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Gleadle N, Cook A, Johnson CE, Walpole G. Antidepressant use and hyperactive delirium at the end of life: retrospective study. BMJ Support Palliat Care 2024; 13:e916-e919. [PMID: 37479249 DOI: 10.1136/spcare-2023-004417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/05/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVES Little is known about the adverse effects associated with antidepressant use in palliative care inpatients imminently approaching death. This study investigates the relationship between antidepressant use and hyperactive delirium in this population. METHODS This is a retrospective medical record review of patients who died in a metropolitan palliative care unit in Victoria, Australia, during 2019. Generalised estimating equations were used to estimate the association between antidepressant use and presence of hyperactive delirium in the final 2 weeks of life. RESULTS Of the 501 adult patients who died in the 12-month period, 113 (22.55%) were on at least one antidepressant at the time of admission. Any antidepressant use in the last 14 days of life was significantly associated with the diagnosis of hyperactive delirium (OR 1.48; 95% CI 1.30, 1.68). Patients prescribed antidepressants also experienced longer durations of delirium (3.89 days; SD 4.23) compared with those not taking any antidepressant (2.99 days; SD 3.70) in the final 2 weeks of life. CONCLUSION Antidepressant use or discontinuation is significantly associated with hyperactive delirium within 14 days of death. Although the causes of delirium are multifactorial and complex, antidepressant use is a potentially modifiable risk factor.
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Affiliation(s)
- Naomi Gleadle
- Supportive and Palliative Care Service, Eastern Health, Melbourne, Victoria, Australia
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia
| | - Claire E Johnson
- Australian Health Services Research Institute, University of Wollongong Faculty of Business, Wollongong, New South Wales, Australia
| | - Grace Walpole
- Supportive and Palliative Care Service, Eastern Health, Melbourne, Victoria, Australia
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Grisales ES, Higuita AM, Correa ME, Gómez JJV, González CP, Daveloza AK, Vásquez JGF. Delirium in oncological palliative care and clinical cardiology units: A comparative analysis. Palliat Support Care 2023; 21:805-811. [PMID: 35894094 DOI: 10.1017/s1478951522000906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to compare the sociodemographic and clinical characteristics of delirium in patients treated in a clinical cardiology unit (CCU) and an oncological palliative care unit (OPCU) at a high-complexity institution. CONTEXT Delirium is a neuropsychiatric syndrome with multicausal etiology, associated with increased morbidity and mortality. METHOD This was a cross-sectional, analytical observational study. CCU and OPCU patients were evaluated for 480 days. The diagnosis was made according to DSM-V. Sociodemographic characteristics, the Karnofsky index, and the Charlson index were evaluated. Possible etiologies were verified. Severity was assessed with the Delirium Severity Scale (DRS-R98). RESULTS A total of 1,986 patients were evaluated, 205 were eligible, and 110 were included in the study (CCU: 61, OPCU: 49). Delirium prevalence was 11.35% in the CCU and 9.87% in the OPCU. CCU patients were 12 years older (p < 0.03) and a history of dementia (41 vs. 8.2%; p < 0.001). Organ failure was the most frequent etiology of delirium in the CCU (41.0%), and in the OPCU, the etiologies were neoplasms (28.6%), side effect of medication (22.4%), and infections (2.5%). Differences were found in the clinical characteristics of delirium evaluated by DRS-R98, with the condition being more severe and with a higher frequency of psychotic symptoms in OPCU patients. CONCLUSION Delirium was a common condition in hospitalized patients in the CCU and the OPCU. The clinical characteristics were similar in both groups; however, significant differences were found in OPCU patients in terms of age, personal history of dementia, and opioid use, as well as the severity of delirium and a greater association with psychotic symptoms. These findings have implications for the early implementation of diagnostic and therapeutic strategies.
