Delirium

Question 1

What is delirium?

Answer 1

Delirium is a disorder of awareness and attention, characterized by its waxing and waning nature, and occurs secondary to an underlying medical condition.

Question 2

How does delirium differ from primary psychiatric diagnoses?

Answer 2

Delirium is not a primary psychiatric diagnosis but occurs due to an underlying medical condition. The cause is often unknown at presentation.

Question 3

What are the risks of untreated delirium in children?

Answer 3

Untreated delirium in children can prolong recovery, interfere with necessary medical care, and may lead to adverse outcomes, including death.

Question 4

What is the mortality rate associated with delirium in children and adolescents?

Answer 4

Delirium in children and adolescents is associated with a 12.5–29% mortality rate.

Question 5

What are the core features of delirium?

Answer 5

Delirium involves an alteration in attention and awareness, as well as disturbances in cognition, such as confusion, disorientation, and difficulty focusing.

Question 6

What are common symptoms that can be mistaken for psychosis or mania in delirium?

Answer 6

Symptoms such as hallucinations, bizarre or purposeless movements, and altered sleep-wake cycles can be mistaken for psychosis or mania.

Question 7

What are the different subtypes of delirium?

Answer 7

The hyperactive subtype involves increased motor activity and restlessness, the hypoactive subtype shows reduced activity and alertness, and the mixed motor subtype features both hyperactive and hypoactive symptoms.

Question 8

What is the no motor subtype of delirium?

Answer 8

The no motor subtype of delirium is characterized by the absence of either hyperactive or hypoactive symptoms.

Question 9

How does delirium present differently in children compared to adults?

Answer 9

In children, developmental differences may complicate the assessment, requiring insights from caregivers and staff regarding behavioral changes such as fussiness or difficulty soothing.

Question 10

What is the prevalence of delirium in hospitalized children?

Answer 10

The prevalence of pediatric delirium is estimated to be 13–44%, with higher rates in ICU patients or those on mechanical ventilation.

Question 11

What are modifiable risk factors for pediatric delirium?

Answer 11

Modifiable risk factors include polypharmacy, deep sedation, benzodiazepines, anticholinergic medications, disrupted sleep, sensory deprivation, and lack of familiar caregivers.

Question 12

What medical conditions are commonly associated with delirium?

Answer 12

Conditions like infections, metabolic disorders, trauma, and some neurological diseases can lead to delirium.

Question 13

What drugs are commonly associated with the development of delirium in children?

Answer 13

Drugs such as benzodiazepines, anticholinergic medications, sedatives, opiates, steroids, and some illicit substances can cause delirium.

Question 14

How is delirium diagnosed?

Answer 14

Delirium is diagnosed clinically through history and physical exam, with diagnostic criteria outlined in the DSM-5, including disturbances in attention and cognition, and evidence of an underlying medical cause.

Question 15

What are the DSM-5 criteria for delirium?

Answer 15

1. Disturbance in attention and awareness, 2. Acute onset with fluctuating symptoms, 3. Cognitive disturbance, 4. Exclusion of preexisting neurocognitive disorder, 5. Evidence of a direct physiological cause.

Question 16

What is the role of EEG in diagnosing delirium?

Answer 16

EEG can help confirm delirium in cases of diagnostic uncertainty, showing diffuse background slowing and disorganization in 65–86% of delirium cases, though it’s not diagnostic on its own.

Question 17

Why is it important to distinguish delirium from psychiatric disorders like psychosis or mania?

Answer 17

Distinguishing delirium from psychiatric disorders is important because treatment approaches differ; for example, treatment of delirium can exacerbate catatonia.

Question 18

How does delirium differ from psychosis?

Answer 18

Delirium has an acute onset with fluctuating symptoms, while psychosis typically has a prodromal nature and involves more structured delusions, often auditory hallucinations rather than visual.

Question 19

How can depression be distinguished from delirium?

Answer 19

Depression does not have the waxing and waning course of delirium and usually presents with slower cognition and intact orientation, unlike delirium where orientation is often impaired.

Question 20

What is the role of rating scales in delirium assessment?

Answer 20

Rating scales like the CAPD, pCAM-ICU, and psCAM-ICU can help identify children at risk for delirium, but are not diagnostic on their own.

Question 21

How do you assess children for delirium?

Answer 21

In young children, caregivers and staff can provide insight into changes in attention and behavior, while older children may undergo more standard assessments.

Question 22

What factors complicate delirium assessment in children?

Answer 22

Developmental differences make it difficult to assess delirium in young children who may not be able to answer standard questions about orientation or attention.

Question 23

How can the history help in diagnosing delirium?

Answer 23

The history should focus on acute onset of symptoms, fluctuating attention and orientation, and any underlying medical conditions or medications that may contribute to delirium.

Question 24

Why is it important to assess both motor and non-motor symptoms of delirium?

Answer 24

Motor symptoms (like restlessness or sluggishness) can help differentiate between subtypes of delirium, while non-motor symptoms (like altered thought content) provide crucial diagnostic information.

Question 25

What are some disorders that can mimic delirium?

Answer 25

Catatonia, depression, and psychosis.

Question 26

What are some key differences between catatonia and delirium?

Answer 26

Catatonia is less likely to have a waxing and waning course and often presents with motor signs not typically seen in delirium.

Question 27

Which rating scale is used to diagnose catatonia?

Answer 27

The Bush-Francis Rating Scale.

Question 28

What is the hallmark difference between delirium and primary psychosis?

Answer 28

Delirium has an acute onset, whereas psychosis develops gradually. Hallucinations in delirium are often visual, while in psychosis they are auditory.

Question 29

What key factor distinguishes delirium from depression?

Answer 29

Delirium has a waxing and waning course, while depression does not.

Question 30

What are some nonpharmacologic interventions for managing delirium?

Answer 30

Frequent reorientation, adherence to normal routines, clustering care, and maintaining a normal sleep–wake cycle.

Question 31

What is the goal of nonpharmacologic interventions in delirium treatment?

Answer 31

To provide a supportive environment and sensory/environmental modifications to help offset hospital care challenges.

Question 32

What pharmacologic medications are commonly used in delirium management?

Answer 32

Antipsychotics, including both first- and second-generation options.

Question 33

What are the main adverse effects of antipsychotic medications in delirium management?

Answer 33

QTc prolongation, requiring ECG monitoring.

Question 34

What is the preferred route of administration for antipsychotics in delirious patients?

Answer 34

Second-generation antipsychotics are preferred for oral administration, while IM or IV haloperidol may be used when oral intake is not possible.

Question 35

What other medications may help in the management of delirium?

Answer 35

Melatonin for circadian rhythm and trazodone for nocturnal sleep maintenance.

Question 36

What medications should be avoided in delirious patients?

Answer 36

Benzodiazepines and anticholinergic medications, as they can worsen delirium.

Question 37

What is the impact of opiate pain medications in delirium?

Answer 37

Opiates can worsen delirium and should be used with caution in patients at risk.

Question 38

What is the course of delirium resolution?

Answer 38

Resolution can be variable, with some patients improving quickly and others taking weeks to months for full recovery.

Question 39

What are the potential long-term sequelae of delirium?

Answer 39

Impaired cognitive functioning and increased risk for subsequent episodes of delirium.

Question 40

How should antipsychotics be managed as delirium improves?

Answer 40

Antipsychotic medications can be weaned as symptoms improve; long-term use is not necessary.