Psychosomatics 44:126-129, April 2003
© 2003 The Academy of Psychosomatic Medicine
The Delirium Rating Scale in Children and Adolescents
Susan Beckwitt Turkel, M.D.,
Kenneth Braslow, M.D.,
C. Jane Tavaré, M.S., and
Paula T. Trzepacz, M.D.
Received April 11, 2002; revision received July 5, 2002; accepted July 24, 2002. From the Department of Psychiatry and the Department of Pediatrics, Childrens Hospital, University of Southern California Keck School of Medicine; the Department of Psychiatry, University of Mississippi School of Medicine, Jackson; the Department of Psychiatry, Tufts University Medical School, Boston; and U.S. Neurosciences, Eli Lilly and Company, Indianapolis. Address reprint requests to Dr. Turkel, Childrens Hospital, University of Southern California Keck School of Medicine, 4650 Sunset Blvd., No. 82, Los Angeles, CA 90027; sbturkel{at}hsc.usc.edu (e-mail).
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ABSTRACT
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The study of delirium has been neglected in pediatric patients, and there are no diagnostic criteria or rating scales adapted for use in this age group. The Delirium Rating Scale is widely used to diagnose and rate the severity of delirium in adults. It was retrospectively administered to 84 children and adolescents diagnosed with delirium to evaluate its applicability in pediatric patients. Delirium Rating Scale scores were comparable to those reported for delirium in adults, although single cross-sectional Delirium Rating Scale scores did not predict length of hospital stay or mortality outcome. Therefore, the Delirium Rating Scale can be used to evaluate delirium in the pediatric population.
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INTRODUCTION
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Delirium is a neuropsychiatric disorder that indicates global dysfunction of the higher cortical centers that can be caused by a variety of medical and postsurgical conditions. Delirium is characterized by diffuse cognitive dysfunction, perceptual disturbances, an altered sleep-wake cycle, thought and language disturbances, altered mood and affect, and psychomotor changes. The onset of symptoms is characteristically acute, and symptoms tend to fluctuate over the course of the day.1,2
The study of delirium has been neglected in pediatric patients, where its diagnosis and treatment are underrecognized. There are no diagnostic criteria or rating instruments developed specifically to aid the diagnosis of delirium in this population. There are a variety of published instruments for diagnosing and assessing symptom severity in adults; these are usually structured to distinguish delirium from dementia, depression, and schizophrenia. Many consist of operationalized DSM or ICD diagnostic criteria, usually in the form of a checklist that incorporates information from patient observation and medical records. Their breadth of symptom coverage varies, as does their application. These instruments include the Delirium Rating Scale, the Confusion Assessment Method, the Saskatoon Delirium Checklist, and the Memorial Delirium Assessment Scale.3
The Delirium Rating Scale4 has been extensively tested in adults and translated into 10 different languages and is the most widely used instrument for diagnosing and rating the severity of delirium. It can distinguish delirium from schizophrenia, dementia, and depression; is more accurate than cognitive tests for the diagnosis of delirium; and can be used to follow patients once the diagnosis is made. Scores on the Delirium Rating Scale may be useful in predicting outcome, and lower Delirium Rating Scale scores correlate with a milder illness course in adults.5 Although the Delirium Rating Scale has been cross-validated several times, and the Delirium Rating Scale score has excellent reliability and very good validity, it does not operationalize inattention, and the scoring of psychomotor behavior may favor agitation over retardation.6
The Delirium Rating Scale is composed of 10 items: two items to determine the temporal onset of symptoms and their relationship to a physical disorder and eight to evaluate the major symptoms of delirium. These eight items rate perceptual disturbances, hallucinations, delusions, changes in psychomotor behavior, diffuse cognitive dysfunction, disturbances of the sleep-wake cycle, lability of mood, and variability of symptoms. The cognitive dysfunction item includes impairment of attention, concentration, and memory. Individual item scores range from 0 to 2, 3, or 4 points, and the maximum total score on the scale is 32 points. A score of 13 or more indicates a diagnosis of delirium.7 This retrospective study was undertaken to evaluate the applicability of the Delirium Rating Scale in pediatric patients.
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METHOD
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All patients with delirium were identified by a retrospective chart review of 1,027 consecutive psychiatric patients seen at Childrens Hospital Los Angeles from April 1991 through December 1995. The diagnosis of delirium was made by the attending child psychiatrist (S.B.T.) at the time of consultation on the basis of DSM-III-R criteria. The Delirium Rating Scale was scored retrospectively from clinical data in the initial psychiatric evaluation only, as recorded by the same psychiatrist. The presumed cause of delirium was classified into eight clinical diagnostic categories: infection, drug-induced, trauma, posttransplant, autoimmune disorder, postoperative, neoplasm, or organ failure.
Since this was a retrospective study, the statistical analysis was primarily descriptive. To determine the suitability of the Delirium Rating Scale in children, the 10 scale items were first evaluated to investigate their frequency, association, and applicability in this study population. Statistical evaluation of the data included tests for differences in age and gender for all 10 items and diagnoses. Additionally, differences in scores by underlying cause of delirium were examined. Finally, scores on the Delirium Rating Scale were reviewed, and the overall usefulness of the scale was assessed. Statistical analyses were restricted to t tests for differences in means, Kruskal-Wallis tests for differences in medians, and Pearson's correlations for associations among variables. Only correlations of 0.6 or greater are reported. A p value of 0.05 or less was used in tests of significance.