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Affiliation(s)
| | | | | | | | - Carolina Palacio González
- Universidad Pontificia Bolivariana and Pyschology Unit, Instituto de Cancerología, Medellín, Colombia
| | | | - José Gabriel Franco Vásquez
- Liaison Psychiatry Research Group, School of Medicine, Universidad Pontificia Bolivariana, Medellín, Colombia
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Chishi KV, Patel BC, Umrania RA, Sanghavi PR, Yadav VS, Raval LV. Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention. Indian J Palliat Care 2023; 29:82-88. [PMID: 36846279 PMCID: PMC9945345 DOI: 10.25259/ijpc_114_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022] Open
Abstract
Objectives The assessment of prevalence of delirium in advanced cancer patients admitted in hospice centre and outcome after palliative intervention. The possible related risk factors for development of delirium. Material and Methods This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019 - July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion criteria (all patient admitted to hospice centre above 18 years, with advance cancer disease and on best supportive care) and exclusion criteria (Lack of informed consent, Inability to participate in study due to mentally retard or coma). The following information were collected: age, gender, address, type of cancer, comorbidities, history of substance abuse, history of (h/o) palliative chemotherapy or radiotherapy within last 3month, general condition, ESAS (Edmonton symptom assessment scale), ECOG (Eastern cooperative oncology group), PaP score (palliative prognostic score), medication including opioids, NSAIDs (Non-steroidal anti-inflammatory drugs), steroids, antibiotic, adjuvant analgesic, PPI (Proton pump inhibitor), anti-emetic etc. Delirium diagnosis was based on diagnostic criterion of DSM-IV text revised and MDAS. Results In our study we found prevalence of delirium was 31.29% in advanced cancer patients admitted to hospice centre. We found most common type of delirium is hypoactive (34.7%) and mixed subtype (34.7%) followed by hyperactive (30.4%) delirium. Resolution of delirium was higher among hyperactive delirium (78.57%) followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%) followed by mixed (43.75%) and hyperactive delirium (14.28%). Conclusion An identification and assessment of delirium is vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalization, expanded time on a ventilator, and by and large more prominent medical services costs. Clinicians should utilize one of a few approved delirium assessment tools to help evaluate and archive cognitive function. Prevention and recognizing the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium. The study results demonstrate that multi component delirium management or projects are generally proficient to lessen the prevalence and negative outcomes of delirium. It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.
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Affiliation(s)
- Kikato V. Chishi
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Bhavna Chirag Patel
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Ravi A. Umrania
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Priti Rashmin Sanghavi
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Varun Shaileshbhai Yadav
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Lekha V. Raval
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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Intervention of Coordination by Liaison Nurse Where Ward Staff Struggled to Establish a Therapeutic Relationship with a Patient Because of Failure to Recognize Delirium: A Case Study. Healthcare (Basel) 2022; 10:healthcare10071335. [PMID: 35885860 PMCID: PMC9319112 DOI: 10.3390/healthcare10071335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022] Open
Abstract
In this case study, ward staff found it difficult to establish a therapeutic relationship with a patient with advanced gastric cancer because they misdiagnosed delirium as a psychogenic reaction to the cancer diagnosis. This article reports on the process and effects of intervention by a liaison nurse. The liaison nurse recognized the misdiagnosis and approached the ward staff via a psychiatrist-led team. This enabled rapid revision of the treatment policy. The liaison nurse contributed to the continuation of treatment by enabling the ward staff and patient to understand each other better and to collaborate to build a relationship and control the patient’s mental health symptoms, including attention disorder and excessive demands. The patient and family had different views on discharge because of the patient’s mental health issues. The liaison nurse encouraged the ward staff to inform the family caregiver about the patient’s medical condition, the expected future course of the disease, and likely symptoms, and provide appropriate professional services. This enabled the patient to be discharged in line with their wishes. This case highlights the role of the liaison nurse in coordinating care and helping ward staff to recognize symptoms and provide appropriate care and support for patients and their families.
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5
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Senderovich H, Gardner S, Berall A, Ganion M, Zhang D, Vinoraj D, Waicus S. Benzodiazepine Use and Morbidity-Mortality Outcomes in a Geriatric Palliative Care Unit: A Retrospective Review. Dement Geriatr Cogn Disord 2022; 50:559-567. [PMID: 34942615 DOI: 10.1159/000520975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Patients often experience delirium at the end of life. Benzodiazepine use may be associated with an increased risk of developing delirium. Alternate medications used in conjunction with benzodiazepines may serve as an independent precipitant of delirium. The aim is to understand the role of benzodiazepines in precipitating delirium and advanced mortality in palliative care population at the end of life. METHODS A retrospective medical chart review was conducted at a hospice and palliative care inpatient unit between the periods of June 2017-December 2017 and October 2017-November 2018. It included patients in hospice and palliative care inpatient units who received a benzodiazepine and those who did not. Patient characteristics, as well as Palliative Performance Scale score, diagnosis, and occurrence of admission, terminal, and/or recurrent delirium, were collected and analyzed. RESULTS Use of a benzodiazepine was not significantly associated with overall mortality nor cause-specific death without terminal delirium rate. However, it was significantly associated with higher cause-specific death with terminal delirium rate and a higher recurrent delirium rate. DISCUSSION This retrospective chart review suggests an association between benzodiazepine use and specific states of delirium and cause-specific death. However, it does not provide strong evidence on the use of this drug, especially at the end of life, as it pertains to the overall mortality rate. Suggested is a contextual approach to the use of benzodiazepines and the need to consider Palliative Performance Scale score and goals of care in the administration of this drug at varying periods during patient length of stay.
