of two re-viewers (all authors participated) for methodological quality, using the appropriate critical appraisal tool from the Joanna Briggs Institute Reviewers’ Manual.16 Each team of reviewers compared the results of this assessment and jointly decided whether to include or exclude each study. Any disagreement was discussed

with the entire team until consensus was achieved. Studies were included if they met at least 80% of the methodological criteria in the critical appraisal tool. The appraisal criteria included questions regarding sample selection, sufficiency of sample descriptions, inclusion criteria, assessment of outcomes, reliability of outcome measures, and appropriateness of sta-tistical measures used. (For details regarding the full search strategy, please contact the corresponding au-thor.)

Data were extracted from articles using a pro forma data extraction tool. For each study, the following data were extracted: information on the sample (age, sex, diagnosis, preexisting conditions, sample size), study design, study location (PICU, non-PICU), delirium incidence, delirium screening method used, identified symptoms of delirium, and time of occurrence of such symptoms.

RESULTSOf the 301 articles originally identified, 52 appeared to meet the inclusion criteria based on the abstract or title. The review team subsequently excluded 31 of these. Reasons for exclusion were as follows: six were single case studies; five used a duplicate sample; five were literature reviews; five were not full text (two were letters to the editor, three were abstracts only); four studied the wrong population (postdis-charge patients); three were non-English publications; two were systematic reviews (one a review of inter-ventions, the other a review of diagnostic tools); and one was about the validity and reliability of tool de-velopment. Our review examined the remaining 21 quantitative studies, of which 11 were cohort studies and 10 were case series or case reports. Of these 21 studies, 10 were conducted in the United States, seven in the Netherlands, three in India, and one in South Africa. (For a flow diagram of the search strategy, see Figure 1.) Per the Joanna Briggs Institute’s levels of ev-idence,17 all 21 studies were graded as level 3 or 4.

Overall, the studies involved 2,616 children. Be-cause of differences in how studies reported delirium diagnosis, it was not possible to determine an overall prevalence rate. Nor did all studies report sex. In the 10 studies that did report both sex and a diagnosis of delirium, 54% of the 633 subjects were boys and 46% were girls, although this difference was not sig-nificant. The majority of subjects were PICU patients and had been diagnosed with delirium using a delir-ium rating scale (22%), by a psychiatric consultation liaison team (14%), or both (64%).

Findings from the 21 studies that met the inclusion criteria are presented according to the purposes of this review: to identify delirium risk factors in children from birth through 21 years of age and to identify characteristics of acute pediatric delirium. (See Table 1 for full details.7, 11, 13, 18-35) We defined risk factors as those conditions and circumstances that predispose

Electronic Databases Searched

• Agency for Healthcare Research and Quality • American Academy of Pediatrics • CINAHL (EBSCO) • ClinicalTrials.gov • Cochrane Library • Joanna Briggs Institute Library • JSTOR • Kaiser Family Foundation • MEDLINE (Ovid) • New York Academy of Medicine • OpenDOAR • ProQuest Dissertations and Theses • PsycINFO (Ovid) • Robert Wood Johnson Foundation • ScienceDirect • Scopus • Theses Canada • University of York Centre for Reviews and Dis-semination

• Virginia Henderson International Nursing Library • Web of Science


a child to the development of acute delirium. We de-fined characteristics as the individual symptoms and patterns of symptoms found in hospitalized children with acute delirium.

Risk factors for acute pediatric delirium. Age. Using the Cornell Assessment of Pediatric Delirium (CAPD) scale to assess PICU patients, Traube and colleagues found that delirium prevalence was lowest in children older than 13 years (3.6%).18 But Schieveld and colleagues, using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for delirium with evaluation by a child neuropsychiatrist, found delir-ium prevalence ranging from 3% in children ages three years or younger to 19% in those ages 16 to 18 years.11

Sex. As noted above, 10 studies reported both sex and a diagnosis of delirium, with delirium occurring overall in more boys than girls.11, 18-26 For example, Traube and colleagues reported that, of 111 PICU patients, the prevalence of delirium was 18.8% in girls and 21.7% in boys.18 And Smith and colleagues found that, of nine patients who developed delirium, 22.2% were girls and 77.8% were boys.24 Similarly, in the other eight study populations, more boys than girls were diagnosed with delirium. This suggests that male sex may be a risk factor.

Anxiety. Jones and colleagues reported that chil-dren with preexisting anxiety were more likely than others “to exhibit apprehension toward staff, inat-tentiveness and distractibility, motor agitation when awake, and misbehavior and disobedience.”27 They found that such children were at higher risk for de-veloping psychological trauma and behavior prob-lems that would require intervention, although they didn’t specifically cite delirium. Schieveld and col-leagues noted that anxiety was associated with a presentation of mixed delirium.11

Developmental delay. Traube and colleagues found that children with developmental delay were diag-nosed with delirium almost three times as often as chil-dren without such delay.18 In a pilot study of 50 PICU patients by Silver and colleagues, the prevalence of de-lirium was 29%, and the researchers noted that 24% of the overall sample had a prior diagnosis of devel-opmental delay.28

Mechanical ventilation. Van Dijk and colleagues investigated pediatric delirium in 29 PICU patients admitted over an eight-year period.26 In their sample, 79% were mechanically ventilated. In a larger study of 877 PICU patients, Schieveld and colleagues found that 85% of those with delirium were on mechanical ventilation.29 Similarly, in a study of 147 PICU pa-tients, Smeets and colleagues found that 84% of those with delirium were on mechanical ventilation, com-pared with 42% of those without delirium.13 Janssen and colleagues, studying 154 PICU patients, reported that 53.8% of those with delirium were mechanically

ventilated, compared with just 11.7% of those with-out delirium.21 And in the study by Traube and col-leagues, the researchers found that delirium prevalence was lowest (5.2%) among children who were not on respiratory support.18

A note on other potential risk factors. Our focus in this review was on noniatrogenic, nonpharmaco-logical risk factors and characteristics that fit within the epidemiological framework of person, place, and time. Thus, we did not consider factors that may be secondary to the patient’s acute illness or iatrogenic in nature, including metabolic disturbances, acute infec-tion, hypoxemia, anemia, acidosis, and hypotension. Some commonly used medications that are consid-ered precipitating risk factors for delirium, such as opioids, anxiolytics, tricyclic antidepressants, and corticosteroids, were also excluded.

Characteristics of acute pediatric delirium identi-fied in the 21 studies included agitation, disorientation,

Scree

ning

Includ

edElig

ibility

Iden

tifica

tion

244 Recordsexcluded

31 Full-text articles excluded6 Single case studies5 Duplicate population5 Literature reviews5 Non–full text editorials4 Wrong population3 Non-English publications2 Systematic reviews1 Tool development

21 Studies included in quantitative synthesis

1 Additional record identi�ed through other sources

300 Records identi�ed through databasesearching

296 Records screened after duplicatesremoved

52 Full-text articles assessed foreligibility

Figure 1. PRISMA Flow Diagram of Study Selection

PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Children in acute care are especially

susceptible to developing delirium.


Tabl

e 1.

