51
|
Wong AK, Demediuk L, Tay JY, Wawryk O, Collins A, Everitt R, Philip J, Buising K, Le B. COVID-19 End-of-life Care: Symptoms and Supportive Therapy Use in an Australian Hospital. Intern Med J 2021; 51:1420-1425. [PMID: 33755283 PMCID: PMC8250873 DOI: 10.1111/imj.15300] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
Background Descriptions of symptoms and medication use at end of life in COVID‐19 are limited to small cross‐sectional studies, with no Australian longitudinal data. Aims To describe end‐of‐life symptoms and care needs of people dying of COVID‐19. Methods This retrospective cohort study included consecutive admitted patients who died at a Victorian tertiary referral hospital from 1 January to 30 September directly due to COVID‐19. Clinical characteristics, symptoms and use of supportive therapies, including medications and non‐pharmacological interventions in the last 3 days of life were extracted. Results The cohort comprised 58 patients (median age 87 years, interquartile range (IQR) 81–90) predominantly admitted from home (n = 30), who died after a median of 11 days (IQR 6–28) in the acute medical (n = 31) or aged care (n = 27) wards of the hospital. The median Charlson Comorbidity Score was 7 (IQR 5–8). Breathlessness (n = 42), agitation (n = 36) and pain (n = 33) were the most frequent clinician‐reported symptoms in the final 3 days of life, with most requiring opioids (n = 52), midazolam (n = 40), with dose escalation commonly being required. While oxygen therapy was commonly used (n = 47), few (n = 13) required an anti‐secretory agent. Conclusions This study presents one of the first and largest Australian report of the end of life and symptom experience of people dying of COVID‐19. This information should help clinicians to anticipate palliative care needs of these patients, for example, recognising that higher starting doses of opioids and sedatives may help reduce prevalence and severity of breathlessness and agitation near death.
Collapse
Affiliation(s)
- Aaron K Wong
- Department of Palliative Care, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| | - Lucy Demediuk
- Palliative Medicine Registrar, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| | - Jia Yin Tay
- Palliative Medicine Registrar, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| | - Olivia Wawryk
- St Vincent's Hospital, Palliative Care Service, Victoria Parade, Fitzroy, Victoria, Australia, 3065
| | - Anna Collins
- St Vincent's Hospital, Palliative Care Service, Victoria Parade, Fitzroy, Victoria, Australia, 3065.,Department of Medicine, University of Melbourne, Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia, 3065
| | - Rachel Everitt
- Palliative Medicine Registrar, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| | - Jennifer Philip
- Palliative Medicine Registrar, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050.,St Vincent's Hospital, Palliative Care Service, Victoria Parade, Fitzroy, Victoria, Australia, 3065.,Department of Medicine, University of Melbourne, Eastern Hill Campus, Victoria Parade, Fitzroy, Victoria, Australia, 3065
| | - Kirsty Buising
- The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| | - Brian Le
- The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050
| |
Collapse
|
52
|
Development and validation of the Terminal Delirium-Related Distress Scale to assess irreversible terminal delirium. Palliat Support Care 2021; 19:287-293. [PMID: 33397541 DOI: 10.1017/s1478951520001340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is no tool to appropriately assess terminal delirium, including the natural terminal course. The objective of this study was to develop an evaluation scale to assess distress from irreversible terminal delirium and to examine the validity of the scale. METHOD Based on previous qualitative analysis and systematic literature searches, we carried out a survey regarding the views of bereaved families and developed a questionnaire. We extracted items that bereaved families regarded as important and constructed an evaluation scale of terminal delirium. Then, we applied the questionnaire in a cross-sectional questionnaire survey of bereaved relatives of cancer patients who were admitted to a hospice or a palliative care unit. RESULTS We developed the Terminal Delirium-Related Distress Scale (TDDS), a 24 item questionnaire consisting of five subscales (support for families and respect for a patient, ability to communicate, hallucinations and delusions, adequate information about the treatment of delirium, and agitation and restlessness). Two hundred and eighty-one bereaved relatives participated in the validation phase. The construct validity was shown to be good by repeated factor analysis. Convergent validity, confirmed by the correlation between the TDDS and the Care Evaluation Scale (r = 0.651, P < 0.001), was also good. The TDDS had good internal consistency (Cronbach's alpha coefficient for all 24 items = 0.84). SIGNIFICANCE OF RESULTS This study showed that the TDDS is a valid and feasible measure of irreversible terminal delirium.
Collapse
|
53
|
Guo D, Lin T, Deng C, Zheng Y, Gao L, Yue J. Risk Factors for Delirium in the Palliative Care Population: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:772387. [PMID: 34744847 PMCID: PMC8566675 DOI: 10.3389/fpsyt.2021.772387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: Delirium is common and highly distressing for the palliative care population. Until now, no study has systematically reviewed the risk factors of delirium in the palliative care population. Therefore, we performed a systematic review and meta-analysis to evaluate delirium risk factors among individuals receiving palliative care. Methods: We systematically searched PubMed, Medline, Embase, and Cochrane database to identify relevant observational studies from database inception to June 2021. The methodological quality of the eligible studies was assessed by the Newcastle Ottawa Scale. We estimated the pooled adjusted odds ratio (aOR) for individual risk factors using the inverse variance method. Results: Nine studies were included in the review (five prospective cohort studies, three retrospective case-control studies and one retrospective cross-section study). In pooled analyses, older age (aOR: 1.02, 95% CI: 1.01-1.04, I 2 = 37%), male sex (aOR:1.80, 95% CI: 1.37-2.36, I 2 = 7%), hypoxia (aOR: 0.87, 95% CI: 0.77-0.99, I 2 = 0%), dehydration (aOR: 3.22, 95%CI: 1.75-5.94, I 2 = 18%), cachexia (aOR:3.40, 95% CI: 1.69-6.85, I 2 = 0%), opioid use (aOR: 2.49, 95%CI: 1.39-4.44, I 2 = 0%), anticholinergic burden (aOR: 1.18, 95% CI: 1.07-1.30, I 2 = 9%) and Eastern Cooperative Oncology Group Performance Status (aOR: 2.54, 95% CI: 1.56-4.14, I 2 = 21%) were statistically significantly associated with delirium. Conclusion: The risk factors identified in our review can help to highlight the palliative care population at high risk of delirium. Appropriate strategies should be implemented to prevent delirium and improve the quality of palliative care services.
Collapse
Affiliation(s)
- Duan Guo
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanyao Deng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxia Zheng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Langli Gao
- West China School of Nursing, Sichuan University, Chengdu, China.,Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
54
|
FitzGerald JM, Price A. Delirium in the acute hospital setting: the role of psychiatry. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2020.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
SUMMARYIn this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.