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Affiliation(s)
- Helen Senderovich
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Toronto, Ontario, Canada.,Division of Palliative Care, Toronto, Ontario, Canada
| | - Sandra Gardner
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,Biostatistics Division, Baycrest, Kunin-Lunenfeld Centre for Applied Research and Evaluation (KL-CARE), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anna Berall
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,Biostatistics Division, Baycrest, Kunin-Lunenfeld Centre for Applied Research and Evaluation (KL-CARE), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael Ganion
- University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Toronto, Ontario, Canada.,Bethell Hospice, Toronto, Ontario, Canada
| | - Dennis Zhang
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Danusha Vinoraj
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Waicus
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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Ganju R, Neeranjun R, Morse R, Lominska C, TenNapel M, Chen AM. Incidence and Predictors of Persistent Opioid Use in Survivors of Head and Neck Cancer Treated With Curative Radiation. Am J Clin Oncol 2022; 45:161-167. [PMID: 35131971 DOI: 10.1097/coc.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We sought to characterize the incidence of chronic opioid dependence among head and neck cancer survivors treated by radiation, as well as to identify patient and treatment factors associated with persistent use. MATERIALS AND METHODS The medical records of patients with head and neck cancer who received radiation therapy from January 2012 to July 2016 were reviewed. All patients received 60 to 70 Gy with curative intent. Patients who progressed or died within 1 year were intentionally excluded. Opioid doses were calculated in morphine equivalent daily doses in milligrams (mg). Univariate and multivariate regression models were used to identify associations between demographic, medical, disease, and persistent opioid use. RESULTS Two hundred and sixty-one patients were included. The median follow-up was 39 months (range: 12 to 83 mo). Two hundred and eleven patients (80%) received opioids for pain control during radiation. The median morphine equivalent daily dose during treatment was 73.8 mg (range: 5 to 561 mg). Rates of persistent opioid use at 6 months, 1 year, and 2 years from completion of radiation were 41.8%, 30.1%, and 26.0%, respectively. On multivariate analysis, only preradiation opioid use correlated with persistent opioid use at all 3 time points (P<0.05). Smoking history and a Charlson comorbidity index ≥2 predicted for persistent opioid use at some time points, but not all. CONCLUSIONS High rates of persistent opioid use exist in patients with head and neck cancer after radiation therapy. Early interventions to appropriately wean patients should be further investigated.
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Affiliation(s)
- Rohit Ganju
- University of Kansas School of Medicine, Kansas City, KS
| | | | - Ryan Morse
- University of Kansas School of Medicine, Kansas City, KS
| | | | - Mindi TenNapel
- University of Kansas School of Medicine, Kansas City, KS
| | - Allen M Chen
- Irvine Chao Family Comprehensive Cancer Center, University of California, Irvine, CA
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Abstract
OBJECTIVE This review aimed to explore and summarise available cases of delirium suspected to be associated with the use of macrolide antibiotics reported in the literature and the United States Food and Drug Administration's Adverse Event Reporting System (FAERS) database. METHODS Electronic searches of the literature were conducted in four online databases: PubMed/MEDLINE, Scopus, Web of Science and Serbian Citation Index (SCIndeks). A search of FAERS database was also conducted to supplement the findings of the literature search. Descriptive statistics, narrative summation and tabulation of the extracted data were made. RESULTS Cases of delirium which satisfied inclusion criteria were found for clarithromycin, azithromycin, erythromycin and telithromycin. Delirium was described in patients of various age groups, including children. Drug-drug interactions may have contributed to its occurrence in some of the cases. Average time to onset of delirium was 2.5 days for azithromycin and 3.3 days for clarithromycin. CONCLUSIONS Considering that these drugs may be a possible cause of delirium, clinicians should be aware that timely recognition of this possible side effect can lead to earlier discontinuation of the culprit drug, reduce time spent in a delirious state and improve patients' outcomes.KEY POINTSCases of delirium which satisfied inclusion criteria were found for clarithromycin, azithromycin, erythromycin and telithromycin.Cases of delirium were described in patients of various age groups, including children.Drug-drug interactions may have contributed to the occurrence of delirium in some of the cases.Time to onset of delirium ranged from 2 to 3.5 days (mean: 2.5 days) for azithromycin and from 1 to 7 days (mean: 3.3 days) for clarithromycin.Cessation of the macrolide antibiotic seems to be the best management strategy, although some of the patients may, in addition, require antipsychotics.
