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    Cornell Assessment of Pediatric Delirium (CAPD)

    Screens for pediatric delirium.
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    INSTRUCTIONS

    Do not use in patients with Richmond Agitation-Sedation Scale (RASS) ≤-4 (deep sedation: no response to voice, but movement or eye opening to physical stimulation, or unarousable: no response to voice or physical stimulation). Includes developmental anchor points for children at 8 weeks and 1 year to improve screening accuracy in very young patients.

    When to Use
    Pearls/Pitfalls
    Why Use
    • In critically ill pediatric patients aged 0-21 years.

    • May be used in both developmentally normal and delayed patients.

    • Pediatric delirium often presents differently than that of adults. Children may be more likely to have a catatonia-like presentation, with general listlessness and paucity of speech.

    • Children with developmental delay are at higher risk of developing delirium than non-delayed children, and therefore should be monitored more closely for delirium symptoms.

    • As in adults, hospitalized children, particularly those in the PICU, are at high risk of developing delirium.

    • In turn, delirium in children is associated with complications such as increased length of stay, post-traumatic stress symptoms, and possible long-term neurodevelopmental issues.

    Newborn
    4 weeks
    6 weeks
    8 weeks
    28 weeks
    1 year
    2 years

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    While all children in the PICU should receive behavioral interventions to prevent potential delirium, making the diagnosis of delirium is often difficult in children. This score can assist the clinician in screening for delirium.

    Management

    • Reorientation with familiar toys, games, and routines is helpful in managing delirium.

    • Maintenance of normal day/night cycle-based lighting in ICU rooms can be difficult but helpful in the prevention and management of delirium for both children and adults.

    • Pediatric delirium that threatens the safety of the patient, family, or staff, or delirium refractory to behavioral and environmental interventions, may require pharmacologic treatment.

    • Avoidance of early morning blood draws and other testing, which can disrupt normal sleep patterns, can help reduce the risk or severity of delirium.

    Critical Actions

    • Monitor especially closely for delirium in developmentally delayed children, who are at higher risk than non-delayed children.

    • A positive CAPD screen for delirium should prompt additional intervention and investigation. Consultation with child life specialists or child psychiatry may be beneficial.

    Formula

    Addition of the selected points, based on interactions with the patient over the course of one nursing shift. Note that the "best" scores (i.e., associated with absence of delirium) are listed first, e.g. Makes eye contact - always (0 points), Inconsolable - never (0 points).

    Criteria

    Points

    Makes eye contact with caregiver

    Always

    0

    Often

    1

    Sometimes

    2

    Rarely

    3

    Never

    4

    Actions are purposeful

    Always

    0

    Often

    1

    Sometimes

    2

    Rarely

    3

    Never

    4

    Aware of surroundings

    Always

    0

    Often

    1

    Sometimes

    2

    Rarely

    3

    Never

    4

    Communicates needs and wants

    Always

    0

    Often

    1

    Sometimes

    2

    Rarely

    3

    Never

    4

    Restless

    Never

    0

    Rarely

    1

    Sometimes

    2

    Often

    3

    Always

    4

    Inconsolable

    Never

    0

    Rarely

    1

    Sometimes

    2

    Often

    3

    Always

    4

    Underactive (very little movement while awake)

    Never

    0

    Rarely

    1

    Sometimes

    2

    Often

    3

    Always

    4

    Takes long time to respond to interactions

    Never

    0

    Rarely

    1

    Sometimes

    2

    Often

    3

    Always

    4

    Refer to Fig 2 in Silver 2015 for developmental anchor points based on age.

    Facts & Figures

    Interpretation:

    CAPD Score

    Delirium

    Recommendation

    ≥9

    Present

    Investigate and treat underlying medical condition(s) causing delirium, consider interventions with parents and child life services, and/or consult to psychiatry or palliative care as appropriate, consider medications like melatonin or QUEtiapine (SEROquel) in select cases

    <9

    Absent

    Continue usual care and monitoring

    Evidence Appraisal

    Traube et al (2014) first developed and tested the CAPD in a single-institution study of 111 children admitted to a tertiary center’s PICU. The scale showed good sensitivity (94% overall) across a wide range of pediatric age groups, including infants. They also did not use developmental delay as a screening factor; while the false positive rate was higher in delayed children, the scale was still viewed as helpful in assessing for the presence of delirium.