Collapse
|
55
|
Thinking clearly about dignity:
relationships between cognitive processes
underlying perceived dignity as determinants
of psychological adjustment. HEALTH PSYCHOLOGY REPORT 2021. [DOI: 10.5114/hpr.2021.111398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
56
|
Lee W, Pulbrook M, Sheehan C, Kochovska S, Chang S, Hosie A, Lobb E, Parker D, Draper B, Agar MR, Currow DC. Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses-A Systematic Review. J Pain Symptom Manage 2021; 61:143-166.e2. [PMID: 32688012 DOI: 10.1016/j.jpainsymman.2020.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Currently, systematic evidence of the prevalence of clinically significant depressive symptoms in people with extremely short prognoses is not available to inform its global burden, assessment, and management. OBJECTIVES To determine the prevalence of clinically significant depressive symptoms in people with advanced life-limiting illnesses and extremely short prognoses (range of days to weeks). METHODS A systematic review and meta-analysis (random-effects model) were performed (PROSPERO: CRD42019125119). MEDLINE, Embase, PsycINFO, CINAHL, and CareSearch were searched for studies (1994-2019). Data were screened for the prevalence of clinically significant depressive symptoms (assessed using validated depression-specific screening tools or diagnostic criteria) of adults with advanced life-limiting illnesses and extremely short prognoses (defined by survival or functional status). Quality assessment was performed using the Joanna Briggs Institute Systematic Reviews Checklist for Prevalence Studies for individual studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) across studies. RESULTS Thirteen studies were included. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n = 10 studies; extremely short prognoses: N = 905) using depression-specific screening tools was 50% (95% CI: 29%-70%; I2 = 97.6%). Prevalence of major and minor depression was 10% (95% CI: 4%-16%) and 5% (95% CI: 2%-8%), respectively. Major limitations included high heterogeneity, selection bias, and small sample sizes in individual studies. CONCLUSIONS Clinically, significant depressive symptoms were prevalent in people with advanced life-limiting illnesses and extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms to allow for timely intervention.
Collapse
Affiliation(s)
- Wei Lee
- University of Technology Sydney, Ultimo, New South Wales, Australia; St Vincent Hospital, Darlinghurst, New South Wales, Australia.
| | - Marley Pulbrook
- St Vincent Hospital, Darlinghurst, New South Wales, Australia
| | | | | | - Sungwon Chang
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Annmarie Hosie
- St Vincent Hospital, Darlinghurst, New South Wales, Australia; University of Notre Dame Australia, New South Wales, Australia
| | - Elizabeth Lobb
- Calvary Hospital, Kogarah, New South Wales, Australia; University of Notre Dame Australia, New South Wales, Australia
| | - Deborah Parker
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Brian Draper
- University of New South Wales, Randwick, New South Wales, Australia
| | - Meera R Agar
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - David C Currow
- University of Technology Sydney, Ultimo, New South Wales, Australia
| |
Collapse
|
57
|
Hamano J, Mori M, Ozawa T, Sasaki J, Kawahara M, Nakamura A, Hashimoto K, Hisajima K, Koga T, Goto K, Fukumoto K, Morimoto Y, Goshima M, Sekimoto G, Baba M, Oya K, Matsunuma R, Azuma Y, Imai K, Morita T, Shinjo T. Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care. Cancer Med 2020; 10:1166-1179. [PMID: 33314743 PMCID: PMC7897964 DOI: 10.1002/cam4.3661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 11/12/2022] Open
Abstract
Background Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death. Methods This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017. Results In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% ‐ 6.3%) vs. 1.4% (0.7% ‐ 2.3%) on admission (p < 0.001) and 7.6% (6.4% ‐ 8.9%) vs. 5.4% (4.0% ‐ 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms. Conclusions There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.
Collapse
Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | | | - Jun Sasaki
- Yushoukai Medical Corporation, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | - Mika Baba
- Department of Palliative Medicine, Suita Tokushukai Hospital, Suita, Japan
| | - Kiyofumi Oya
- Department of Palliative and Supportive Care, Aso Iizuka Hospital, Fukuoka, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate school of Medicine, Hyogo, Japan
| | - Yukari Azuma
- Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | | |
Collapse
|
58
|
Arias F, Chen F, Fong TG, Shiff H, Alegria M, Marcantonio ER, Gou Y, Jones RN, Travison TG, Schmitt EM, Kind AJ, Inouye SK. Neighborhood-Level Social Disadvantage and Risk of Delirium Following Major Surgery. J Am Geriatr Soc 2020; 68:2863-2871. [PMID: 32865254 PMCID: PMC7744425 DOI: 10.1111/jgs.16782] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between neighborhood-level characteristics and delirium incidence and severity, and compared neighborhood- with individual-level indicators of socioeconomic status in predicting delirium incidence. DESIGN A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status. SETTING Two academic medical centers in Boston, MA. PARTICIPANTS A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery. INTERVENTION The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage. MEASUREMENTS Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM-S) occurring during daily hospital assessments (CAM-S Peak). RESULTS Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3-3.1). The CAM-S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P = .009). Mean CAM-S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual-level markers of socioeconomic status and cultural background were: 1.2 (0.9-1.7) for education of 12 years or less; 1.3 (0.8-2.1) for non-White race; and 1.7 (1.1-2.6) for annual household income of less than $20,000. None of these individual-level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk. CONCLUSIONS Neighborhood-level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure-response relationship. Future studies should consider contextual-level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention.
Collapse
Affiliation(s)
- Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Fan Chen
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Haley Shiff
- Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine and Psychiatry, Harvard Medical School, Boston, MA 02115
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA 02115, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI 02912, USA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA 02115, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
| | - Amy J.H. Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI 53705, USA
- Madison VA Geriatrics Research Education and Clinical Center (GRECC), Middleton VA Hospital, Madison WI 53705, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Harvard Medical School, Boston, MA 02115, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| |
Collapse
|
59
|
Zipser CM, Seiler A, Deuel J, Ernst J, Hildenbrand F, von Känel R, Boettger S. Hospital-wide evaluation of delirium incidence in adults under 65 years of age. Psychiatry Clin Neurosci 2020; 74:669-670. [PMID: 32945082 DOI: 10.1111/pcn.13155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/26/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Carl M Zipser
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland.,Balgrist University Hospital, Department of Neurology and Neurophysiology, Zurich, Switzerland
| | - Annina Seiler
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jeremy Deuel
- Department of Hematology, School of Clinical Medicine, University of Cambridge, Cambridge, UK.,Department of Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Institute of Nursing Science, University of Zurich, Zurich, Switzerland
| | - Florian Hildenbrand
- Department of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Soenke Boettger
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
60
|
Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 414] [Impact Index Per Article: 103.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
Collapse
Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| |
Collapse
|
61
|
Maeda I, Ogawa A, Yoshiuchi K, Akechi T, Morita T, Oyamada S, Yamaguchi T, Imai K, Sakashita A, Matsumoto Y, Uemura K, Nakahara R, Iwase S. Safety and effectiveness of antipsychotic medication for delirium in patients with advanced cancer: A large-scale multicenter prospective observational study in real-world palliative care settings. Gen Hosp Psychiatry 2020; 67:35-41. [PMID: 32950826 DOI: 10.1016/j.genhosppsych.2020.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To clarify the safety and effectiveness of antipsychotic medication for delirium in patients with advanced cancer receiving palliative care. METHODS This was a prospective observational study involving consecutive patients with advanced cancer and delirium receiving antipsychotics in inpatient hospices or psycho-oncology settings. Adjusted mean scores of the Delirium Rating Scale Revised-98 (DRS; range: 0-39) were calculated at baseline and Day 3 using generalized estimating equations. Adverse events over 7 days were evaluated. RESULTS Data from 756 patients were analyzed (Mage = 72 ± 11 years, 62% male, 48% bedridden). The adjusted mean DRS score significantly decreased after antipsychotics administration (21.5 [95% confidence interval 19.5 to 23.4] to 20.8 [18.9 to 22.8], p = 0.03, effect size [ES] = 0.02). Significant improvement was associated with age of 75 or older (ES = 0.07), better performance status (0.32), longer estimated prognosis (0.25), psycho-oncological consultation settings (0.20), hyperactive (0.14) or mix-motor subtypes (0.24) of delirium, and quetiapine administration (0.19); significant deterioration was observed in patients with "days" prognosis (0.18). Extrapyramidal symptoms (9.8%) and somnolence (8.5%) were the most prevalent adverse events. CONCLUSIONS The use of antipsychotics as part of comprehensive delirium management was safe and may provide some symptomatic benefits for patients with terminal illness and delirium. Along with adequate non-pharmacological interventions, judicious use of antipsychotics is still recommended.