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RESULTS
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Eighty-four patients were identified as having delirium. They ranged in age from 6 months to 19 years. The average age was 10.4 years (SD=5.0), and the median age was 11 years, with a range of 6 months to 19 years. There was a slight preponderance of boys (N=45, 53.6%) compared to girls (N=39, 46.4%). These were seriously ill children with prolonged hospitalizations and high mortality. The mean hospital length of stay was 43 days (SD=51, median=19, range=1–255). Seventeen of the patients (20.2%) died during the index hospitalization. Delirium Rating Scale items for changes in psychomotor behavior, perceptual disturbances, cognitive dysfunction, relationship to physical illness, disturbances of sleep-wake cycle, lability of mood, and diurnal variability could be scored for the majority of patients (>90%) (Table 1).
Information regarding the presence or absence of hallucinations and delusions was often missing from the charts (32 and 33 patients, respectively), especially for the younger children, who were less likely to be able to report these symptoms. The mean age of the children with missing information for both hallucinations and delusions was 8.4 years (SD=4.9), compared to the mean ages of 11.7 years (SD=4.4) (t=–3.14, df=81, p=0.002) and 11.8 years (SD=4.4) (t=–3.30, df=80, p=0.001), respectively, for the children with data recorded concerning hallucinations and delusions. When pairs of items on the Delirium Rating Scale were chosen for analysis, a Pearson's correlation greater than 0.6 was found only between disturbances of the sleep-wake cycle and cognitive dysfunction (r=0.64, p<0.001).
When the Delirium Rating Scale was scored for the 51 patients with information for all 10 items, the total ranged from 14 to 32 points, and both the mean (SD=4.39) and the median were 25 points (Table 1). When we assumed that an item was missing when information about it was not recorded on the consultation report, the total Delirium Rating Scale score for the entire group of 84 patients also ranged from 14 to 32 points, with a mean of 24.60 (SD=4.10) and a median of 25. Because of the similarity of these two analyses, all items not noted in the charts were consistently recorded as absent and the Delirium Rating Scale scores were analyzed for all 84 patients. The following results are based on this assumption.
The minimum Delirium Rating Scale score of 14 points in this study is in agreement with the recommended score of at least 13 points for a diagnosis of delirium. For each of the 10 items, including psychotic symptoms, there was no significant difference in mean age between the patients with the symptom compared to those without the symptom. There was no significant difference between the sexes for age or Delirium Rating Scale score. There was no difference in mean or median Delirium Rating Scale score, according to the categories for underlying primary cause of delirium (Table 2). There were no significant correlations between Delirium Rating Scale score and age (r=–0.001) or between score and length of hospital stay (r=0.01). Delirium Rating Scale scores did not differ significantly according to underlying medical condition (Table 2). In addition, the index mortality rate (approximately 15% with a hospital stay of 30 days) was similar among the patients with high scores (above the median of 25 points) and the patients with low scores (25 or less).
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TABLE 2. Delirium Rating Scale Score, by Cause of Delirium, for 84 Children and Adolescents Diagnosed With Delirium
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DISCUSSION
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Delirium is a clinical syndrome characterized by a rapid alteration in level of consciousness and cognition, inattention, disorientation, memory impairment, and visual-spatial ability. The key features of delirium include acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness, according to DSM-IV.2 Visual, auditory, and tactile hallucinations sometimes occur—as do delusions—although these may not be core symptoms of delirium.8 There is less need in children than in adults to differentiate dementias from delirium. It is not necessary to include hallucinations, delusions, or perceptual disturbances in the diagnosis of delirium in children; these are not considered core symptoms of the disorder. This study illustrates the value of the DSM-III-R criteria throughout the age range, from infants to elderly persons.
Although retrospectively completed, this is the first report evaluating the Delirium Rating Scale in children, to our knowledge. The Delirium Rating Scale was found to be applicable in children with delirium, and scores were comparable with those reported for adults with delirium.5,9 Total Delirium Rating Scale scores did not predict mortality outcome or length of hospital stay in this group of children, which has been possible in adults.
This study suggests that the Delirium Rating Scale can be applied to the pediatric age group when administered prospectively by using all relevant sources of information. Because the Delirium Rating Scale was originally validated in groups of patients whose diagnoses were based on the DSM criteria and subsequently tested for sensitivity and specificity in diagnosing delirium, it could assist in confirming the diagnosis in children. The Delirium Rating Scale can enhance assessment and monitoring of the course of delirium in a standardized fashion, including in studies of effectiveness of delirium treatments in clinical trials. The Delirium Rating Scale could serve as a template for a modified instrument specifically formulated for the pediatric population. Prospective studies of the application of a pediatric Delirium Rating Scale could then follow.
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REFERENCES
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- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised (DSM-III-R). Washington, DC, APA, 1989
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR). Washington, DC, APA, 2000
- American Psychiatric Association: Practice Guideline for the Treatment of Patients With Delirium. Am J Psychiatry 1999; 156(May suppl)
- Trzepacz PT: The Delirium Rating Scale: its use in consultation-liaison research. Psychosomatics 1999; 40:193-204[Abstract/Free Full Text]
- Wada Y, Yamaguchi N: Delirium in the elderly: relationship of clinical symptoms to outcome. Dementia 1993; 4:113-116
- Rockwood K, Goodman J, Flynn M, Stolee P: Cross-validation of the Delirium Rating Scale in older patients. J Am Geriatr Soc 1996; 44:839-842[Medline]
- Trzepacz PT, Baker RW, Greenhouse J: A symptom rating scale for delirium. Psychiatry Res 1988; 23:89-97[CrossRef][Medline]
- Trzepacz PT: Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999; 10:330-334[CrossRef][Medline]
- Trzepacz PT, Dew MA: Further analyses of the Delirium Rating Scale. Gen Hosp Psychiatry 1995; 17:75-79[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
