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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.
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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
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Barahona E, Pinhao R, Galindo V, Noguera A. The Diagnostic Sensitivity of the Memorial Delirium Assessment Scale-Spanish Version. J Pain Symptom Manage 2018; 55:968-972. [PMID: 29155289 DOI: 10.1016/j.jpainsymman.2017.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/01/2017] [Accepted: 11/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although Memorial Delirium Assessment Scale (MDAS) is a successful tool for delirium evaluation and monitoring, it is nevertheless important to determine whether cutoff scores vary according to the studied population. The main objective of this study was to evaluate the diagnostic sensitivity of the recently validated Spanish version of the MDAS. The secondary objective was to analyze possible diagnostic differences when used in a hospice or general hospital setting. METHODOLOGY A prospective study was conducted with advanced cancer patients in two settings (hospice and general hospital). A diagnosis of delirium was established according to clinical criteria and the Confusion Assessment Method. Sensitivity (S), specificity (Sp), positive predictive value, and negative predictive value were determined according to the receiver operating characteristics curve. The MDAS values for different centers were studied using nonparametric tests (Mann-Whitney). RESULTS A total of 67 patients were included, 28 of whom had been diagnosed with delirium (15/40 hospice and 13/27 general hospital). The mean MDAS scores were 13.6 and 5.5 for the delirium and nondelirium groups, respectively. A cutoff score of 7 gave the optimal screening diagnosis balance (S 92.6%, Sp 71.8%, positive predictive value 70.1%, and negative predictive value 93.3%). Diagnoses of anxiety and depression were not related with delirium (P ≤ 0.44). A diagnosis of dementia was related to delirium (P ≤ 0.052) but did not influence the diagnostic sensitivity of MDAS (P ≤ 0.26). No differences were found between hospice and general hospital settings as regards the diagnostic sensitivity of MDAS. CONCLUSION A screening cutoff of 7 appears to be optimal for MDAS Spanish version. No differences were found between advanced cancer patients cared for in a hospice or general hospital. However, more research is required to define the MDAS cutoff for patients with advanced cancer and dementia.
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Affiliation(s)
- Elena Barahona
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Rita Pinhao
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Victoria Galindo
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Antonio Noguera
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.
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Fong TG, Albuquerque A, Inouye SK. The Search for Effective Delirium Treatment for Persons with Dementia in the Postacute-Care Setting. J Am Geriatr Soc 2016; 64:2421-2423. [DOI: 10.1111/jgs.14585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tamara G. Fong
- Department of Neurology; Beth Israel Deaconess Medical Center; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
| | - Asha Albuquerque
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
| | - Sharon K. Inouye
- Harvard Medical School; Boston Massachusetts
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
- Department of Medicine; Beth Israel Deaconess Medical Center; Boston Massachusetts
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Abstract
Dementia is an illness that progressively affects cognition, emotion, and functional status. It can be complicated by delirium, an acute disturbance of consciousness and cognition that develops over a short course with fluctuating symptoms. Patients with dementia who experience delirium tend to have slower resolution of symptoms, more adverse events, and poorer outcomes. There are significant health care expenditures associated with delirium. Many health care providers fail to recognize and diagnose delirium. The confusion assessment method is a suggested tool for diagnosing delirium. Delirium is multifactorial, occurring in an individual who has a predisposing factor (dementia is the number 1 risk factor) and is exposed to further precipitating risk factors that are often preventable. The main focus of treatment and management of delirium should be on prevention, which can be achieved through assessing patients for predisposing and precipitating factors. If a patient does develop delirium, a reassessment of precipitating factors is the first step in treatment, and then nonpharmacologic or pharmacologic treatment can be considered. The use of antipsychotics or melatonin to treat delirium in dementia is considered off-label.
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Affiliation(s)
- Martha Roden
- Resident, Department of Family, Community, and Preventative Medicine, Drexel University College of Medicine, Philadelphia, PA.
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Haloperidol, risperidone, olanzapine and aripiprazole in the management of delirium: A comparison of efficacy, safety, and side effects. Palliat Support Care 2014; 13:1079-85. [PMID: 25191793 DOI: 10.1017/s1478951514001059] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of this study was to compare the efficacy and side-effect profile of the typical antipsychotic haloperidol with that of the atypical antipsychotics risperidone, olanzapine, and aripiprazole in the management of delirium. METHOD The Memorial Delirium Assessment Scale (MDAS), the Karnofsky Performance Status (KPS) scale, and a side-effect rating were recorded at baseline (T1), after 2-3 days (T2), and after 4-7 days (T3). Some 21 cases were case-matched by age, preexisting dementia, and baseline MDAS scores, and subsequently analyzed. RESULTS The baseline characteristics of the medication groups were not different: The mean age of the patients ranged from 64.0 to 69.6 years, dementia was present in between 23.8 and 28.6%, and baseline MDAS scores were 19.9 (haloperidol), 18.6 (risperidone), 19.4 (olanzapine), and 18.0 (aripiprazole). The doses of medication at T3 were 5.5 mg haloperidol, 1.3 mg risperidone, 7.1 mg olanzapine, and 18.3 mg aripiprazole. Over one week, the decline in MDAS scores between medications was equal, and no differences between individual MDAS scores existed at T2 or T3. After one week, the MDAS scores were 6.8 (haloperidol), 7.1 (risperidone), 11.7 (olanzapine), and 8.3 (aripiprazole). At T2, delirium resolution occurred in 42.9-52.4% of cases and at T3 in 61.9-85.7%; no differences in assessments between medications existed. Recorded side effects were extrapyramidal symptoms (EPSs) in haloperidol- and risperidone-managed patients (19 and 4.8%, respectively) and sedation with olanzapine (28.6%). SIGNIFICANCE OF RESULTS Haloperidol, risperidone, aripiprazole, and olanzapine were equally effective in the management of delirium; however, they differed in terms of their side-effect profile. Extrapyramidal symptoms were most frequently recorded with haloperidol, and sedation occurred most frequently with olanzapine.