Collapse
Affiliation(s)
- Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, 1-4-3 Shin-senri Higashi-machi, Toyonaka, Osaka, Japan.
| | - Asao Ogawa
- Department of Psycho-Oncology Service, National Cancer Center Hospital East, 6-5-1 Kashiwa-no-ha, Kashiwa, Chiba, Japan.
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan.
| | - Tatsuo Akechi
- Division of Psycho-Oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, Japan.
| | - Shunsuke Oyamada
- Department of Biostatistics, JORTC Data Center, KS building 301, Nishi-nippori, Arakawa-ku, Tokyo, Japan.
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University School of Medicine, 2-1 Seiryo-cho, Aoba-ku, Sendai, Japan.
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, Japan.
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Kobe, Hyogo, Japan.
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, 6-5-1 Kashiwa-no-ha, Kashiwa, Chiba, Japan.
| | - Keiichi Uemura
- Department of Psychiatry, Tonan Hospital, 3-8 Kita-4jo, Nishi-7jo, Chuo-ku, Sapporo, Hokkaido, Japan.
| | - Rika Nakahara
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
| | - Satoru Iwase
- Department of Palliative Medicine, Saitama Medical University, 38 Moroyama-hongo, Moroyama-co, Iruma, Saitama, Japan
| | | |
Collapse
|
62
|
Shim EJ, Ha H, Kim WH, Lee MH, Park J, Lee KM, Son KL, Yeom CW, Hahm BJ. Phenomenological examinations of delirium in advanced cancer patients: exploratory structural equation modelling and latent profile analysis. BMC Palliat Care 2020; 19:162. [PMID: 33076898 PMCID: PMC7574192 DOI: 10.1186/s12904-020-00668-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study examined phenomenological manifestations of delirium in advanced cancer patients by examining the factor structure of the Delirium Rating Scale-Revised-98 (DRS-R-98) and profiles of delirium symptoms. Methods Ninety-three patients with advanced cancer admitted to inpatient palliative care units in South Korea were examined by psychiatrists using the DRS-R-98 and the Confusion Assessment Method (CAM). The factor structure of the DRS-R-98 was examined by exploratory structural equation modelling analysis (ESEM) and profiles of delirium were examined by latent profile analysis (LPA). Results CAM-defined delirium was present in 66.6% (n = 62) of patients. Results from the ESEM analysis confirmed applicability of the core and noncore symptom factors of the DRS-R-98 to advanced cancer patients. LPA identified three distinct profiles of delirium characterizing the overall severity of delirium and its core and noncore symptoms. Class 1 (n = 55, 59.1%) showed low levels of all delirium symptoms. Class 2 (n = 17, 18.3%) showed high levels of core symptoms only, whereas Class 3 (n = 21, 22.6%) showed high levels of both core and noncore symptoms except motor retardation. Conclusions Clinical care for delirium in advanced cancer patients may benefit from consideration of the core and noncore symptom factor structure and the three distinct phenomenological profiles of delirium observed in the present study.
Collapse
Affiliation(s)
- Eun-Jung Shim
- Department of Psychology, Pusan National University, Busan, Republic of Korea
| | - Hyeju Ha
- Department of Psychology, Pusan National University, Busan, Republic of Korea
| | - Won-Hyoung Kim
- Department of Psychiatry, Inha University Hospital, Incheon, Republic of Korea
| | - Moon-Hee Lee
- Department of Hematology-Oncology, Inha University Hospital, Incheon, Republic of Korea
| | - Jisun Park
- Department of Hematology-Oncology, Inha University Hospital, Incheon, Republic of Korea
| | | | - Kyung-Lak Son
- Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Chan-Woo Yeom
- Department of Psychiatry, National Rehabilitation Center, Seoul, Republic of Korea
| | - Bong-Jin Hahm
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea. .,Department of Psychiatry and Behavioral Sciences, Seould National University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
63
|
Sutherland M, Pyakurel A, Nolen AE, Stilos KK. Improving the Management of Terminal Delirium at the End of Life. Asia Pac J Oncol Nurs 2020; 7:389-395. [PMID: 33062836 PMCID: PMC7529019 DOI: 10.4103/apjon.apjon_29_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/04/2020] [Indexed: 11/05/2022] Open
Abstract
Objective: Terminal delirium is a distressing process that occurs in the dying phase, often misdiagnosed and undertreated. A hospital developed the “comfort measures order set” for dying patients receiving comfort care in the final 72 h of life. A chart review of patients experiencing terminal delirium revealed that the current medication option initially included in the order set was suboptimally effective and patients with terminal delirium were consistently undertreated. The purpose of this pilot study was to highlight an in-service intervention educating nurses on the management of terminal delirium at the end of life and to assess its effect on their knowledge of the management of patients with terminal delirium. Methods: A before-and-after survey design was used to assess the effect of the in-service training on nurses' knowledge of terminal delirium. Results: We describe the results from a small sample of nurses at a large urban tertiary care center in Canada. Of the twenty nurses who attended the in-services, 60% had cared for a patient with terminal delirium; however, 50% felt that their knowledge of the topic was inadequate. Despite no statistical significance between the pre- and posttest scores for both the oncology and the medicine unit nurses, all participants who completed posttest survey found the in-services useful. Conclusions: The findings from this study provide initial insights into the importance of in-service trainings to improve the end-of-life care and nursing practice. Future research will include expanding this pilot project with sufficient power to assess the significance of these types of interventions.
Collapse
Affiliation(s)
| | | | - Amy E Nolen
- Sunnybrook Health Sciences Centre, Toronto, Canada.,Palliative Care Consult Team, Toronto, Canada
| | - Kalliopi Kalli Stilos
- Sunnybrook Health Sciences Centre, Toronto, Canada.,Palliative Care Consult Team, Toronto, Canada.,Adjunct Clinical Faculty, University of Toronto's Lawrence Bloomberg Faculty of Nursing, Toronto, Canada
| |
Collapse
|
64
|
Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients. Palliat Support Care 2020; 19:274-282. [DOI: 10.1017/s1478951520000887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectivesPatients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.MethodsIn this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.ResultsIn 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).Significance of resultsThe results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.