    The scale showed good interrater reliability and external validity when compared to diagnoses of delirium made by child psychiatrists using DSM-IV criteria. The specificity of the score was relatively high for a screening tool (79%), but suggests that the CAPD is less useful as a diagnostic tool.

    Dr. Chani Traube

    From the Creator

    Why did you develop the Cornell Assessment of Pediatric Delirium (CAPD)? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    In my role as a pediatric intensivist, I noted that many of my patients were not acting appropriately for age—some were extremely agitated and others inappropriately docile. From reading the literature, I knew that delirium was a frequent and severe complication of critical illness in adults. However, this was not well described within pediatrics, mostly due to the absence of a feasible bedside screening tool that could be used in children of all ages. In collaboration with Dr. Gabrielle Silver, an expert child psychiatrist, we developed the Cornell Assessment of Pediatric Delirium (CAPD) to fill that void.

    What pearls, pitfalls and/or tips do you have for users of the Cornell Assessment of Pediatric Delirium (CAPD)? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    Score the CAPD based on your observation of the child over several hours, not as a single-point-in-time screen.

    How do I score the CAPD in children with developmental delay?

    SCORE IT AS YOU SEE IT! No need to interpret or adjust for baseline (e.g. if the child never makes eye contact, score as “never”). We do not automatically assume that a CAPD score >9 means delirium in a child with developmental delay, but the numerical score is important and something we trend.

    How do I score the CAPD in very young children?

    A developmental anchor points chart is available for kids under 2 years of age, to use as a reference if you need it, when scoring the individual items (see Evidence section).

    Who needs to be screened for delirium?

    EVERY PATIENT, EVERY SHIFT, especially on the day of admission, and even on the day of discharge. The only exclusions are children who are unarousable to verbal stimulation as they cannot be assessed.

    What recommendations do you have for doctors once they have applied the Cornell Assessment of Pediatric Delirium (CAPD)? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    Some keys to success:

    1. Implement delirium screening as standard of care in your unit. Every patient, every shift.

    2. Get your colleagues educated and onboard. The nurses will not comply with screening if they present delirium scores on rounds and the doctors don’t know what to do with the information.

    3. Add the CAPD tool to your electronic medical record as part of the flowsheet. This will make it much easier for the nurses to score and will allow for monitoring of compliance.

    4. Monitor compliance intensively for the first few months.

    5. EARLY SUCCESS: a few key patients will make this all work. Your team will recognize and address delirium, and the child will get better. Then they will become believers!

    How do you use the Cornell Assessment of Pediatric Delirium (CAPD) in your own clinical practice? Can you give an example of a scenario in which you use it?

    Every patient, every shift. Our nurses score the CAPD on every child at approximately 6 pm (end of day shift) and approximately 6 am (end of night shift).

    Any other research in the pipeline that you’re particularly excited about?

    So much work to be done! We are particularly excited about addressing the modifiable factors for delirium. For example: prescribing practices (including benzodiazepines and anticholinergics) and sleep disruption. We are also very interested in the long-term effects of delirium on children's cognition and psychological health.

    About the Creator

    Chani Traube, MD, is an assistant professor of pediatrics in the department of critical care medicine at Weill Cornell Medical College. She is also a pediatrician at New York-Presbyterian Hospital. Dr. Traube’s primary research is focused on pediatric respiratory failure, shock, and delirium.

    To view Dr. Chani Traube's publications, visit PubMed

    Dr. Gabrielle Silver

    About the Creator

    Gabrielle Silver, MD, is a practicing child and adolescent psychiatrist at New York Presbyterian Hospital. She is also a clinical associate professor of psychiatry at the Weill Cornell Medical College. Dr. Silver’s primary research is focused on screening critically ill children for delirium.

    To view Dr. Gabrielle Silver's publications, visit PubMed

    Content Contributors
    Reviewed By
    • Mohamed Gaffoor, MD
    About the Creator
    Dr. Chani Traube
    Dr. Gabrielle Silver
    Content Contributors
    Reviewed By
    • Mohamed Gaffoor, MD