8.5 Pediatric, Perinatal, & Geriatric Psychiatry (Cognitive Impairment / Delirium)
Key Takeaways
- ADHD diagnosis requires >=6 symptoms of inattention and/or hyperactivity-impulsivity present before age 12 across >=2 settings; first-line pharmacotherapy consists of stimulant medications (methylphenidate, amphetamines).
- Postpartum Blues is mild, self-limiting affective disturbance peaking 3-5 days postpartum and resolving within 2 weeks, whereas Postpartum Psychosis is a medical emergency requiring urgent psychiatric hospitalization.
- Delirium is an acute, fluctuating disturbance in attention and awareness caused by underlying medical illness or toxicity, diagnosed using the Confusion Assessment Method (CAM).
- Non-pharmacological environmental interventions are first-line for delirium management; low-dose atypical antipsychotics (e.g., haloperidol or quetiapine) are reserved exclusively for severe agitation endangering safety.
- Lewy Body Dementia is characterized by visual hallucinations, parkinsonism, REM sleep behavior disorder, and extreme sensitivity to antipsychotics (neuroleptics can precipitate severe extrapyramidal crisis or death).
8.5 Pediatric, Perinatal, & Geriatric Psychiatry (Cognitive Impairment / Delirium)
Psychiatric care across the lifespan requires tailored diagnostic frameworks and specialized management strategies for pediatric, perinatal, and geriatric populations.
Pediatric Psychiatry
Attention-Deficit/Hyperactivity Disorder (ADHD)
- Diagnostic Criteria: Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning, with $\ge 6$ symptoms present before age 12 across $\ge 2$ settings (e.g., home and school) for $\ge 6$ months.
- Treatment Hierarchy:
- First-Line Pharmacotherapy: Stimulants — Methylphenidate-based (e.g., Concerta, Ritalin) or Amphetamine-based (e.g., Vyvanse, Adderall) compounds. Block dopamine and norepinephrine reuptake.
- Monitoring Requirements: Height, weight (risk of appetite suppression and growth delay), blood pressure, and heart rate at baseline and follow-up.
- Second-Line / Non-Stimulant Options: Atomoxetine (selective SNRI), Guanfacine XR, or Clonidine (alpha-2 adrenergic agonists; useful if tic co-morbidity or severe insomnia).
Autism Spectrum Disorder (ASD)
Characterized by persistent deficits in social communication and interaction across multiple contexts, alongside restricted, repetitive patterns of behavior, interests, or activities. Early behavioral intervention (Applied Behavior Analysis - ABA) is pivotal.
Disruptive Behavior Disorders
- Oppositional Defiant Disorder (ODD): Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting $\ge 6$ months toward authority figures without severe violation of societal norms.
- Conduct Disorder (CD): Repetitive pattern of behavior violating basic rights of others or major age-appropriate societal norms (aggression to people/animals, destruction of property, deceitfulness/theft, serious rule violations). Precursor to Antisocial Personality Disorder (diagnosed only after age 18).
Perinatal Psychiatry
Perinatal mood disturbances represent a spectrum ranging from transient emotional lability to life-threatening emergencies.
| Condition | Onset & Duration | Clinical Features & Risk Profile | Management Strategy |
|---|---|---|---|
| Postpartum Blues | Onset 2–3 days postpartum; peaks at day 5; resolves within 2 weeks. | Mild mood swings, tearfulness, irritability, anxiety. Affects up to 80% of mothers. Functional impairment absent. | Reassurance, psychoeducation, sleep hygiene, support from partner/family. |
| Postpartum Depression (PPD) | Onset within 4 weeks postpartum (or during pregnancy); lasts months if untreated. | Major depressive episode (SIGECAPS), intense anxiety, feelings of inadequacy, guilt regarding infant care. | Screen with Edinburgh Postnatal Depression Scale (EPDS). Psychotherapy (CBT) for mild-moderate; Sertraline preferred for moderate-severe (low excretion into breast milk). |
| Postpartum Psychosis | Medical Emergency! Onset within 1–2 weeks postpartum. | Rapid onset of delirium-like confusion, severe mood lability, delusions (often involving the baby, e.g., infant is possessed), command hallucinations. | Immediate psychiatric hospitalization. High risk of infanticide or suicide. Antipsychotics + Mood Stabilizers. Electroconvulsive Therapy (ECT) highly effective. |
Geriatric Psychiatry & Neurocognitive Disorders
Differentiating among Delirium, Dementia, and Depression ("Pseudodementia") is a cornerstone of geriatric evaluation on the MCCQE Part I.