Stu

dies

on

Pedi

atric

Del

irium

Incl

uded

in th

is Re

view

Stud

yLe

vel o

f Ev

iden

ceRe

sear

ch Q

uest

ion

or

Obj

ectiv

eD

esig

n Sa

mpl

e an

d Se

ttin

gSc

reen

ing

Met

hod

Risk

Fac

tors

Char

acte

ristic

s and

Oth

er N

otes

Gro

ver S

, et

al,20

200

94

To d

escr

ibe

the

clin

ical

pr

ofile

of c

hild

ren

and

adol

esce

nts r

efer

red

to a

ps

ychi

atric

serv

ice

over

a

7-ye

ar p

erio

d w

ho w

ere

diag

nose

d w

ith d

eliri

um

by IC

D-1

0 cr

iteria

Coho

rt, r

etro

spec

-tiv

e ch

art r

evie

w21

5 ch

ildre

n an

d ad

oles

-ce

nts a

ge 1

4 ye

ars o

r yo

unge

r ref

erre

d to

a p

sy-

chia

tric c

onsu

ltatio

n lia

ison

team

; of t

hese

, 46

(21%

) w

ere

diag

nose

d w

ith d

elir-

ium

, and

full r

ecor

ds w

ere

avai

labl

e fo

r 38

Indi

a

Patie

nts w

ere

diag

nose

d w

ith d

eliri

um p

er th

e IC

D-1

0 an

d th

e ps

ychi

at-

ric c

onsu

ltatio

n lia

ison

team

.

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um. U

n-de

rlyin

g pa

thol

ogy

was

infe

c-tio

n fo

llow

ed b

y ne

opla

sms.

All c

hild

ren

exhi

bite

d sle

ep–w

ake

cycl

e di

stur

banc

e an

d di

sorie

n-ta

tion.

Oth

er c

omm

on c

hara

cter

-ist

ics w

ere

inat

tent

ion

(89.

5%),

impa

ired

shor

t-te

rm m

emor

y (8

4.2%

), agi

tatio

n (6

8.4%

), and

la-

bilit

y of

affe

ct (6

0.5%

). Del

usio

ns

and

hallu

cina

tions

wer

e al

so re

-po

rted

.

Gro

ver S

, et

al,19

201

2 3

To d

evel

op a

sym

ptom

pr

ofile

of d

eliri

um in

ch

ildre

n an

d ad

oles

-ce

nts (

with

com

paris

ons

to a

dult

and

elde

rly p

ro-

file)

Case

serie

s30

chi

ldre

n ag

es 8

–18

year

s wer

e co

mpa

red

with

12

0 ad

ults

age

s 19–

64

year

s and

109

eld

erly

pa-

tient

s age

s 65

and

olde

r.

Indi

a

DSM

-IV-T

R cr

iteria

; DEC

Boys

wer

e m

ore

likel

y tha

n gi

rls

to d

evel

op d

eliri

um. M

ost c

om-

mon

risk

fact

ors w

ere

met

a-bo

lic a

nd e

ndoc

rine

caus

es,

follo

wed

by

infe

ctio

ns (s

ys-

tem

ic o

r int

racr

ania

l); m

ost

com

mon

etio

logi

es w

ere

sep-

sis (5

3.3%

), hy

poxi

a (4

3.3%

), an

emia

(40%

), an

d tr

aum

a (2

3.3%

), whi

ch in

clud

ed tr

au-

mat

ic b

rain

inju

ry.

Com

mon

ly o

bser

ved

sym

ptom

s in

chi

ldre

n an

d ad

oles

cent

s with

de

liriu

m w

ere

inat

tent

ion,

diso

ri-en

tatio

n, sl

eep–

wak

e cy

cle

dis-

turb

ance

s, sh

ort-

term

mem

ory

dist

urba

nces

, and

mot

or a

gita

-tio

n. D

eliri

um in

child

ren

and

ado-

lesc

ents

was

sim

ilar t

o th

at se

en in

ad

ults

and

the

elde

rly, w

ith c

hil-

dren

hav

ing

a hi

gher

freq

uenc

y of

la

bilit

y of

affe

ct.

Gro

ver S

, et

al,31

201

4 4

To e

xplo

re th

e fre

quen

cy

of d

iffer

ent m

otor

sub-

type

s of d

eliri

um in

chil-

dren

and

ado

lesc

ents

, an

d to

stud

y the

rela

tion-

ship

of m

otor

subt

ypes

w

ith o

ther

sym

ptom

s, et

iolo

gies

, and

out

com

es

Coho

rt49

chi

ldre

n ag

es 8

–19

year

s (48

.9%

mal

e) d

iag-

nose

d w

ith d

eliri

um

Indi

a

DSM

-IV-T

R cr

iteria

; D

RS-R

-98;

am

ende

d D

MSS

; DEC

; kno

wn

risk

fact

ors

Girl

s wer

e sli

ghtly

mor

e lik

ely

than

boy

s to

deve

lop

delir

ium

. Co

mm

on ri

sk fa

ctor

s inc

lude

d m

etab

olic

or e

ndoc

rine

dist

ur-

banc

es (4

9%) a

nd sy

stem

ic in

-fe

ctio

n (3

4.6%

).

The

hype

ract

ive

type

of d

eliri

um

was

mos

t com

mon

(53%

), fol

low

ed

by m

ixed

(26.

5%) a

nd h

ypoa

ctiv

e (1

6%).

Hal

luci

natio

ns w

ere

seen

w

ith th

e hy

pera

ctiv

e an

d m

ixed

su

btyp

es.

Hat

heril

l S,

et a

l,35 2

010

4To

des

crib

e th

e de

mo-

grap

hic

and

clin

ical

pro

-fil

e, m

orta

lity

rate

s, an

d ef

fect

iven

ess o

f tre

at-

men

t in

hosp

italiz

ed

child

ren

and

adol

es-

cent

s with

del

irium

re-

ferr

ed to

psy

chia

try

Coho

rt se

ries

23 ch

ildre

n ag

es 2

8 m

onth

s to

16

year

s (52

% fe

mal

e) d

i-ag

nose

d w

ith d

eliri

um

Sout

h Af

rica

Patie

nts w

ere

diag

-no

sed

with

del

irium

per

D

SM-IV

-TR

crite

ria a

nd

by a

psy

chia

tric

con

sul-

tatio

n lia

ison

team

.

Girl

s wer

e m

ore

likel

y th

an

boys

to d

evel

op d

eliri

um. In

ab

out h

alf o

f cas

es (5

7%),

pre-

scrib

ed m

edic

atio

n w

as su

s-pe

cted

as a

risk

fact

or. O

f the

23

pat

ient

s with

del

irium

, 78%

su

bseq

uent

ly re

ceiv

ed a

nti-

psyc

hotic

med

icat

ion.

Six

of

the

23 ch

ildre

n (2

6%) d

ied.

Com

mon

char

acte

ristic

s inc

lude

d ag

itatio

n (8

3%),

inso

mni

a (7

8%),

anxi

ety/

fear

fuln

ess (

61%

), mar

ked

moo

d la

bilit

y (5

7%),

visu

al (5

2%)

and

audi

tory

(35%

) hal

luci

natio

ns,

inco

nsol

abilit

y (5

0%), d

isinh

ibiti

on

(35%

), m

otor

reta

rdat

ion

(30%

), m

arke

d re

gres

sion

(26%

), de

lu-

sions

(22%

), ag

gres

sion

(22%

), an

d ap

athy

(17%

). O

nset

was

ac

ute

with

mar

ked

fluct

uatio

n.