Collapse
|
65
|
Delirium Rates in Advanced Cancer Patients Admitted to Different Palliative Care Settings: Does It Make the Difference? J Palliat Med 2020; 23:1227-1232. [DOI: 10.1089/jpm.2019.0414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
66
|
Jeong E, Park J, Lee J. Diagnostic test accuracy of the Nursing Delirium Screening Scale: A systematic review and meta‐analysis. J Adv Nurs 2020; 76:2510-2521. [DOI: 10.1111/jan.14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eunhye Jeong
- College of Nursing Korea University Seoul Republic of Korea
| | - Jinkyung Park
- College of Nursing Korea University Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
| |
Collapse
|
67
|
Liu Y, Zhang Q, Zhao Y, Gao Z, Wei Z, Guo Z, Chen M, Zhang Q, Yang X. Delirium screening tools: A protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21595. [PMID: 32871875 PMCID: PMC7458233 DOI: 10.1097/md.0000000000021595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Delirium is a frequent form of acute brain dysfunction in mechanically ventilated patients. Screening tools have been developed to identify delirium, but it is unclear which tool is the most accurate. Therefore, we provide a protocol of systematic evaluation to assess the accuracy of delirium screening tools in mechanically ventilated patients. METHODS PubMed, PsycINFO, EMBASE, and the Cochrane Library will be searched. Studies involving mechanically ventilated patients which compared diagnostic tools with the Diagnostic and Statistical Manual of Mental Disorders criteria as a reference standard will be included. We will use MetaDiSC and STATA 15.1 to analyze carefully when a network meta-analysis is allowed. RESULTS This study will provide a high-quality synthesis to assess the accuracy of different screening methods in mechanically ventilated patients. CONCLUSION The conclusion of our systematic review will provide evidence to judge which screening method is the best for mechanically ventilated patients.
Collapse
Affiliation(s)
| | - Qian Zhang
- School of Nursing, Lanzhou University, Lanzhou, China
| | - Yayun Zhao
- Second Hospital of Lanzhou University
- School of Nursing, Lanzhou University, Lanzhou, China
| | | | | | - Ziqi Guo
- Second Hospital of Lanzhou University
| | | | | | - Xuemei Yang
- Second Hospital of Lanzhou University
- School of Nursing, Lanzhou University, Lanzhou, China
| |
Collapse
|
68
|
Cherak SJ, Soo A, Brown KN, Ely EW, Stelfox HT, Fiest KM. Development and validation of delirium prediction model for critically ill adults parameterized to ICU admission acuity. PLoS One 2020; 15:e0237639. [PMID: 32813717 PMCID: PMC7437909 DOI: 10.1371/journal.pone.0237639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/29/2020] [Indexed: 12/23/2022] Open
Abstract
Background Risk prediction models allow clinicians to forecast which individuals are at a higher risk for developing a particular outcome. We developed and internally validated a delirium prediction model for incident delirium parameterized to patient ICU admission acuity. Methods This retrospective, observational, fourteen medical-surgical ICU cohort study evaluated consecutive delirium-free adults surviving hospital stay with ICU length of stay (LOS) greater than or equal to 24 hours with both an admission APACHE II score and an admission type (e.g., elective post-surgery, emergency post-surgery, non-surgical) in whom delirium was assessed using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors included in the model were readily available in electric medical records. Least absolute shrinkage and selection operator logistic (LASSO) regression was used for model development. Discrimination was determined using area under the receiver operating characteristic curve (AUC). Internal validation was performed by cross-validation. Predictive performance was determined using measures of accuracy and clinical utility was assessed by decision-curve analysis. Results A total of 8,878 patients were included. Delirium incidence was 49.9% (n = 4,431). The delirium prediction model was parameterized to seven patient cohorts, admission type (3 cohorts) or mean quartile APACHE II score (4 cohorts). All parameterized cohort models were well calibrated. The AUC ranged from 0.67 to 0.78 (95% confidence intervals [CI] ranged from 0.63 to 0.79). Model accuracy varied across admission types; sensitivity ranged from 53.2% to 63.9% while specificity ranged from 69.0% to 74.6%. Across mean quartile APACHE II scores, sensitivity ranged from 58.2% to 59.7% while specificity ranged from 70.1% to 73.6%. The clinical utility of the parameterized cohort prediction model to predict and prevent incident delirium was greater than preventing incident delirium by treating all or none of the patients. Conclusions Our results support external validation of a prediction model parameterized to patient ICU admission acuity to predict a patients’ risk for ICU delirium. Classification of patients’ risk for ICU delirium by admission acuity may allow for efficient initiation of prevention measures based on individual risk profiles.
Collapse
Affiliation(s)
- Stephana J. Cherak
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Kyla N. Brown
- PolicyWise for Children & Families, Calgary, AB, Canada
| | - E. Wesley Ely
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center, Nashville, TN, United States of America
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Henry T. Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Kirsten M. Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
- * E-mail:
| |
Collapse
|
69
|
Clinical characteristics and treatment of delirium in palliative care settings. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2020. [DOI: 10.1007/s12254-020-00641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
SummaryDelirium is commonly seen in palliative care. It usually develops over a short period of time and is characterized by a disturbance of attention and awareness. As delirium is associated with increased mortality, prevention and early identification of this severe neurocognitive disorder is of high clinical relevance. This paper provides a brief overview of risk factors, preventive measures, current screening and diagnostic procedures, as well as nonpharmacological and pharmacological treatment options of delirium in the palliative care setting.
Collapse
|
70
|
Curry A. Psychiatric Issues in Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
71
|
Graham CA, Chaves G, Harrison R, Gauthier LR, Nissim R, Zimmermann C, Chan V, Rodin G, Stevens B, Gagliese L. Health Care Professionals' Reports of Cancer Pain Cues Among Older People With Delirium: A Qualitative-Quantitative Content Analysis. J Pain Symptom Manage 2020; 60:28-36.e1. [PMID: 32058011 DOI: 10.1016/j.jpainsymman.2020.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
CONTEXT Health care professionals (HCPs) currently judge pain presence and intensity in patients with delirium despite the lack of a valid, standardized assessment protocol. However, little is known about how they make these judgments. This information is essential to develop a valid and reliable assessment tool. OBJECTIVES To identify pain cues that HCPs report to judge pain in patients with delirium and to examine whether the pain cues differed based on patient cognitive status and delirium subtype. METHODS Mixed qualitative-quantitative design. Doctors and nurses were recruited. All participants provided written informed consent, and before the recorded interview, demographic information was collected; then participants were asked to describe their practices and beliefs regarding pain assessment and management with older patients who are cognitively intact and patients with delirium. Interviews were transcribed verbatim and coded for pain cues. Coded data were imported into SPSS software (IBM SPSS Statistics Version 24; IBM Corporation, Armonk, NY) to conduct bivariate analyses. RESULTS The pain cue self-report was stated more often for intact than for delirium patients (χ2 [1; N = 106] = 22.56; P < 0.001). HCPs stated yelling (χ2 [2; N = 159] = 11.14; P = 0.004), when describing pain in hyperactive than in hypoactive and mixed delirium patients; and significantly more HCPs stated grimace (χ2 [2; N = 159] = 6.88; P = 0.03), when describing pain in hypoactive than hyperactive and mixed patients. CONCLUSION This study outlines how HCPs conduct pain assessment in patients who are delirious and, also, identifies pain behavior profiles for the subtypes of delirium.