Delirium: Diagnosis & Evidence-Based Management
Delirium is an acute, fluctuating decline in attention and awareness secondary to an underlying medical etiology.
Diagnostic Criteria — Confusion Assessment Method (CAM):
Diagnosis requires the presence of Features 1 AND 2, plus EITHER Feature 3 OR 4:
- Acute Onset and Fluctuating Course: Change in baseline mental status, fluctuating severity.
- Inattention: Difficulty focusing, sustaining, or shifting attention.
- Disorganized Thinking: Rambling, irrelevant, or incoherent speech.
- Altered Level of Consciousness: Hyperalert, lethargic, stuporous, or comatose.
Common Etiologies of Delirium (I WATCH CONFUSED):
I - Infection (UTI, Pneumonia)
W - Withdrawal (Alcohol, Benzodiazepines)
A - Acute Metabolic (Electrolytes, Hypoglycemia)
T - Trauma (Subdural hematoma, Hip fracture)
C - CNS Pathology (Stroke, Encephalopathy)
H - Hypoxia / Hypercapnia
C - Constipation / Urinary Retention
O - Oxygen Deficiency
N - Neoplasm
F - Fluid/Electrolyte Balance
U - Uremia / Renal Failure
S - Sepsis / Severe Pain
E - Endocrine (Thyroid, Adrenal)
D - Drugs (Anticholinergic, Sedatives, Opioids)
Management Strategy:
- First-Line: Non-pharmacological Environmental Interventions — Frequent reorientation, daylight exposure, restoring visual/hearing aids, early mobilization, hydration, minimizing sleep interruptions.
- Pharmacotherapy: Reserved ONLY for severe agitation or psychotic symptoms that threaten patient/staff safety. Low-dose Haloperidol (0.5–1.0 mg PO/IM) or short-acting SGA (Quetiapine, Risperidone).
- Contraindication: Avoid Benzodiazepines in delirium, as they worsen cognitive confusion and disinhibition (EXCEPT in cases of alcohol or benzodiazepine withdrawal).
Major Neurocognitive Disorders (Dementia Spectrum)
Differential Diagnosis of Dementia Types:
Alzheimer's Disease: Insidious memory decline, amyloid/tau pathology
Vascular Dementia: Stepwise decline, focal neuro deficits, cardiovascular risk factors
Lewy Body Dementia: Visual hallucinations, REM sleep disorder, Parkinsonism, EXTREME neuroleptic sensitivity
Frontotemporal Dementia: Early personality/behavioral changes or language impairment (<65 years)
Key Clinical Features & Treatments
- Alzheimer's Disease: Most common cause. Insidious memory impairment followed by executive dysfunction.
- Treatment: Cholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) for mild-to-moderate; Memantine (NMDA receptor antagonist) for moderate-to-severe.
- Vascular Dementia: Second most common. Stepwise cognitive decline linked to cerebrovascular accidents/TIA.
- Treatment: Vascular risk factor optimization (hypertension, lipid control, antiplatelet therapy).
- Dementia with Lewy Bodies (DLB): Fluctuating cognition, recurrent detailed visual hallucinations, spontaneous Parkinsonism, and REM sleep behavior disorder.
- CRITICAL WARNING: Extreme Sensitivity to Antipsychotics. Administration of neuroleptics can trigger life-threatening rigidity, fever, or profound coma. If severe psychosis requires treatment, low-dose Quetiapine or Pimavanserin is preferred with extreme caution.
- Frontotemporal Dementia (FTD / Pick's Disease): Early onset (age 50–60). Early loss of social inhibitions, apathy, hyperorality, loss of empathy, or progressive aphasia. Relative preservation of memory early on.
An 82-year-old female on the postoperative surgical floor becomes acutely confused, agitated, and disoriented on postoperative day 2 following a hip repair. Her symptoms fluctuate throughout the day, worsening at night. She is unable to maintain focus during conversation. What is the most appropriate initial management step?
A 76-year-old male is brought to the clinic by his wife due to progressive cognitive decline, detailed recurrent visual hallucinations of small animals in his living room, and spontaneous parkinsonian symptoms (resting tremor and rigidity). Which medication class carries a severe black-box warning for life-threatening hypersensitivity reactions in this patient?
A 26-year-old mother, 10 days postpartum after the delivery of her first child, is brought to the emergency department by her partner. She has not slept in 4 days, insists that her baby is possessed by evil spirits, and hears voices commanding her to protect the child by burying it. What is the most appropriate immediate setting of care?