Jans

sen

N,

et a

l,21 2

011

3

To in

vest

igat

e w

heth

er

the

DRS

, the

DRS

-R-9

8,

or th

e PA

ED w

ere

diag

-no

stic

in h

ospi

taliz

ed

child

ren

Coho

rt, p

rosp

ec-

tive

pane

l stu

dy15

4 ch

ildre

n ag

es 1

–17

year

s who

wer

e el

ectiv

ely

adm

itted

to th

e PI

CU a

nd

wer

e ei

ther

ven

tilat

ed o

r no

nven

tilat

ed; o

f the

se, 2

6 (5

4% m

ale)

wer

e di

ag-

nose

d w

ith d

eliri

um

Net

herla

nds

PAED

; DRS

; DRS

-R-9

8;

and

per D

SM-IV

crit

eria

by

ped

iatr

ic n

euro

psy-

chia

trist

Boys

wer

e m

ore

likel

y tha

n gi

rls

to d

evel

op d

eliri

um. P

rimar

y PI

CU d

iagn

oses

for t

he d

elir-

ium

gro

up w

ere

resp

irato

ry

(30.

8%),

neur

olog

ic (2

6.9%

), an

d cir

cula

tory

(23.

1%) d

isor-

ders

. In

the

delir

ium

gro

up,

53.8

% w

ere

on m

echa

nica

l ve

ntila

tion.

In th

e fu

ll sa

mpl

e, o

bser

ved

char

-ac

teris

tics i

nclu

ded

long

- and

shor

t-te

rm m

emor

y dist

urba

nces

(65%

an

d 57

%, r

espe

ctiv

ely)

, del

usio

ns

(52%

), pe

rcep

tual

dist

urba

nces

an

d ha

lluci

natio

ns (4

6%),

diso

rien-

tatio

n (4

4%),

inat

tent

ion

(36%

), la

bilit

y of a

ffect

(35%

), and

slee

p–w

ake

cycl

e di

stur

banc

es (1

9%).

Jone

s SM

, et

al,27

199

2

3To

com

pare

man

ifest

a-tio

ns a

nd se

verit

y of

anx

i-et

y, de

pres

sion,

del

irium

, an

d w

ithdr

awal

in P

ICU

pa

tient

s and

gen

eral

uni

t pa

tient

s

Case

serie

s43

child

ren

ages

6–1

7 ye

ars

(44%

mal

e); o

f the

se, 1

8 w

ere

from

the

PICU

or c

ar-

diov

ascu

lar I

CU, 2

5 w

ere

from

priv

ate

or se

mip

rivat

e ro

oms i

n ge

nera

l uni

ts

Uni

ted

Stat

es

Verb

al a

sses

smen

t of

com

mun

icat

ion

abili

ty;

PRIS

M; D

ICA;

DIC

A-P;

H

OBS

; sle

ep a

nd p

aren

-ta

l visi

tatio

n do

cum

en-

tatio

n by

nur

se

Girl

s wer

e m

ore

likel

y th

an

boys

to d

evel

op d

eliri

um. R

isk

fact

ors i

nclu

ded

PICU

adm

is-sio

n, m

ore

seve

re ill

ness

, lon-

ger h

ospi

taliz

atio

n, h

istor

y of

pr

evio

us h

ospi

taliz

atio

ns, a

nd

pree

xist

ing

anxi

ety

or m

ood

diso

rder

.

ICU

pat

ient

s wer

e m

ore

likel

y th

an

gene

ral u

nit p

atie

nts t

o ex

hibi

t be-

havi

oral

exp

ress

ions

of a

nxie

ty, d

e-pr

essio

n, a

nd w

ithdr

awal

. Pat

ient

s w

ith p

reex

istin

g an

xiet

y ha

d m

ore

seve

re d

eliri

um sy

mpt

oms.

Karn

ik N

, et

al,32

200

7 4

To d

escr

ibe

the

onse

t of

delir

ium

in tw

o ad

oles

-ce

nt g

irls w

ith d

istin

ct

delir

ium

subt

ypes

de-

rived

from

diff

eren

t pre

-ex

istin

g di

seas

e st

ates

Case

repo

rts

Two

patie

nts:

a 16

-yea

r-old

gi

rl w

ith a

hist

ory

of a

cute

ly

mph

obla

stic

leuk

emia

an

d a

14-y

ear-o

ld g

irl w

ith

a hi

stor

y of

syst

emic

lupu

s er

ythe

mat

osus

Uni

ted

Stat

es

Char

t rev

iew

; obs

erva

-tio

n; D

RSBo

th g

irls d

evel

oped

del

irium

. Th

e ris

k fa

ctor

s wer

e ce

ntra

l ne

rvou

s sys

tem

invo

lvem

ent

from

dise

ase

proc

esse

s or

trea

tmen

t.

Char

acte

ristic

s of d

eliri

um in

clud

ed

agita

tion,

conf

usio

n, d

isorie

ntat

ion,

ha

llucin

atio

ns (a

udito

ry a

nd v

isual

), pr

essu

red

spee

ch, a

nd ye

lling.

Kelly

P, F

rosc

h E,

22 2

012

3To

det

erm

ine

the

frequ

ency

with

whi

ch

pedi

atric

del

irium

is re

c-og

nize

d in

pat

ient

s re-

ferr

ed fo

r psy

chia

tric

co

nsul

tatio

n fo

r any

re

ason

and

whe

ther

th

e di

agno

sis o

f del

ir-iu

m a

ppea

red

on th

e di

scha

rge

prob

lem

list

Coho

rt, r

etro

spec

-tiv

e ch

art r

evie

w51

5 pa

tient

s adm

itted

to

any

pedi

atric

serv

ice

at a

la

rge

urba

n m

edic

al c

ente

r ov

er a

n 8-

year

per

iod;

of

thes

e, 5

3 (1

0.3%

) wer

e di

-ag

nose

d w

ith d

eliri

um

Uni

ted

Stat

es

Six

patie

nts (

1.2%

) wer

e di

agno

sed

with

del

irium

by

the

pedi

atric

team

, w

ith co

nfirm

atio

n by

ps

ychi

atry

usin

g D

SM-IV

-TR

crite

ria. A

n ad

ditio

nal

47 p

atie

nts (

9.1%

) wer

e di

agno

sed

by p

sych

iatr

y us

ing

DSM

-IV-T

R cr

iteria

.

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um.

Onl

y 8

of th

e 53

pat

ient

s (15

.1%

) di

agno

sed

with

del

irium

by

ei-

ther

met

hod

had

this

cond

ition

lis

ted

on th

e di

scha

rge

prob

lem

lis

t.

Leen

tjens

A,

et a

l,23 2

008

4To

des

crib

e th

e ph

e-no

men

on o

f ped

iatr

ic

delir

ium

in h

ospi

taliz

ed

child

ren

and

com

pare

it

with

adu

lt an

d ge

riatr

ic

delir

ium

Coho

rt46

chi

ldre

n ag

es 0

–17

year

s (64

% m

ale)

; com

par-

ison

grou

ps w

ere

49 a

dult

patie

nts a

ges 1

8–65

yea

rs

and

70 g

eria

tric

pat

ient

s ag

es 6

6 ye

ars a

nd o

lder

Net

herla

nds

Char

t rev

iew

; DSM

-IV-T

R cr

iteria

, sub

ject

to c

on-

sens

us p

roce

dure

; DRS

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um.