Collapse
Affiliation(s)
- Carol A Graham
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; University of Queensland School of Medicine, University of Queensland, Herston, Australia
| | - Gabriela Chaves
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Rebecca Harrison
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lynn R Gauthier
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec City, Quebec, Canada; l'Équipe de Recherche Michel-Sarrazin en Oncologie Psychosociale et Soins Palliatifs, CHU de Québec-Université Laval Research Center, Québec City, Quebec, Canada; Oncology Division, Université Laval Cancer Research Center, Québec City, Quebec, Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Bonnie Stevens
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucia Gagliese
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada.
| |
Collapse
|
72
|
Lai XB, Huang Z, Chen CY, Stephenson M. Delirium screening in patients in a palliative care ward: a best practice implementation project. ACTA ACUST UNITED AC 2020; 17:429-441. [PMID: 30870333 DOI: 10.11124/jbisrir-2017-003646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objective was to promote evidence-based practice in screening for delirium in patients in the palliative care ward of a cancer hospital in Shanghai. INTRODUCTION Delirium is common but under recognized among patients in palliative care settings. Early detection is essential for timely management. Practice guidelines recommend an initial screening at first contact, followed by continuous screening. METHODS The Joanna Briggs Institute's three-phase Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback tool were used to enhance evidence-based practice. In phase 1, four audit criteria were developed and a baseline audit was conducted. In phase 2, barriers to compliance were identified, and strategies were adopted to promote best practice. In phase 3, a follow-up audit was conducted. RESULTS In the baseline audit, no delirium screening was performed, either on admission or regularly during hospitalization, hence compliance with these two audit criteria was 0%. Two out of 18 nurses had received training in delirium management, however neither had been trained to use the delirium screening tool. Compliance with the two criteria for nurse training was 11% and 0%, respectively. Four barriers were identified, including lack of a standardized screening tool, lack of a standardized screening procedure, inadequate knowledge on the part of the nurses, and potential inconsistencies between nurses in the rating of screening criteria. After applying strategies to address these barriers, compliance with the four audit criteria was 100%, 100%, 72%, and 72%, respectively, in the follow-up audit. CONCLUSIONS Best practice in delirium screening was successfully established in the ward.
Collapse
Affiliation(s)
- Xiao Bin Lai
- School of Nursing, Fudan University, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Zhe Huang
- Palliative Care Ward, Fudan University Shanghai Cancer Center, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Chun Yan Chen
- Palliative Care Ward, Fudan University Shanghai Cancer Center, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Matthew Stephenson
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| |
Collapse
|
73
|
Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
Collapse
Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
74
|
Hui D, De La Rosa A, Wilson A, Nguyen T, Wu J, Delgado-Guay M, Azhar A, Arthur J, Epner D, Haider A, De La Cruz M, Heung Y, Tanco K, Dalal S, Reddy A, Williams J, Amin S, Armstrong TS, Breitbart W, Bruera E. Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomised trial. Lancet Oncol 2020; 21:989-998. [PMID: 32479786 DOI: 10.1016/s1470-2045(20)30307-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. METHODS In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov, NCT03021486. FINDINGS Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h -3·6 [95% CI -5·0 to -2·2]), rotation group (n=11, -3·3 [-4·4 to -2·2]), and combination group (n=10, -3·0 [-4·6 to -1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. INTERPRETATION Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. FUNDING National Institute of Nursing Research.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Allison De La Rosa
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annie Wilson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thuc Nguyen
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jimin Wu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marvin Delgado-Guay
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maxine De La Cruz
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sapna Amin
- Department of Investigational Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, Centre for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
75
|
Shrestha P, Fick DM. Family caregiver's experience of caring for an older adult with delirium: A systematic review. Int J Older People Nurs 2020; 15:e12321. [PMID: 32374518 DOI: 10.1111/opn.12321] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 01/05/2023]
Abstract
AIM To enhance understanding of how family caregivers perceive the experience of caring for an older adult with delirium across care settings and to identify the challenges in recognising and managing delirium to inform future research and best practices. METHOD A systematic literature review was conducted in five databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Primary or secondary peer-reviewed articles published between 1987 and October 2018 describing the experiences of family caregivers caring for older adults with delirium or delirium superimposed on dementia were included in the review. Mixed Method Appraisal Tool (MMAT) was used to evaluate the methodological quality. A thematic synthesis of results was conducted to extract relevant data as per the aims of the study. RESULTS Eighteen articles met the eligibility criteria, which were reviewed and analysed in regard to purpose, sample, research design, variables and results. Seven themes emerged in the process. The current challenges and gaps in our knowledge of this phenomenon have also been highlighted, which should be helpful to inform best practices, and finally, an agenda for future research is proposed. CONCLUSION Family caregivers are an important partner in the detection and management of delirium. The impact of caring for an older adult with delirium on the family caregivers should not be overlooked. This paper highlights the dearth of research on family caregiver's experience of caring for older adults with delirium and even less in the context of delirium superimposed on dementia. More research is required to further understand the family caregiver's experience and their challenges in order to support them in their caregiving role and to determine their needs and preferences of being involved in the plan of care. IMPLICATIONS FOR PRACTICE These findings suggest that family caregivers are a valuable resource in the recognition and management of delirium and should be included as care partners in the health care team, while also catering to their health and well-being in the process.
Collapse
Affiliation(s)
| | - Donna M Fick
- Penn State College of Nursing, State College, PA, USA
| |
Collapse
|
76
|
Abstract
Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.
Collapse
Affiliation(s)
- Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Building 10, Level 3, 235 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Shirley H Bush
- The Ottawa Hospital, General Campus, 501 Smyth Road, Box 206, Ottawa, ON K1H 8L6, Canada; Bruyère Research Institute, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada; Ottawa Hospital Research Institute, 053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; Palliative Care, Bruyère Continuing Care, The Ottawa Hospital, 43, Bruyère Street, Ottawa, Ontario K1N 5C8, Canada
| |
Collapse
|
77
|
Abstract
Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst strategies to prevent and reverse delirium are the cornerstones of optimal care, the care for delirious patients who are approaching the end of life and their families pose specific challenges particularly if delirium is refractory flagging a grave prognosis. These include addressing additional supportive care needs, clinical decision-making about the degree of investigation and intervention, minimising distress from the symptoms of delirium itself and considering other concurrent problems contributing to agitation. A fine balance is needed to address other symptoms such as pain whilst minimizing psychoactive medication load. There is need for regular and clear information and communication about prognosis and goals of care. Witnessing a delirium episode in a loved one in close proximity to death requires consideration of the needs of the family into bereavement care. Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease; who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise quality of life. It is an approach which can be provided regardless of setting and diagnosis, and by both specialist palliative care teams and other health professionals.
Collapse
Affiliation(s)
- Meera R Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
| |
Collapse
|
78
|
Amgarth-Duff I, Hosie A, Caplan G, Agar M. A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes. BMC Psychiatry 2020; 20:182. [PMID: 32321448 PMCID: PMC7178636 DOI: 10.1186/s12888-020-02584-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 04/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.