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Affiliation(s)
- Ana V Pejčić
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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8
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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.
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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
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9
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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.
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle SE, Cumming A, Caplan GA, Chye R, Le B, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Brown L, Fazekas B, Cheah SL, Edwards L, Agar M. Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial. BMJ Open 2019; 9:e026177. [PMID: 30696686 PMCID: PMC6352777 DOI: 10.1136/bmjopen-2018-026177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies. TRIAL REGISTRATION NUMBER ACTRN12617001070325; Pre-results.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Beverly Noble
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meg Brassil
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Susan E Kurrle
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Health Service, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Brian Le
- Palliative and Supportive Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University, and the Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville TN USA, Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Palliative Care, Calvary Health Care Kogarah, Sydney, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Linda Brown
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Layla Edwards
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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Hosie A, Agar M, Lobb E, Davidson PM, Phillips J. Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis. Int J Nurs Stud 2017; 75:123-129. [PMID: 28783489 DOI: 10.1016/j.ijnurstu.2017.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 07/04/2017] [Accepted: 07/08/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Delirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess. OBJECTIVES To report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units. METHODS The Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion. RESULTS There was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units. CONCLUSION Improving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Elizabeth Lobb
- Calvary Health Care Sydney, Palliative Care Department, 91-111 Rocky Point Rd, Kogarah, NSW 2217, Australia
| | - Patricia M Davidson
- Johns Hopkins University, School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, United States
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
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Hosie A, Lobb E, Agar M, Davidson PM, Phillips J. Identifying the barriers and enablers to palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study. J Pain Symptom Manage 2014; 48:815-30. [PMID: 24726761 DOI: 10.1016/j.jpainsymman.2014.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/21/2014] [Accepted: 02/07/2014] [Indexed: 12/27/2022]
Abstract
CONTEXT Delirium is underrecognized by nurses, including those working in palliative care settings where the syndrome occurs frequently. Identifying contextual factors that support and/or hinder palliative care nurses' delirium recognition and assessment capabilities is crucial, to inform development of clinical practice and systems aimed at improving patients' delirium outcomes. OBJECTIVES The aim of the study was to identify nurses' perceptions of the barriers and enablers to recognizing and assessing delirium symptoms in palliative care inpatient settings. METHODS A series of semistructured interviews, guided by critical incident technique, were conducted with nurses working in Australian palliative care inpatient settings. A hypoactive delirium vignette prompted participants' recall of delirium and identification of the perceived factors (barriers and enablers) that impacted on their delirium recognition and assessment capabilities. Thematic content analysis was used to analyze the qualitative data. RESULTS Thirty participants from nine palliative care services provided insights into the barriers and enablers of delirium recognition and assessment in the inpatient setting that were categorized as patient and family, health professional, and system level factors. Analysis revealed five themes, each reflecting both identified barriers and current and/or potential enablers: 1) value in listening to patients and engaging families, 2) assessment is integrated with care delivery, 3) respecting and integrating nurses' observations, 4) addressing nurses' delirium knowledge needs, and 5) integrating delirium recognition and assessment processes. CONCLUSION Supporting the development of palliative care nursing delirium recognition and assessment practice requires attending to a range of barriers and enablers at the patient and family, health professional, and system levels.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia.
| | - Elizabeth Lobb
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Palliative Care Department, Calvary Health Care Sydney, Kogarah, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Meera Agar
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Prairiewood, New South Wales, Australia; Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Patricia M Davidson
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Faculty of Health, University of Technology, Broadway, New South Wales
| | - Jane Phillips
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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