Del

irium

ons

et in

chi

ldre

n w

as

mor

e ac

ute

with

a le

ss fl

uctu

atin

g co

urse

. Chi

ldre

n w

ere

likel

y to

hav

e m

ore

seve

re a

gita

tion,

del

usio

ns,

hallu

cina

tions

, per

cept

ual d

istur

-ba

nces

, and

labi

lity

of m

ood,

but

fe

wer

slee

p–w

ake

cycl

e di

stur

-ba

nces

.


Tabl

e 1.

Con

tinue

d

Stud

yLe

vel o

f Ev

iden

ceRe

sear

ch Q

uest

ion

or

Obj

ectiv

eD

esig

n Sa

mpl

e an

d Se

ttin

gSc

reen

ing

Met

hod

Risk

Fac

tors

Char

acte

ristic

s and

Oth

er N

otes

Schi

evel

d J,

et

al,11

200

7 4

To st

udy

the

phen

ome-

nolo

gy, c

linica

l cor

rela

tes,

and

resp

onse

s to

trea

t-m

ent o

f del

irium

in c

riti-

cally

ill c

hild

ren

Case

serie

s, de

-sc

riptiv

e st

udy o

f a

coho

rt of

child

psy

-ch

iatr

ic c

onsu

lta-

tions

40 c

hild

ren

(25

boys

, 15

girls

) adm

itted

to th

e PI

CU;

80%

wer

e yo

unge

r tha

n 9

year

s

Net

herla

nds

Asse

ssm

ent b

y ch

ild

neur

opsy

chia

trist

usin

g D

SM-IV

crite

ria fo

r del

ir-iu

m. P

rovi

siona

l dia

gno-

ses w

ere

follo

wed

up

via

a m

ultid

iscip

linar

y co

n-se

nsus

mee

ting.

Und

erly

ing

risk

fact

ors w

ere

neur

olog

ical

diso

rder

s (n

= 21

), in

fect

ions

(n =

20)

, and

resp

i-ra

tory

diso

rder

s (n

= 12

). In

m

ost c

ases

ther

e w

ere

a co

m-

bina

tion

of th

ese.

Char

acte

ristic

s tha

t pro

mpt

ed a

re-

ques

t for

neu

rops

ychi

atric

con

sul-

tatio

n in

clud

ed a

gita

tion,

anx

iety

, m

oani

ng, d

iscom

fort

, and

beh

av-

iora

l dist

urba

nce.

Schi

evel

d J,

et

al,29

200

8

4To

ass

ess w

heth

er th

e PI

M a

nd th

e PR

ISM

II

scor

ing

inst

rum

ents

are

us

eful

in th

e ris

k as

sess

-m

ent a

nd d

iagn

osis

of

pedi

atric

del

irium

in th

e PI

CU

Coho

rt, p

rosp

ec-

tive

obse

rvat

iona

l st

udy

Of 8

77 ca

ses,

61 w

ere

re-

ferre

d fo

r chi

ld p

sych

iatri

c co

nsul

tatio

n; o

f the

se, 4

0 ag

es 4

–17

year

s (63

% m

ale)

w

ere

diag

nose

d w

ith d

elir-

ium

Net

herla

nds

Asse

ssm

ent b

y ch

ild

neur

opsy

chia

trist

usin

g D

SM-IV

-TR

crite

ria fo

r de

liriu

m

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um.

Child

ren

with

del

irium

wer

e m

ore

likel

y th

an th

ose

with

-ou

t del

irium

to b

e on

me-

chan

ical

ven

tilat

ion

(85%

) an

d to

hav

e a

neur

olog

ic

(40%

) or r

espi

rato

ry d

isord

er

(30%

).

Char

acte

ristic

s inc

lude

d un

ex-

plai

ned

conf

usio

n, a

gita

tion,

anx

-ie

ty, m

oani

ng, d

isco

mfo

rt, a

nd

beha

vior

al d

istur

banc

es. B

ased

on

clin

ical

pre

sent

atio

n, 1

4 ch

ildre

n w

ere

foun

d to

hav

e hy

pera

ctiv

e de

liriu

m; 9

, hyp

oact

ive

delir

ium

; an

d 17

, mix

ed d

eliri

um. A

PIM

or

PRIS

M II

scor

e ab

ove

the

60th

per

-ce

ntile

indi

cate

d a

high

er ri

sk o

f de

liriu

m.

Schi

evel

d J,

Leen

tjens

A,33

20

05

4To

des

crib

e de

liriu

m in

se

vere

ly il

l you

ng c

hil-

dren

Case

repo

rt, c

ase

serie

sTw

o fe

mal

e pa

tient

s, ag

es

28 a

nd 4

2 m

onth

s, in

a

PICU

Net

herla

nds

Char

t rev

iew

; DSM

-IV-

TR, u

sed

retr

ospe

ctiv

ely.

Fo

rmal

psy

chia

tric

eva

l-ua

tion

was

foun

d to

be

impo

ssib

le in

bot

h ca

ses.

Both

girl

s had

del

irium

. Ad-

mitt

ing

diag

nose

s inc

lude

d m

enin

goco

ccal

men

ingi

tis,

sept

ic sh

ock,

and

pne

umo-

nia.

In v

ery

youn

g se

vere

ly il

l chi

ldre

n,

the

occu

rrenc

e of

psy

chia

tric s

ymp-

tom

s and

beh

avio

ral d

istur

banc

es

shou

ld b

e co

nsid

ered

as d

eliri

um.

Regr

essio

n to

an

earli

er d

evel

op-

men

tal s

tage

, cha

otic

beh

avio

r, an

xiet

y, an

d m

oani

ng sh

ould

pr

ompt

susp

icio

n of

del

irium

.

Silv

er G

, et

al,28

201

2

4To

dev

elop

a sc

reen

ing

tool

for t

he d

etec

tion

of

delir

ium

in P

ICU

pat

ient

s th

roug

h co

mpa

rison

with

ps

ychi

atric

eva

luat

ion

us-

ing

DSM

-IV-T

R cr

iteria

Pros

pect

ive

blin

ded

pilo

t stu

dy50

chi

ldre

n an

d ad

oles

-ce

nts (

30 b

oys,

20 g

irls)

ag

es 3

mon

ths–

21 y

ears

; 46

% w

ere

youn

ger t

han

5 ye

ars

Uni

ted

Stat

es

CAPD

; eva

luat

ion

by p

e-di

atric

inte

nsiv

ist o

r chi

ld

psyc

hiat

rist u

sing

DSM

-IV

-TR

crite

ria to

dia

gnos

e de

liriu

m. T

he tw

o st

udy

team

s (“s

cree

n te

am”

and

“psy

chia

try

team

”)

wor

ked

inde

pend

ently

. Pr

eval

ence

was

com

pa-

rabl

e (2

8% a

nd 2

9%, r

e-sp

ectiv

ely)

.

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um. F

or

all s

ubje

cts,

the

prim

ary

ad-

mitt

ing

diag

nose

s wer

e on

-co

logi

c (2

6%),

card

iac

(16%

), an

d ne

uros

urgi

cal (

16%

). D

e-ve

lopm

enta

l del

ay w

as se

en

in 2

4% o

f tho

se w

ith d

eliri

um.