Collapse
Affiliation(s)
- Ingrid Amgarth-Duff
- University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW, Australia.
| | - Annmarie Hosie
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia
| | - Gideon Caplan
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, University of New South Wales, Sydney, NSW Australia ,grid.415193.bDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW Australia
| | - Meera Agar
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia ,grid.1005.40000 0004 4902 0432South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales Australia ,grid.429098.eClinical Trials, Ingham Institute of Applied Medical Research, Liverpool, New South Wales Australia
| |
Collapse
|
79
|
Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
Collapse
Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | | |
Collapse
|
80
|
Koirala B, Hansen BR, Hosie A, Budhathoki C, Seal S, Beaman A, Davidson PM. Delirium point prevalence studies in inpatient settings: A systematic review and meta‐analysis. J Clin Nurs 2020; 29:2083-2092. [DOI: 10.1111/jocn.15219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Binu Koirala
- Johns Hopkins School of Nursing Baltimore Maryland
| | | | - Annmarie Hosie
- School of Nursing Sydney The University of Notre Dame Australia Darlinghurst NSW Australia
| | | | - Stella Seal
- Johns Hopkins University and Medicine Welch Medical Library Baltimore Maryland
| | - Adam Beaman
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| | - Patricia M. Davidson
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| |
Collapse
|
81
|
van der Vorst MJ, Neefjes EC, Boddaert MS, Verdegaal BA, Beeker A, Teunissen SC, Beekman AT, Wilschut JA, Berkhof J, Zuurmond WW, Verheul HM. Olanzapine Versus Haloperidol for Treatment of Delirium in Patients with Advanced Cancer: A Phase III Randomized Clinical Trial. Oncologist 2020; 25:e570-e577. [PMID: 32162816 PMCID: PMC7066704 DOI: 10.1634/theoncologist.2019-0470] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Treatment of delirium often includes haloperidol. Second-generation antipsychotics like olanzapine have emerged as an alternative with possibly fewer side effects. The aim of this multicenter, phase III, randomized clinical trial was to compare the efficacy and tolerability of olanzapine with haloperidol for the treatment of delirium in hospitalized patients with advanced cancer. MATERIALS AND METHODS Eligible adult patients (≥18 years) with advanced cancer and delirium (Delirium Rating Scale-Revised-98 [DRS-R-98] total score ≥17.75) were randomized 1:1 to receive either haloperidol or olanzapine (age-adjusted, titratable doses). Primary endpoint was delirium response rate (DRR), defined as number of patients with DRS-R-98 severity score <15.25 and ≥4.5 points reduction. Secondary endpoints included time to response (TTR), tolerability, and delirium-related distress. RESULTS Between January 2011 and June 2016, 98 patients were included in the intention-to-treat analysis. DRR was 45% (95% confidence interval [CI], 31-59) for olanzapine and 57% (95% CI, 43-71) for haloperidol (Δ DRR -12%; odds ratio [OR], 0.61; 95% CI, 0.2-1.4; p = .23). Mean TTR was 4.5 days (95% CI, 3.2-5.9 days) for olanzapine and 2.8 days (95% CI, 1.9-3.7 days; p = .18) for haloperidol. Grade ≥3 treatment-related adverse events occurred in 5 patients (10.2%) and 10 patients (20.4%) in the olanzapine and haloperidol arm, respectively. Distress rates were similar in both groups. The study was terminated early because of futility. CONCLUSION Delirium treatment with olanzapine in hospitalized patients with advanced cancer did not result in improvement of DRR or TTR compared with haloperidol. Clinical trial identification number. NCT01539733. Dutch Trial Register. NTR2559. IMPLICATIONS FOR PRACTICE Guidelines recommend that pharmacological interventions for delirium treatment in adults with cancer should be limited to patients who have distressing delirium symptoms. It was suggested that atypical antipsychotics, such as olanzapine, outperform haloperidol in efficacy and safety. However, collective data comparing the efficacy and safety of typical versus atypical antipsychotics in patients with cancer are limited. If targeted and judicious use of antipsychotics is considered for the treatment of delirium in patients with advanced cancer, this study demonstrated that there was no statistically significant difference in response to haloperidol or olanzapine. Olanzapine showed an overall better safety profile compared with haloperidol, although this difference was not statistically significant.
Collapse
Affiliation(s)
- Maurice J.D.L. van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of Internal Medicine, Rijnstate HospitalArnhemThe Netherlands
| | - Elisabeth C.W. Neefjes
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | - Bea A.T.T. Verdegaal
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Aart Beeker
- Department of Internal Medicine, Spaarne GasthuisHoofddorpThe Netherlands
| | - Saskia C.C. Teunissen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrechtThe Netherlands
- Academic Hospice DemeterDe BiltThe Netherlands
| | - Aartjan T.F. Beekman
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Janneke A. Wilschut
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Wouter W.A. Zuurmond
- Department of Anesthesiology, Amsterdam UMC, Vrije UniversiteitAmsterdamThe Netherlands
- Hospice KuriaAmsterdamThe Netherlands
| | - Henk M.W. Verheul
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
82
|
Santivasi WL, Partain DK, Whitford KJ. The role of geriatric palliative care in hospitalized older adults. Hosp Pract (1995) 2020; 48:37-47. [PMID: 31825689 DOI: 10.1080/21548331.2019.1703707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.
Collapse
Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel K Partain
- Center for Palliative Medicine & Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Center for Palliative Medicine & Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
83
|
Abstract
Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.
Collapse
Affiliation(s)
- Anne M Meehan
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lena Kassab
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Haixia Qin
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
84
|
Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database Syst Rev 2020; 1:CD004770. [PMID: 31960954 PMCID: PMC6984445 DOI: 10.1002/14651858.cd004770.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004. OBJECTIVES To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries. SELECTION CRITERIA We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older). DATA COLLECTION AND ANALYSIS We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables. MAIN RESULTS We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported. SECONDARY OUTCOMES use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE. AUTHORS' CONCLUSIONS We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.
Collapse
Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh45 Frogston Road WestEdinburghUKEH10 7DR
- University of EdinburghUsher InstituteEdinburghUK
| | - Louise Jones
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Baptiste Leurent
- London School of Hygiene and Tropical MedicineDepartment of Medical StatisticsLondonUK
| | - Elizabeth L Sampson
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Patrick Stone
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | | - Bridget Candy
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | |
Collapse
|
85
|
Kruser JM, Aaby DA, Stevenson DG, Pun BT, Balas MC, Barnes-Daly MA, Harmon L, Ely EW. Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States. JAMA Netw Open 2019; 2:e1917344. [PMID: 31825508 PMCID: PMC6991207 DOI: 10.1001/jamanetworkopen.2019.17344] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death. OBJECTIVE To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019. MAIN OUTCOMES AND MEASURES Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU. RESULTS Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events. CONCLUSIONS AND RELEVANCE In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.
Collapse
Affiliation(s)
- Jacqueline M. Kruser
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University, Chicago, Illinois
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - David A. Aaby
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - David G. Stevenson
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Lori Harmon
- Society of Critical Care Medicine, Mount Prospect, Illinois
| | - E. Wesley Ely
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| |
Collapse
|
86
|
Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review. Curr Opin Support Palliat Care 2019; 13:384-391. [DOI: 10.1097/spc.0000000000000458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
87
|
Predisposing and precipitating risk factors for delirium in palliative care patients. Palliat Support Care 2019; 18:437-446. [DOI: 10.1017/s1478951519000919] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractObjectiveDelirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.MethodIn this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.ResultsThe prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).Significance of resultsOur study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.
Collapse
|
88
|
Klankluang W, Pukrittayakamee P, Atsariyasing W, Siriussawakul A, Chanthong P, Tongsai S, Tayjasanant S. Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients. Oncologist 2019; 25:e335-e340. [PMID: 32043769 PMCID: PMC7011635 DOI: 10.1634/theoncologist.2019-0399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale‐Thai version (MDAS‐T) in PC patients. Materials and Methods The MDAS was translated into Thai. Content validity, inter‐rater reliability, and internal consistency were explored. The construct validity of the MDAS‐T was analyzed using exploratory factor analysis. Instrument testing of the MDAS‐T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU‐T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded. Results The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one‐factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93–0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS‐T were 0.92 (0.85–0.96) and 0.90 (0.82–0.94), respectively, with a cutoff score of 9, whereas the CAM‐ICU‐T yielded 0.58 (0.48–0.67) and 0.98 (0.93–0.99), respectively. The median MDAS‐T assessment time was 5 minutes. Conclusion This study established and validated the MDAS‐T as a good and feasible tool for delirium screening and severity rating in PC settings. Implications for Practice Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS‐T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population. Delirium is often misdiagnosed. This article reports on the value of assessment tools for diagnosis of delirium, in particular the Memorial Delirium Assessment Scale, which was translated into Thai for purposes of this study.
