Differential Diagnosis

The diagnosis of delirium is not generally as problematic in children and adolescents as in adults, in whom delirium and dementia can be difficult to differentiate (Meagher and Trzepacz 2007). Early pedi-

atric delirium may be associated with subtle neuro-psychiatric signs, including inattention, decreased awareness of the caregiver or surroundings, purposeless actions, restlessness, irritability, and inconsol-ability (Schieveld et al. 2007). Hallucinations occur in about 40% of pediatric patients with delirium, and visual, auditory, and tactile hallucinations are more common than olfactory and gustatory hallucinations (Rummans et al. 1995; Turkel and Tavare 2003).

Delirium associated with high fever in children is likely due to systemic viral, bacterial, or other infections, including serious CNS infection. Abnormal neurological findings, such as meningeal signs, disturbed consciousness, and slowing on electroencephalogram (EEG), may indicate delirium due to meningoencephalitis (Kashiwagi et al. 2003).

Delirium is often misdiagnosed as depression, because disordered sleep, changes in activity level, cognitive impairment, irritability, or apathy may be present in both (Nicolas and Lindsay 1995). Agitation or withdrawal may suggest an adjustment disorder, but confusion and a fluctuating course indicate delirium instead. Missing the diagnosis is of concern when the presumption of depression or a reactive behavioral disturbance delays the appropriate care of a delirious patient (Boland et al. 1996).

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