Sym

ptom

fluc

tuat

ion

was

evi

-de

nt. T

he m

ost c

omm

on ty

pes

diag

nose

d w

ere

hypo

activ

e de

lir-

ium

(43%

) and

mix

ed d

eliri

um

(43%

). H

yper

activ

e de

liriu

m w

as

the

leas

t com

mon

type

(14%

).


Smee

ts I,

et

al,13

201

0 3

To in

vest

igat

e, u

nder

cir-

cum

stan

ces o

f rou

tine

care

, the

impa

ct o

f ped

i-at

ric d

eliri

um o

n PI

CU

leng

ths o

f sta

y, as

wel

l as

on d

irect

fina

ncia

l cos

ts

Coho

rt14

7 ch

ildre

n ag

es 1

–18

year

s; of

thes

e, 4

9 ha

d de

-lir

ium

and

98

did

not

Net

herla

nds

Sym

ptom

atic

child

ren

wer

e re

ferre

d to

child

ne

urop

sych

iatr

ist fo

r ev

alua

tion.

Ass

essm

ent

was

bas

ed o

n D

SM-IV

-TR

crit

eria

; rec

all o

f par

-en

ts, n

urse

s, an

d m

edica

l te

am; a

nd th

e ps

ychi

atric

ev

alua

tion.

Fina

l dia

gno-

sis re

ache

d vi

a co

nsen

-su

s of a

ttend

ing

pedi

atric

in

tens

ivist

and

child

psy

-ch

iatri

st.

A di

agno

sis o

f del

irium

pro

-lo

nged

leng

th o

f PIC

U st

ay b

y an

ave

rage

of 2

.39

days

, inde

-pe

nden

t of s

ever

ity o

f illn

ess,

age,

sex,

mec

hani

cal v

entil

a-tio

n, o

r med

ical

indi

catio

n fo

r ad

miss

ion.

Com

pare

d w

ith c

hild

ren

with

-ou

t del

irium

, tho

se w

ith d

elir-

ium

tend

ed to

be

olde

r, rec

eive

d m

ore

mec

hani

cal v

entil

atio

n, a

nd

show

ed a

tren

d to

war

d hi

gher

PR

ISM

II sc

ores

.

Smith

H,

et a

l,24 2

011

4To

val

idat

e th

e pC

AM-IC

U

(whi

ch u

ses s

tand

ardi

zed,

de

velo

pmen

tally

app

ro-

pria

te m

easu

rem

ents

) as

a di

agno

stic

tool

for p

edi-

atric

del

irium

in c

ritic

ally

ill

chi

ldre

n, b

oth

vent

i-la

ted

and

nonv

entil

ated

Coho

rt, p

rosp

ec-

tive

obse

rvat

iona

l st

udy

68 c

hild

ren

(63%

mal

e)

age

5 ye

ars o

r old

er

Uni

ted

Stat

es

Dai

ly a

sses

smen

t by

two

criti

cal c

are

clin

i-ci

ans u

sing

the

pCAM

-IC

U, c

ompa

red

with

ev

alua

tion

by p

edia

tric

ps

ychi

atris

t usin

g D

SM-

IV-T

R cr

iteria

Boys

wer

e m

ore

likel

y tha

n gi

rls

to d

evel

op d

eliri

um. T

he m

ost

com

mon

adm

issio

n di

agno

ses

wer

e su

rgic

al in

terv

entio

n fo

r co

ngen

ital h

eart

dise

ase

(18%

) an

d re

spira

tory

insu

ffici

ency

fro

m st

atus

ast

hmat

icus (

12 %

).

The

mea

n PR

ISM

scor

e w

as 8

.6

(SD

, 7),

whi

ch p

uts i

t nea

r the

60

th p

erce

ntile

.

Trau

be C

, et

al,18

201

4

4To

det

erm

ine

the

valid

-ity

and

relia

bilit

y of

the

CAPD

, a ra

pid

obse

rva-

tiona

l scr

eeni

ng to

ol

Coho

rt

111

child

ren

ages

0–2

1 ye

ars (

60%

mal

e) se

en a

t a

maj

or u

rban

aca

dem

ic

med

ical

cen

ter

Uni

ted

Stat

es

Dou

ble-

blin

d as

sess

-m

ent b

y nu

rse

usin

g th

e CA

PD; e

valu

atio

n by

ped

iatr

ic in

tens

ivist

or

chi

ld p

sych

iatr

ist u

s-in

g D

SM-IV

-TR

crite

ria

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um. D

e-ve

lopm

enta

l del

ay w

as a

sig-

nific

ant r

isk fa

ctor

. Chi

ldre

n yo

unge

r tha

n ag

e 13

yea

rs,

thos

e on

resp

irato

ry su

ppor

t, an

d th

ose

who

wer

e “sic

ker”

w

ere

also

mor

e lik

ely

to d

e-ve

lop

delir

ium

.

The

fluct

uatin

g co

urse

of d

eliri

um

was

evi

dent

. The

re w

as a

ver

y lo

w

prev

alen

ce o

f del

irium

in a

dole

s-ce

nts o

lder

than

13

year

s and

in

child

ren

who

wer

en’t

on re

spira

-to

ry su

ppor

t. Th

e ra

te o

f fal

se

posit

ives

was

hig

her i

n ch

ildre

n w

ith d

evel

opm

enta

l del

ays.

Trau

be C

, et

al,30

201

4

4To

des

crib

e th

e pr

esen

-ta

tion

and

trea

tmen

t of

pedi

atric

del

irium

in 4

ch

ildre

n w

ith n

euro

blas

-to

ma

Case

serie

s4

patie

nts a

ges 7

mon

ths

to 3

yea

rs (7

5% fe

mal

e)

Uni

ted

Stat

es

Twic

e-da

ily C

APD

as-

sess

men

t by

nurs

e;

eval

uatio

n by

ped

iatr

ic

inte

nsiv

ist o

r chi

ld p

sy-

chia

trist

usin

g D

SM-IV

-TR

crit

eria

All 4

pat

ient

s dev

elop

ed d

e-lir

ium

; 75%

wer

e gi

rls. O

ther

ris

k fa

ctor

s inc

lude

d ha

ving

ca

ncer

and

pro

long

ed in

tu-

batio

n.

Agita

tion,

lack

of e

ye c

onta

ct,

thra

shin

g in

bed

, no

sust

aine

d sle

ep


Tabl

e 1.

Con

tinue

d

Stud

yLe

vel o

f Ev

iden

ceRe

sear

ch Q

uest

ion

or

Obj

ectiv

eD

esig

n Sa

mpl

e an

d Se

ttin

gSc

reen

ing

Met

hod

Risk

Fac

tors

Char

acte

ristic

s and

Oth

er N

otes

Turk

el S

B,

et a

l,7 200

3 4

To e

valu

ate

the

appl

ica-

bilit

y of

the

DRS

in p

edi-

atric

pat

ient

s

Case

serie

s, re

tro-

spec

tive

char

t re-

view

84 p

atie

nts w

ith d

eliri

um

ages

6 m

onth

s to

19 y

ears

(5

4% m

ale,

46%

fem

ale)

Uni

ted

Stat

es

DRS

, ret

rosp

ectiv

ely

calc

ulat

ed; d

iagn

osis

by

child

psy

chia

trist

usin

g D

SM-II

I-R c

riter

ia;

char

t rev

iew

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um. T

he

mos

t com

mon

und

erly

ing

caus

e of

del

irium

was

infe

c-tio

n (3

2.1%

).