Collapse
Affiliation(s)
| | | | | | - Arunotai Siriussawakul
- Department Anesthesiology, Mahidol UniversityBangkokThailand
- Department Integrated Perioperative Geriatric Excellent Research Center, Mahidol UniversityBangkokThailand
| | | | - Sasima Tongsai
- Department Office for Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol UniversityBangkokThailand
| | | |
Collapse
|
89
|
Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement. Pain Manag Nurs 2019; 20:404-417. [PMID: 31610992 DOI: 10.1016/j.pmn.2019.07.005] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/25/2019] [Accepted: 07/21/2019] [Indexed: 11/18/2022]
Abstract
Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.
Collapse
Affiliation(s)
- Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa.
| | - Patrick J Coyne
- Palliative Care Department, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Ely
- Department of Nursing Research, University of Chicago Hospitals, Chicago, Illinois
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS, Centre-West-Montréal, Montréal, Québec, Canada
| | - Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
90
|
Barnes CJ, Webber C, Bush SH, McNamara-Kilian M, Brodeur J, Marchington K, Sabri E, Lawlor PG. Rating Delirium Severity Using the Nursing Delirium Screening Scale: A Validation Study in Patients in Palliative Care. J Pain Symptom Manage 2019; 58:e4-e7. [PMID: 31283968 DOI: 10.1016/j.jpainsymman.2019.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Christopher J Barnes
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada.
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jennifer Brodeur
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada
| | - Katie Marchington
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| |
Collapse
|
91
|
Wilson JE, Boehm L, Samuels LR, Unger D, Leonard M, Roumie C, Ely EW, Dittus RS, Misra S, Han JH. Use of the brief Confusion Assessment Method in a veteran palliative care population: A pilot validation study. Palliat Support Care 2019; 17:569-573. [PMID: 30887938 PMCID: PMC6752980 DOI: 10.1017/s1478951518001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample. METHOD This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans' Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other. RESULT We enrolled 36 patients who were a median of 67 years (interquartile range 63-73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96). SIGNIFICANCE OF RESULTS Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
Collapse
Affiliation(s)
- Jo Ellen Wilson
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Critical Illness, Brain Dysfunction, and Survivorship, Nashville, TN
| | - Leanne Boehm
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Vanderbilt Center for Critical Illness, Brain Dysfunction, and Survivorship, Nashville, TN
- Vanderbilt University School of Nursing, Nashville, TN
| | - Lauren R. Samuels
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Deborah Unger
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs TN Valley, Palliative Care Consultation Service
| | - Martha Leonard
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs TN Valley, Palliative Care Consultation Service
| | - Christianne Roumie
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - E. Wesley Ely
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Vanderbilt Center for Critical Illness, Brain Dysfunction, and Survivorship, Nashville, TN
- Department of Medicine, Division of Pulmonary and Critical Care, and the Center for Health Services Research and Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S. Dittus
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Vanderbilt Center for Critical Illness, Brain Dysfunction, and Survivorship, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Sumi Misra
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs TN Valley, Palliative Care Consultation Service
| | - Jin H. Han
- Veteran’s Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC)
- Vanderbilt Center for Critical Illness, Brain Dysfunction, and Survivorship, Nashville, TN
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
92
|
Waterfield K, Weiand D, Dewhurst F, Kiltie R, Pickard J, Karandikar U, MacCormick F, Vidrine J, Rowley G, Coulter P, Lee M, Frew K. A qualitative study of nursing staff experiences of delirium in the hospice setting. Int J Palliat Nurs 2019; 24:524-534. [PMID: 30457465 DOI: 10.12968/ijpn.2018.24.11.524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND: Delirium is a common condition occurring in 13-42% of people admitted to palliative care units and up to 88% of these patients are at the end of their lives. It is frequently unrecognised and distressing to all those affected-patients, families and health professionals. In addition, there is considerable uncertainty surrounding its trajectory and optimal management, both of which can be inconsistent. AIMS: This study aims to explore the experience of nursing staff who are caring for patients with delirium in the hospice environment and understand any potential barriers to its management. METHODS: Semistructured interviews using emotional touchpoints were conducted with 12 nurses and six healthcare assistants in three hospices in North East England. Data was analysed using interpretative phenomenological analysis. FINDINGS: The results highlighted gaps in knowledge and understanding in the management of delirium. The results demonstrated delirium had significant emotional effects, which were associated with uncertainty in managing the condition and the impact of this uncertainty on the relationship between staff and patients. CONCLUSION: This study highlights the emotional impact of caring for patients with delirium. Future work is needed to address the areas of uncertainty identified and ascertain how to best support nursing staff in these challenges.
Collapse
Affiliation(s)
- Kerry Waterfield
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Donna Weiand
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Felicity Dewhurst
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Rachel Kiltie
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jonathan Pickard
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Ulka Karandikar
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Fiona MacCormick
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jen Vidrine
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Grace Rowley
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Paul Coulter
- Consultant, Palliative Medicine, Queen Elizabeth Hospital, Gateshead
| | - Mark Lee
- Consultant, Palliative Medicine, St Benedict's hospice, Sunderland
| | - Katie Frew
- Consultant, Palliative Medicine, Northumbria Healthcare NHS Foundation Trust
| |
Collapse
|
93
|
Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
Collapse
Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| |
Collapse
|
94
|
Fischer T, Hosie A, Luckett T, Agar M, Phillips J. Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review. J Pain Symptom Manage 2019; 58:487-502.e11. [PMID: 31195076 DOI: 10.1016/j.jpainsymman.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023]
Abstract
CONTEXT Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment. OBJECTIVES The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium. METHODS A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed. RESULTS A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications. CONCLUSION The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.
Collapse
Affiliation(s)
| | - Annmarie Hosie
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Tim Luckett
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Jane Phillips
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| |
Collapse
|
95
|
Watt CL, Momoli F, Ansari MT, Sikora L, Bush SH, Hosie A, Kabir M, Rosenberg E, Kanji S, Lawlor PG. The incidence and prevalence of delirium across palliative care settings: A systematic review. Palliat Med 2019; 33:865-877. [PMID: 31184538 PMCID: PMC6691600 DOI: 10.1177/0269216319854944] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
Collapse
Affiliation(s)
- Christine L Watt
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,4 Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- 5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- 6 Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Annmarie Hosie
- 8 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Erin Rosenberg
- 9 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,10 Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,11 Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada.,12 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| |
Collapse
|
96
|
Felton MA, Jarrett JB, Hoffmaster R, D'Amico FJ, Sakely H, Pruskowski J. Comparison of haloperidol, non-haloperidol antipsychotics, and no pharmacotherapy for the management of delirium in an inpatient geriatric palliative care population. J Pain Palliat Care Pharmacother 2019; 32:141-148. [PMID: 31066639 DOI: 10.1080/15360288.2018.1513434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antipsychotics are frequently used for treatment of delirium, although little evidence exists that they improve delirium outcomes. Our objective was to evaluate haloperidol (HAL) compared to non-haloperidol antipsychotics (NHAP) or no pharmacologic treatment (NP) in the management of delirium in older adults under the care of a palliative care consult service across a large, integrated health care system. A retrospective chart review examined data from September 2014-September 2015. All hospitalized patients ≥65 years old with a diagnosis of delirium during palliative care consultation were included (n = 304). Primary outcome was length of stay after delirium diagnosis. Secondary outcomes included delirium symptom length, sedation, and QTc prolongation. Univariate statistical tests, analysis of covariance, and multiple regression methods were used to compare groups. Post-delirium length of stay in the HAL, NHAP, and NP groups were 8.5, 7.0, and 6.8 days, respectively (p = 0.19). Delirium duration in the HAL, NHAP, and NP groups were 6.7, 6.0, and 4.9 days, respectively (p = 0.05). Safety outcomes were statistically different than the reference group (NHAP). Congruent with existing literature in other generalized patient populations, no significant difference in post-delirium length of stay existed in geriatric, palliative care population.
