Altered mental status and delirium in children

Souganidis E, Grala M, Chinsky J. Six-year-old with altered mental status: no “LACk” of clues. Pediatr Emerg Care. 2015 Apr 14. [Epub ahead of print]

“The clinical approach to a child with altered mental status requires both a broad differential diagnosis as well as prompt efforts to resuscitate and stabilize the child. While the diagnostic work-up may require extensive laboratory testing and imaging, there should always be an initial focus on rapidly reversible causes, most notably hypoglycemia in this case. Although the differential diagnosis of hypoglycemia is in itself extensive and largely influenced by the age of the child, the ability to promptly administer glucose, as that was done with our patient, can be life-saving before the etiology of the hypoglycemic episode is identified.”

Full-text for Children’s and Emory users.

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

“The commonly observed symptoms in children and adolescents with delirium were disturbance in attention, orientation, sleep-wake cycle disturbances, fluctuation of symptoms, disturbance of short-term memory and motor agitation. The least commonly seen symptoms included delusions and motor retardation. Compared to adults, children and adolescents had lower frequency of long-term memory and visuospatial disturbances. Compared to the elderly, children and adolescents had higher frequency of lability of affect. For severity of symptoms, compared to adults, the children and adolescents had lower severity of sleep-wake disturbances, abnormality of thought, motor agitation, orientation, attention, short-term memory, long-term memory and visuospatial abilities. When compared to elderly patients, children and adolescents had higher severity of lability of affect and lower severity of language disturbances, short-term memory and visuospatial abilities.”

Full-text for Children’s and Emory users.

Chapter 131. Altered Mental Status in Children. From Tintinalli’s Emergency Medicine, 7th ed. (2011) 

“The spectrum of alteration of mental status ranges from confusion or delirium (disorders in perception) to lethargy, stupor, and coma (states of decreased awareness). A lethargic child has decreased awareness of self and the environment. In the ED, this translates to decreased eye contact with family members and health care personnel. A stuporous child has decreased eye contact, decreased motor activity, and unintelligible vocalization. Stuporous patients can be aroused with vigorous noxious stimulation. Comatose patients are unresponsive and cannot be aroused by verbal or physical stimulation, such as phlebotomy, arterial catheterization, or lumbar puncture.”

Hatherill S, Flisher AJ. Delirium in children and adolescents: A systematic review of the literature. J Psychosom Res. 2010 Apr;68(4):337-44.

“Delirium is presumed to be the same syndrome in all ages. Comparing pediatric and adult studies, the authors found many of the same symptoms reported, but often at significantly different rates. Sleep–wake disturbance, fluctuating symptoms, impaired attention, irritability, agitation, affective lability, and confusion were more often noted in children; impaired memory, depressed mood, speech disturbance, delusions, and paranoia, more often in adults; impaired alertness, apathy, anxiety, disorientation, and hallucination occurrence were similar. These may represent true differences in the presentation of delirium across the life-cycle, or may be attributable to inconsistent methodologies. Prospective studies are needed to resolve this question.”

Full-text for Emory users.

Basu AP, George SM, Udpa G, et al. Spotting the wolf in sheep’s clothing. Arch Dis Child Educ Pract Ed. 2010 Aug;95(4):105-11.

“In adults, several tools exist for the assessment of delirium, but few have been validated in children. In all cases, the process should begin with taking a good history to determine the onset and fluctuating course. A history of sleep–wake cycle disruption is often elicited. Deficits in maintaining attentional focus and restlessness can be gauged during a period of observation or interaction. It may be possible to establish whether he or she is orientated in person, place and time by asking some simple questions, but cognitive changes can be difficult to assess in a delirious patient. Any cognitive assessment used must take into consideration the premorbid level of functioning. Listening to the carers’ comments about how the person’s behaviour and abilities have changed may provide additional information when formal neuropsychological testing is not possible.”

Full-text for Children’s users.

Avner JR. Altered states of consciousness. Pediatr Rev. 2006 Sep;27(9):331-8.

  • List the common causes of altered level of consciousness.
  • Discuss how to differentiate medical and structural causes of altered level of consciousness.
  • Develop a plan for the initial phase of evaluation for an altered level of consciousness.
  • Recognize the importance of radiologic imaging in a child who has an altered level of consciousness.
  • Know which ingestions are likely to cause neurologic adverse effects.

Full-text for Children’s users.

King D, Avner JR Altered mental status. Clin Ped Emerg Med. 2003 Sept; 4(3);171–178.

“Normal consciousness requires both awareness and arousal. Awareness is the combination of cognition and affect that can be inferred based on the patient’s interaction with the environment. Thus, alterations of consciousness may be the result of deficits in awareness, arousal, or both. Awareness is determined by the cerebral hemispheres whereas arousal is controlled by the ascending reticular activating system (ARAS) commonly called the sleep center. A helpful analogy is a bulb-switch model where the cerebral hemispheres function as a light bulb and the ARAS functions as a light switch. Normal consciousness requires the light bulb to be lit; to do so requires both the bulb and the switch to function properly. If the bulb is “out,” there can either be a problem with the bulb itself, the switch, or both. Similarly, altered mental status can result from depression of both cerebral hemispheres, localized abnormality of the sleep center, or global central nervous system dysfunction. Components necessary for the bulb to function are relative normothermia and blood flow, delivery of energy substrates (oxygen and glucose), and absence of toxins (metabolic waste products, poisons, and infectious material).”

Full-text for Emory users.

More PubMed results on delirium.

Created 01/25/13; updated 01/14/14; reviewed 10/23/14; updated 12/03/15, 02/15/17 – citations added to PubMed collection.  

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