All t

he c

hild

ren

had

impa

ired

at-

tent

ion.

A m

ajor

ity co

uld

be sc

ored

on

one

or m

ore

of th

e fo

llow

ing

DRS

item

s: ch

ange

s in

psyc

hom

o-to

r beh

avio

r, pe

rcep

tual

dist

ur-

banc

es, c

ogni

tive

dysf

unct

ion,

sle

ep–w

ake

cycl

e di

stur

banc

es,

and

labi

lity

of a

ffect

; 51

child

ren

(60.

7%) w

ere

able

to b

e sc

ored

on

all

10 D

RS it

ems.

Turk

el S

B,

et a

l,34 2

012

4To

des

crib

e th

e us

e of

at

ypic

al a

ntip

sych

otic

s in

con

trol

ling

sym

ptom

s of

del

irium

in c

hild

ren

and

adol

esce

nts

Case

serie

s, re

tro-

spec

tive

char

t re-

view

110

child

ren

(56

boys

, 54

girls

)

Uni

ted

Stat

es

DRS

-R-9

8, re

tros

pec-

tivel

y ca

lcul

ated

; pha

r-m

acy

reco

rds

All c

hild

ren

wer

e se

rious

ly il

l. D

eliri

um w

as m

ost l

ikel

y m

ul-

tifac

toria

l.

Obs

erve

d sy

mpt

oms o

f del

irium

in

clud

ed a

gita

tion,

con

fusio

n,

hallu

cina

tions

, and

inso

mni

a.

Turk

el S

B,

et a

l,25 2

013

4

To d

escr

ibe

the

use

of

atyp

ical

ant

ipsy

chot

ics i

n co

ntro

lling

sym

ptom

s of

delir

ium

in in

fant

s and

to

ddle

rs

Retr

ospe

ctiv

e ch

art r

evie

w19

chi

ldre

n ag

es 7

–34

mon

ths (

52.6

% m

ale)

Uni

ted

Stat

es

DSM

-IV-T

R cr

iteria

; DRS

, re

tros

pect

ivel

y ca

lcu-

late

d

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um.

Man

y of

the

patie

nts w

ere

seen

in th

e IC

U se

ttin

g, a

nd

man

y w

ere

intu

bate

d.

Clin

ical

obs

erva

tions

incl

uded

sle

ep d

istur

banc

es (1

00%

), ag

ita-

tion

(94.

7%),

impa

ired

atte

ntio

n (8

9.5%

), an

d irr

itabi

lity

(89.

5%).

van

Dijk

M,

et a

l,26 2

012

4To

con

firm

that

sym

p-to

ms o

f with

draw

al o

ver-

lap

with

sym

ptom

s of

delir

ium

Coho

rt, r

etro

spec

-tiv

e ch

art r

evie

w;

lett

er to

edi

tor

29 c

hild

ren

(17

boys

, 12

girls

) adm

itted

to P

ICU

s w

ith c

hild

psy

chia

trist

–co

nfirm

ed d

iagn

oses

of

delir

ium

Net

herla

nds

Char

t rev

iew

; sym

p-to

ms w

ere

inde

pen-

dent

ly d

ocum

ente

d by

two

rese

arch

ers;

dis-

crep

anci

es w

ere

dis-

cuss

ed u

ntil

cons

ensu

s w

as re

ache

d

Boys

wer

e m

ore

likel

y th

an

girls

to d

evel

op d

eliri

um. A

d-m

ittin

g di

agno

ses i

nclu

ded

trau

ma

(37.

9%),

card

iac

con-

ditio

ns (2

4.1%

), an

d re

spira

-to

ry c

ondi

tions

(10.

3%);

79%

of

the

child

ren

wer

e on

me-

chan

ical

ven

tilat

ion.

Mos

t pat

ient

s (86

.2%

) exh

ibite

d ag

-ita

tion,

whi

ch in

clud

ed ir

ritab

ility

; at

tem

pts t

o pu

ll out

lines

, tub

es, o

r ca

thet

ers;

and

rest

less

ness

or f

idg-

etin

g; 2

2 pa

tient

s (76

%) e

xhib

ited

hallu

cina

tions

, mos

tly v

isual

.

Del

irium

shou

ld b

e su

spec

ted

in c

hild

ren

if on

e or

mor

e of

four

ch

arac

teris

tics a

re se

en: d

isorie

nta-

tion

(per

son,

pla

ce, t

ime)

; hal

lucin

a-tio

ns (v

isual

or a

udito

ry);

impa

ired

or co

nfus

ed sp

eech

; and

forg

etfu

l-ne

ss o

r im

paire

d m

emor

y.

CAPD

= C

orne

ll As

sess

men

t of P

edia

tric

Del

irium

; DEC

= D

eliri

um E

tiolo

gy C

heck

list;

DIC

A =

Dia

gnos

tic In

terv

iew

for C

hild

ren

and

Adol

esce

nts;

DIC

A-P

= D

iagn

ostic

Inte

rvie

w fo

r Chi

ldre

n an

d Ad

oles

cent

s–Pa

rent

s; D

MSS

=

Del

irium

Mot

or S

ympt

om S

cale

; DRS

= D

eliri

um R

atin

g Sc

ale;

DRS

-R-9

8 =

Del

irium

Rat

ing

Scal

e Re

vise

d-98

; DSM

-III-R

= D

iagn

ostic

and

Sta

tistic

al M

anua

l of M

enta

l Dis

orde

rs, T

hird

Edi

tion,

Rev

ised

; DSM

-IV =

Dia

gnos

tic a

nd S

ta-

tistic

al M

anua

l of M

enta

l Dis

orde

rs, F

ourt

h Ed

ition

; DSM

-IV-T

R =

Dia

gnos

tic a

nd S

tatis

tical

Man

ual o

f Men

tal D

isor

ders

, Fou

rth

Editi

on, T

ext R

evis

ion;

HO

BS =

Hos

pita

l Obs

erve

d Be

havi

or S

cale

; ICD

-10

= In

tern

atio

nal C

lass

ifica

tion

of

Dis

ease

s, 10

th R

evis

ion;

PIC

U =

ped

iatr

ic IC

U; P

AED

= P

edia

tric

Ane

sthe

sia

Emer

genc

e D

eliri

um s

cale

; pCA

M-IC

U =

Ped

iatr

ic C

onfu

sion

Ass

essm

ent M

etho

d fo

r the

ICU

; PIM

= P

edia

tric

Inde

x of

Mor

talit

y; P

RISM

= P

edia

tric

Ris

k of

Mor

talit

y; P

RISM

II =

Ped

iatr

ic R

isk

of M

orta

lity

II.


hallucinations (primarily visual), inattention, and sleep–wake cycle disturbances. Aggression, irritability, restlessness or fidgeting, and impaired memory were among others noted. Jones and colleagues reported that such characteristics were significantly more com-mon in children in pediatric or cardiovascular ICUs than in children in general units.27 In a case series of very young children with neuroblastoma, Traube and colleagues described a lack of sustained sleep, agita-tion (such as thrashing in bed), and a lack of eye con-tact as characteristics of postoperative delirium.30