Collapse
Affiliation(s)
- Maria A Felton
- a MedStar Health Department of Medicine , Baltimore , MD , USA
| | - Jennie B Jarrett
- b University of Illinois at Chicago College of Pharmacy , Chicago , IL , USA
| | - Richard Hoffmaster
- c UPMC St. Margaret Department of Medical Education , Pittsburgh , PA , USA
| | - Frank J D'Amico
- d UPMC Palliative and Supportive Institute (PSI) , Pittsburgh , PA , USA
| | - Heather Sakely
- e Department of Mathematics and Computer Science at Duquesne University , Pittsburgh , PA , USA
| | | |
Collapse
|
97
|
Nguyen TH, Atayee RS, Derry KL, Hirst J, Biondo A, Edmonds KP. Characteristics of Hospitalized Patients Screening Positive for Delirium. Am J Hosp Palliat Care 2019; 37:142-148. [PMID: 31362517 DOI: 10.1177/1049909119867046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Delirium in the hospitals leads to worse outcomes for patients. There were no previous studies that characterize patients with delirium from multiple hospital locations. OBJECTIVE To describe patient characteristics screening positive for delirium and identify any correlations with hospital location and medication use. DESIGN, SETTINGS, PATIENTS Retrospective chart review of 227 hospitalized patients from a large, academic, tertiary referral, 2-campus health system. Patients were ≥18 years old and had delirium for at least ≥24 hours. Validated delirium screening tools were utilized. MEASUREMENTS Patients' demographics, inpatient stay information, delirium episodes characteristics, drugs, and palliative and psychiatry teams' involvement. RESULTS Most patients were older with a mean age of 64.1 years. The most common primary diagnoses were infection, cardiac, and pulmonary. Average length of delirium was 7.2 days (standard deviation [SD] = 8.2), and average length of stay (LOS) was 18.7 days (median = 10.5, SD = 35.1, 95% confidence interval = 14.1-23). Thirty-day readmission rate was 24.8% (65/262 hospitalizations); 12.8% of patients died in the hospital (29/227). Around one-third of hospitalizations had involvement of palliative care, palliative psychiatry, or general psychiatry team. There was a decrease in the number of medications administered 24 hours after the first recording of delirium compared to the immediate preceding 48 hours. Those hospitalizations where delirium first occurred in the intensive care unit (ICU) did have a longer LOS (average = 22.9, SD = 45.7) than those where delirium first occurred outside the ICU (average = 14.8, SD = 20.5). Patients were likely to have received an opioid within 48 hours in 51% of hospitalizations and to have received benzodiazepines in 16% of hospitalizations. CONCLUSION In our study, we found that delirium significantly impacted length of delirium episode, number of episodes of delirium, length of hospital admission, and mortality. The population most sensitive to the impacts of delirium were elderly patients.
Collapse
Affiliation(s)
- Trinh H Nguyen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Rabia S Atayee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA.,Doris A. Howell Palliative Care Teams, UC San Diego Health, La Jolla, CA, USA.,Department of Pharmacy, UC San Diego Health, La Jolla, CA, USA
| | - Katrina L Derry
- Department of Pharmacy, UC San Diego Health, La Jolla, CA, USA
| | - Jeremy Hirst
- Doris A. Howell Palliative Care Teams, UC San Diego Health, La Jolla, CA, USA
| | - Anthony Biondo
- Department of Pharmacy, UC San Diego Health, La Jolla, CA, USA
| | - Kyle P Edmonds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA.,Doris A. Howell Palliative Care Teams, UC San Diego Health, La Jolla, CA, USA
| |
Collapse
|
98
|
Boland JW, Kabir M, Bush SH, Spiller JA, Johnson MJ, Agar M, Lawlor P. Delirium management by palliative medicine specialists: a survey from the association for palliative medicine of Great Britain and Ireland. BMJ Support Palliat Care 2019; 12:73-80. [PMID: 30837278 DOI: 10.1136/bmjspcare-2018-001586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/21/2018] [Accepted: 02/11/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Delirium is common in palliative care settings. Management includes detection, treatment of cause(s), non-pharmacological interventions and family support; strategies which are supported with varying levels of evidence. Emerging evidence suggests that antipsychotic use should be minimised in managing mild to moderate severity delirium, but the integration of this evidence into clinical practice is unknown. METHODS A 21-question online anonymous survey was emailed to Association for Palliative Medicine members in current clinical practice (n=859), asking about delirium assessment, management and research priorities. RESULTS Response rate was 39%: 70% of respondents were palliative medicine consultants. Delirium guidelines were used by some: 42% used local guidelines but 38% used none. On inpatient admission, 59% never use a delirium screening tool. Respondents would use non-pharmacological interventions to manage delirium, either alone (39%) or with an antipsychotic (58%). Most respondents (91%) would prescribe an antipsychotic and 6% a benzodiazepine, for distressing hallucinations unresponsive to non-pharmacological measures. Inpatient (57%) and community teams (60%) do not formally support family carers. Research priorities were delirium prevention, management and prediction of reversibility. CONCLUSION This survey of UK and Irish Palliative Medicine specialists shows that delirium screening at inpatient admission is suboptimal. Most specialists continue to use antipsychotics in combination with non-pharmacological interventions to manage delirium. More support for family carers should be routinely provided by clinical teams. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.
Collapse
Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Monisha Kabir
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Juliet Anne Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, UK.,IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Meera Agar
- IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Peter Lawlor
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
| |
Collapse
|
99
|
Lawlor PG, Rutkowski NA, MacDonald AR, Ansari MT, Sikora L, Momoli F, Kanji S, Wright DK, Rosenberg E, Hosie A, Pereira JL, Meagher D, Rice J, Scott J, Bush SH. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. J Pain Symptom Manage 2019; 57:661-681.e12. [PMID: 30550832 DOI: 10.1016/j.jpainsymman.2018.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
CONTEXT Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.
Collapse
Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | | | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David K Wright
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Critical Care, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jose L Pereira
- Department of Family Medicine, University of Ottawa, Ontario, Canada; Division of Palliative Medicine, McMaster University, Ontario, Canada
| | - David Meagher
- University of Limerick School of Medicine, Limerick, Ireland
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Scott
- The Ottawa Hospital, Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
100
|
Boland JW, Currow D, Johnson M. Response to "Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later". J Pain Symptom Manage 2019; 57:e12-e13. [PMID: 30496789 DOI: 10.1016/j.jpainsymman.2018.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/06/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK.
| | - David Currow
- The University of Technology, Sydney, NSW, Australia
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| |
Collapse
|