International Childhood Cancer Day 2018: A Message From Luisella Magnani

I received a message from Professor Luisella Magnani yesterday about her contribution (CANCER DAY ) to International Childhood Cancer Day, which is today. I was reminded of what I see occasionally on Code Greens in the hospital–children suffering from delirium, which is sometimes a complication of childhood cancer. Code Green events in our general hospital are marked by a sort of designated mobile pit crew of nurses, nurse assistants, the consultation-liaison psychiatrist, and others who are trained and experienced in hurrying like a fire brigade to the medical units, including pediatric wards, where a patient is potentially or actually a physical threat to self or others. Often they are terrified because they are in the throes of the nightmare of delirium. Sadly, often they suffer from cancer. The goal is to use non-violent methods to ensure that the patients, caregivers, and families are safe from harm and to minimize the risk of further psychological trauma to all involved.

These events may go by different names at different hospitals, but they are an unfortunate and necessary part of managing delirium. My hat’s off to the nurses and doctors who call us. They have a remarkable ability to focus and maintain poise in these emergencies, including the trainees. In the heat of the moment, we collaborate on decisions about the safest way to help children who are too young and too sick to know what’s happening to them. Often enough the parents are in the room, and they are not just witnesses to their child’s terror and extreme agitation. In many cases, they are galvanized to help calm their son or daughter in the best way they know how. In a way, they can become a vital part of the pit crew. My hat’s off to them as well.

After the pit crew leaves, every member reflects on how the event could have gone better, what we might have done differently, and search diligently for every available guide or resource to help us understand all the possible causes and remedies known to science.

I search the medical literature for anything new about the underlying science and clinical interventions that would help me help patients, especially children, caught in the net of delirium, frequently in the context of a life-limiting disease such as cancer. The research on pediatric delirium is in the early stages. It’s often not recognized yet occurs in 29% of critically ill children. There are similarities to adult delirium as well as important differences, notably in preverbal children. For example, it’s important to suspect pediatric delirium in the child who is “inconsolable” or “non-sedatable.” Antipsychotics are generally safe to help calm agitation, hallucinations, and terror in children though doses are lower and keyed to the body weight. The evaluation of preverbal children is especially challenging.

Professor Magnani has written movingly about her own experience with the “inconsolable” preverbal child:

“…no parent can see his/her little child tearing his hair out and crying, crying in his inconsolability, because he is unable to express himself. No parent must say “This is not my child anymore. Where is my child? Why has he so changed?”–Professor Luisella Magnani on delirium in preverbal children.

There are many similarities between adult and pediatric delirium. The diagnosis of delirium is often missed in both populations. The preference for non-pharmacologic methods of managing the behavioral consequences of delirium are well-documented in adults though less studied in children. Prevention is the ultimate goal. Misconceptions about delirium persist, as every consultation-liaison psychiatrist knows.

We keep trying and never quit. The time is now. There can be no more “but.”

References:

Robyn P. Thom (2017). “Pediatric Delirium.” American Journal of Psychiatry Residents’ Journal 12(2): 6-8. (Dr. Thom is a second-year psychiatry resident at Harvard Longwood, Boston.)

Mark A. Oldham, et al. (2018). “Responding to Ten Common Delirium Misconceptions With Best Evidence: An Educational Review for Clinicians.” The Journal of Neuropsychiatry and Clinical Neurosciences 30(1): 51-57.
Delirium (acute confusion) is a serious, common health condition, and it predicts poor outcomes, including greater rates of mortality, institutionalization, prolonged hospitalization, and cognitive impairment. Expedient diagnosis and management are critical to address modifiable delirium causes and improve both quality of care and outcomes. Moreover, more than a third of delirium is preventable. Despite the clear significance of delirium and our increasingly sophisticated understanding of the condition, the gap between evidence and practice persists. The authors provide an educational review of 10 prevalent misconceptions of delirium pertaining to recognition, etiology, natural history, and best management. The authors respond to each with best evidence. Several themes emerge, chief among which is that casual observation is seldom sufficient to detect delirium. Use of open-ended questions, regular neurocognitive testing, and validated delirium screening instruments will aid in accurately identifying cases of delirium. Delirium is typically multifactorial, with several physiological and/or pharmacological contributors. Because of its multidetermined nature and its relationship with cognitive vulnerability, delirium can persist for days to months after acute causes have resolved. Furthermore, patients often have long-term cognitive impairment after delirium rather than returning to their predelirium cognitive baseline. Finally, nonpharmacological management of delirium is first-line, both for prevention and treatment. Psychotropic drugs such as neuroleptics are not recommended for routine use in delirium. They are best reserved for treating dangerous or distressing symptoms, including severe agitation, psychosis, or emotional lability. Challenging these 10 misconceptions stands to improve patient care, quality of life, and clinical outcomes substantially.

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Comments

  1. Great insights into delirium and pediatric delirium.

    That is a great table that every physician should know about.

    I used to run a clinic where we specialized in dementia and delirium. I was always impressed at how long delirium could persist and how often it was misdiagnosed as dementia. I also really liked the EEG as an assist in diagnosing and following some of those cases, but was probably fortunate in being able to work with an outstanding EEG lab.

    George
    George Dawson, MD

    Liked by 1 person

    • Great to hear from you, George! I really like the table. The medical students who rotate through the C-L Psychiatry service here get practice right away in bedside delirium assessments using the Mini-Cog, which Oldham referred to in the paper cited above. One of our senior residents alerted me to a new, UIHC-approved form for the Mini-Cog adapted from the International Journal of Geriatric Psychiatry, 1993; 8:487-496. A colleague in our psychiatry department has teamed up with a surgeon to develop a two-lead EEG to assess for delirium, see my December post, https://thepracticalpsychosomaticist.com/2017/12/18/more-about-the-eeg-and-delirium/

      Liked by 1 person

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