Patterns of delirium symptoms in children are similar to those seen in adults, especially older adults. In seven studies involving a total of 447 pediatric pa-tients and use of the Delirium Rating Scale Revised-98 (DRS-R-98)—which incorporates the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi-tion, criteria and is often used to assess delirium in adults—all of the children exhibited characteristics of delirium according to the scale.7, 21, 23, 31-34 This suggests that the presentation of delirium episodes in children and adolescents is similar to that in adults. In one study of 38 patients by Grover and colleagues, all of the subjects had sleep–wake cycle disturbances and disorientation, and a majority had impaired attention (89.5%), impaired short-term memory (84.2%), agi-tation (68.4%), and lability of affect (rapid changes in emotion unrelated to external events; 60.5%).20 Karnik and colleagues reported that delirium symptoms ob-served in two hospitalized adolescents were compara-ble and included impaired attention, agitation, periods of confusion, memory loss, and sleep–wake cycle disturbances.32 In a study of 110 children by Turkel and colleagues, delirium symptoms included sleep–wake disturbances, motor agitation, altered thought process, disorientation, inattention, short- and long-term memory problems, and visual–spatial difficul-ties.34

There was some evidence of differences in the presentation of pediatric and adult delirium. Another study by Grover and colleagues, conducted among 30 children ages eight to 18 years, concluded that al-though the pattern of delirium in this population was similar to that seen in adults, children had a higher fre-quency of lability of affect.19 Leentjens and colleagues, comparing delirium symptoms in 46 children and 119 adults, reported that children tended to have more se-vere perceptual disturbances, hallucinations, agitation, and lability of affect.23 But children were less likely to exhibit sleep–wake cycle disturbances.

DISCUSSIONWhile the precise mechanism in the development of acute delirium is unknown, the results of this review indicate that children who are more severely ill or de-velopmentally delayed are at higher risk. Children who are in a PICU, mechanically ventilated, and male may also be at greater risk, as are those with a high

Pediatric Risk of Mortality II (PRISM II) score (at or above the 60th percentile).

Overall, acute pediatric delirium presents with disturbances in behavior, circadian rhythm, cogni-tion, consciousness, and perception (see Character-istics of Pediatric Delirium). The characteristics of pediatric delirium were found to be wide ranging. The five most common characteristics overall were agitation, disorientation, hallucinations (primarily visual), inattention, and sleep–wake cycle distur-bances (see Table 220, 25, 26, 31, 35). Symptoms reflective of the hyperactive type of delirium were the most

Characteristics of Pediatric Delirium

Disturbances in behavior • Aggression • Agitation • Fidgeting • Increased activity level • Restlessness

Disturbances in circadian rhythm • Insomnia • Sleep–wake cycle disturbance

Disturbances in cognition and mood • Anxiety • Depression • Disorientation • Impaired short-term memory • Irritability • Language disturbance • Memory deficit • Pressured speech

Disturbances in consciousness • Confusion • Disorientation

Disturbances in perception • Apprehension • Hallucinations • Poor judgment (pulling out catheters or iv lines, for example)

Early recognition of pediatric delirium can

be enhanced by the routine use of valid

screening tools in PICUs.


prevalent. These include aggression, agitation, hal-lucinations, and restlessness or fidgeting.

Early recognition of acute pediatric delirium can be enhanced by the routine use of valid screening tools in PICUs. Such assessment is an important basic ele-ment in timely recognition, management, and pre-vention strategies. Since the clinical course of delirium fluctuates, screening may be most useful if done at least once per shift. It stands to reason that frequent screening, leading to earlier detection and appropri-ate treatment, could also shorten lengths of stay. The CAPD, a recently developed eight-question rapid as-sessment tool, has the potential to facilitate early rec-ognition.18 This tool has been found to be comparable to the use of DSM-IV-TR criteria and psychiatric eval-uation in recognizing acute pediatric delirium.28 The CAPD uses age-based developmental anchor points (newborn; four, six, eight, and 28 weeks; and one and two years), and can be completed by nurses in less than five minutes.18 It has shown excellent reliability and validity, and provides a structured, developmen-tally informed approach to the screening and assess-ment of delirium in children.18, 35

Given that delirium has a rapid onset and fluctuat-ing course, it’s essential to use delirium screening tools first at the time of admission to establish a baseline for comparison with later status. As Hatherill and colleagues stated, the “temporal aspect” of cognitive changes “underscor[es] the need for a longitudinal assessment and serial interviews.”36 This is especially important for children with developmental delays or preexisting anxiety, as these conditions have been found to be risk factors for the development of delir-ium.18, 27 The PRISM II score has also been found to be predictive of delirium for children scoring in the 60th percentile or above.13, 29

It’s useful to consider the similarities between the characteristics of delirium in children and the elderly in the hospital setting. These include rapid onset, ag-gression, agitation, impaired attention, irritability, and memory disturbances.7, 19, 23, 25 Two studies found that in children, symptoms were more often seen at night.19, 26 In a study comparing symptoms in children and older adults, Grover and colleagues noted that children had more severe lability of affect, but less se-vere language, short-term memory, and visual–spatial disturbances.19 Furthermore, it’s important to note that Traube and colleagues found that parents were often aware of their child’s cognitive and behavioral changes before the hospital staff were.18

Implications. The clinical signs of delirium vary and are often dependent on a patient’s age and, among infants and children, developmental stage. Of all health care professionals, nurses interact most closely and often with patients, and are thus vital to both early recogni-tion and prevention of delirium in hospitalized children.

Delirium as a potential cause of agitation and sleeplessness must be considered. Indeed, Schieveld and Leentjens found that in severely ill young chil-dren, psychiatric symptoms and behavior changes were more likely due to delirium than to a psychiatric disorder.33 The early recognition and management of pediatric delirium may help prevent unwarranted lab-oratory testing and imaging studies, which can cause children and families unnecessary distress, as well as increasing hospital costs.

Measures to support and maintain a child’s usual sleep–wake cycles include fostering a routine sleep schedule, reducing ambient noise, and lower-ing light levels at night.37 Nurses and other hospital staff need to ensure that loud discussions don’t take place near a sleeping child and that any unnecessary noise-producing equipment is shut off. Usual age-appropriate comfort measures are also important. These may include providing a pacifier or other fa-vorite toy and singing songs to lessen fear and anxi-ety during both routine and nonroutine procedures, and encouraging parents to physically and verbally support and comfort their child.38

Facilitating parental presence at the bedside and listening to parents’ concerns about changes in their

Characteristic Range, % Selected Studies

Agitation, irritabilitya 68.4–94.7 Grover, et al,20 2009Grover, et al,31 2014Hatherill, et al,35 2010Turkel, et al,25 2013van Dijk, et al,26 2012

Disorientation 0–100 Grover, et al,20 2009Grover, et al,31 2014Hatherill, et al,35 2010Turkel, et al,25 2013van Dijk, et al,26 2012

Hallucinationsb 1–75.8 (visual, 30.5–52;auditory, 7.9–35)

Grover, et al,20 2009Hatherill, et al,35 2010Turkel, et al,25 2013van Dijk, et al,26 2012

Impaired attention 78–93.8 Grover, et al,20 2009Grover, et al,31 2014Hatherill, et al,35 2010Turkel, et al,25 2013

Sleep–wake cycle dis-turbances (including insomnia)

41.3–100 Grover, et al,20 2009Grover, et al,31 2014Hatherill, et al,35 2010Turkel, et al,25 2013van Dijk, et al,26 2012

Table 2. Common Characteristics of Acute Delirium in Children

a Most studies considered agitation and irritability separately, but van Dijk and colleagues com-bined the two.b Not all studies listed auditory and visual hallucinations separately.


child’s behavior are also important for the early recog-nition of delirium. Parents may be the first to observe changes in their child’s cognition or behavior that are symptomatic of delirium. Moreover, parental presence at the bedside may enhance the child’s comfort and lessen anxiety, and might prevent delirium from de-veloping. Parents need education regarding delirium prevention, treatment, and follow-up care, including the fact that delirium symptoms may persist after dis-charge.5, 37 Emotional support for parents who witness the often upsetting behaviors of a child with delirium is essential. Because hallucinations are a commonly reported characteristic, staff education on the poten-tial for delusional activity may be needed. Lastly, in-creased psychological monitoring and support for children with delirium and their families should be considered, as well as routine psychiatric consultation for children at risk for delirium.

