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24 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
HOURS
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
26 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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
[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 27
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.
28 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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.
[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 29
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
.
30 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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%
).
[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 31
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
32 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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.
[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 33
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.
34 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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.
[email protected] AJN ▼ April 2018 ▼ Vol. 118, No. 4 35
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.
36 AJN ▼ April 2018 ▼ Vol. 118, No. 4 ajnonline.com
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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