Limitations. Per the Joanna Briggs Institute’s levels of evidence,17 all 21 studies were graded as level 3 or 4, meaning that our findings must be viewed in light of their limitations. For example, several studies used a retrospective design, inferring data from recorded facts or narratives in the medical record. Because of the studies’ low levels of evidence grades and varying methods of assessment, a meta-analysis was not possi-ble. This review is further limited by its observational nature, which does not allow for causal attribution.

The severity of delirium episodes could not be consid-ered as an outcome measure because only a few of the studies assessed delirium using a standardized rating scale.

CONCLUSIONSAcute delirium is reportedly among the top six pre-ventable conditions in hospitalized older adults,39 and may rank similarly high in the pediatric population. Children in acute care are especially susceptible to de-veloping delirium. This systematic review examined the evidence regarding risk factors for and characteris-tics of pediatric delirium. It is our hope that the find-ings will lead to more timely recognition and enhance prevention.

In accordance with the epidemiological framework of person, place, and time, we found the following: risk factors may include male sex, preexisting anxiety,

developmental delay, and being on mechanical venti-lation (person); the five most common characteristics of pediatric delirium include agitation, disorientation, hallucinations (primarily visual), inattention, and sleep–wake cycle disturbances; patterns of delirium symptoms in children are similar to, but not exactly the same as, those found in adults and the elderly; among hospitalized children, the most susceptible were those admitted to a PICU (place); and, although the symptoms of pediatric delirium fluctuate, many

Consideration Definition Findings of This Review

Person Demographic information; per-sonal characteristics

Children from birth through 21 years experienced de-lirium, with boys slightly more susceptible than girls. Children with developmental delays or preexisting anxiety disorders were also more prone to delirium.

Place Information on the origins of the problem

Children admitted to a pediatric ICU were more likely to develop delirium than those admitted to a general unit. Studies in this review were conducted in four dif-ferent countries; acute pediatric delirium may be a global issue.

Time Information regarding the onset of the problem

The onset of delirium symptoms was acute and fluc-tuating, although most episodes occurred at night.

Table 3. Epidemiological Considerations in Assessing Acute Pediatric Delirium

The five most common characteristics of pediatric delirium

include agitation, disorientation, hallucinations, inattention,

and sleep–wake cycle disturbances.


episodes occurred at night (time). (See Table 3.) A key finding of this review is that delirium is multifac-torial, related to treatment (specifically, mechanical ventilation) and to a hospital environment (such as the PICU) that deprives patients of normal sleep–wake cycles and familiar routines. ▼

Cheryl Holly is a professor, senior methodologist, and codirector of the Northeast Institute for Evidence Synthesis and Translation at Rutgers School of Nursing, Newark, NJ, where Sallie Porter is an assistant professor and Margaret Dreker is a research librarian. Mercedes Echevarria is an associate professor at George Washing-ton University, Washington, DC, and Sevara Ruzehaji is a staff nurse at Englewood Hospital, Englewood, NJ; at the time of this writing, Echevarria was an associate professor in the Advanced Practice Division at Rutgers School of Nursing, where Ruzehaji was an honors student. Funding from the Society of Pediatric Nurses partially supported the research reported in this study. Contact author: Cheryl Holly, [email protected]. The au-thors and planners have disclosed no potential conflicts of interest, financial or otherwise.

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19. Grover S, et al. Symptom profile of delirium in children and adolescent—does it differ from adults and elderly? Gen Hosp Psychiatry 2012;34(6):626-32.

20. Grover S, et al. Delirium in children and adolescents. Int J Psychiatry Med 2009;39(2):179-87.

21. Janssen NJ, et al. On the utility of diagnostic instruments for pediatric delirium in critical illness: an evaluation of the Pedi-atric Anesthesia Emergence Delirium Scale, the Delirium Rat-ing Scale 88, and the Delirium Rating Scale-Revised R-98. Intensive Care Med 2011;37(8):1331-7.

22. Kelly P, Frosch E. Recognition of delirium on pediatric hos-pital services. Psychosomatics 2012;53(5):446-51.

23. Leentjens AF, et al. A comparison of the phenomenology of pediatric, adult, and geriatric delirium. J Psychosom Res 2008; 64(2):219-23.

24. Smith HA, et al. Diagnosing delirium in critically ill children: validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit. Crit Care Med 2011;39(1): 150-7.

25. Turkel SB, et al. The diagnosis and management of delirium in infancy. J Child Adolesc Psychopharmacol 2013;23(5): 352-6.

26. van Dijk M, et al. Screening pediatric delirium with an adapted version of the Sophia Observation withdrawal Symptoms scale (SOS). Intensive Care Med 2012;38(3):531-2.

27. Jones SM, et al. Behavioral changes in pediatric intensive care units. Am J Dis Child 1992;146(3):375-9.

28. Silver G, et al. Detecting pediatric delirium: development of a rapid observational assessment tool. Intensive Care Med 2012;38(6):1025-31.

29. Schieveld JN, et al. Pediatric illness severity measures predict delirium in a pediatric intensive care unit. Crit Care Med 2008; 36(6):1933-6.

30. Traube C, et al. Neuroblastoma and pediatric delirium: a case series. Pediatr Blood Cancer 2014;61(6):1121-3.

31. Grover S, et al. Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile? Gen Hosp Psychiatry 2014;36(2):187-91.

32. Karnik NS, et al. Subtypes of pediatric delirium: a treatment algorithm. Psychosomatics 2007;48(3):253-7.

33. 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(4):392-5.

34. Turkel SB, et al. Atypical antipsychotic medications to control symptoms of delirium in children and adolescents. J Child Adolesc Psychopharmacol 2012;22(2):126-30.

35. Silver G, et al. Delirium screening anchored in child develop-ment: The Cornell Assessment for Pediatric Delirium. Palliat Support Care 2015;13(4):1005-11.

36. Hatherill S, et al. Delirium among children and adolescents in an urban sub-Saharan African setting. J Psychosom Res 2010;69(2):187-92.

37. Madden K, et al. Recurrent delirium after surgery for con-genital heart disease in an infant. Pediatr Crit Care Med 2011;12(6):e413-e415.

38. Porter S, et al. Infants with delirium: a primer on prevention, recognition, and management. Pediatr Nurs 2016;42(5):223-9.

39. Rothschild JM, Leape LL. The nature and extent of medical injury in older patients. Washington, DC: AARP, Public Policy Institute; 2000 Sept. https://assets.aarp.org/rgcenter/health/ 2000_17_injury.pdf.

For 176 additional continuing nursing education activities related to pediatric topics, go to www.nursingcenter.com/ce.

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