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Leonard MM, Agar M, Spiller JA, Davis B, Mohamad MM, Meagher DJ, Lawlor PG. Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes. J Pain Symptom Manage 2014; 48:199-214. [PMID: 24879995 DOI: 10.1016/j.jpainsymman.2014.03.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/17/2014] [Accepted: 04/02/2014] [Indexed: 12/19/2022]
Abstract
CONTEXT Delirium often presents difficult diagnostic and classification challenges in palliative care settings. OBJECTIVES To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review. RESULTS We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness. CONCLUSION Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.
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Affiliation(s)
- Maeve M Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Juliet A Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh and West Lothian Palliative Care Service, Edinburgh, United Kingdom
| | - Brid Davis
- Milford Care Centre, University of Limerick, Limerick, Ireland
| | - Mas M Mohamad
- Milford Care Centre, University of Limerick, Limerick, Ireland
| | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Meagher DJ, McLoughlin L, Leonard M, Hannon N, Dunne C, O'Regan N. What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy. Am J Geriatr Psychiatry 2013; 21:1223-38. [PMID: 23567421 DOI: 10.1016/j.jagp.2012.09.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/06/2012] [Accepted: 09/26/2012] [Indexed: 12/31/2022]
Abstract
Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.
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Affiliation(s)
- David J Meagher
- Department of Adult Psychiatry, University Hospital Limerick, Ireland; University of Limerick Medical School, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland.
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A longitudinal study of delirium phenomenology indicates widespread neural dysfunction. Palliat Support Care 2013; 13:187-96. [PMID: 24183238 DOI: 10.1017/s147895151300093x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Delirium affects all higher cortical functions supporting complex information processing consistent with widespread neural network impairment. We evaluated the relative prominence of delirium symptoms throughout episodes to assess whether impaired consciousness is selectively affecting certain brain functions at different timepoints. METHODS Twice-weekly assessments of 100 consecutive patients with DSM-IV delirium in a palliative care unit used the Delirium Rating Scale Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). A mixed-effects model was employed to estimate changes in severity of individual symptoms over time. RESULTS Mean age = 7 0.2 ± 10.5 years, 51% were male, and 27 had a comorbid dementia. A total of 323 assessments (range 2-9 per case) were conducted, but up to 6 are reported herein. Frequency and severity of individual DRS-R98 symptoms was very consistent over time even though the majority of patients (80%) experienced fluctuation in symptom severity over the course of hours or minutes. Over time, DRS-R98 items for attention (88-100%), sleep-wake cycle disturbance (90-100%), and any motor disturbance (87-100%), and CTD attention and vigilance were most frequently and consistently impaired. Mixed-effects regression modeling identified only very small magnitudes of change in individual symptoms over time, including the three core domains. SIGNIFICANCE OF RESULTS Attention is disproportionately impaired during the entire episode of delirium, consistent with thalamic dysfunction underlying both an impaired state of consciousness and well-known EEG slowing. All individual symptoms and three core domains remain relatively stable despite small fluctuations in symptom severity for a given day, which supports a consistent state of impaired higher cortical functions throughout an episode of delirium.
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Steis MR, Evans L, Hirschman KB, Hanlon A, Fick DM, Flanagan N, Inouye SK. Screening for delirium using family caregivers: convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method. J Am Geriatr Soc 2012; 60:2121-6. [PMID: 23039310 PMCID: PMC3498543 DOI: 10.1111/j.1532-5415.2012.04200.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To explore agreement between the Family Confusion Assessment Method (FAM-CAM) for delirium identification and interviewer-rated CAM delirium ratings. DESIGN Exploratory analysis of agreement. SETTING Community. PARTICIPANTS Fifty-two family caregivers and 52 elderly adults with preexisting impairment according to standardized cognitive testing. MEASUREMENTS The interviewer-rating for delirium was determined by fulfillment of the CAM algorithm RESULTS The total sample included 52 paired CAM:FAM-CAM assessments completed across 52 dyads of elderly adults with preexisting cognitive impairment and family caregivers. The point prevalence of delirium was 13% (7/52). Characteristics did not differ significantly between the groups with and without delirium. The FAM-CAM questions that mapped directly to the original four-item CAM algorithm had the best overall agreement with the interviewer-rated CAM (kappa = 0.85, 95% confidence interval (CI) = 0.65-1.0), sensitivity of 88% (95% CI = 47-99%), and specificity of 98% (95% CI = 86-100%). CONCLUSION The FAM-CAM is a sensitive screening tool for detection of delirium in elderly adults with cognitive impairment using family caregivers, with relevance for research and clinical practice.
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Affiliation(s)
| | - Lois Evans
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Karen B. Hirschman
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Alexandra Hanlon
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Donna M. Fick
- School of Nursing, The Pennsylvania State University, University Park, Pennsylvania
| | - Nina Flanagan
- Decker School of Nursing, Binghamton University, Binghamton, New York
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
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Steis MR, Shaughnessy M, Gordon SM. Delirium: a very common problem you may not recognize. J Psychosoc Nurs Ment Health Serv 2012; 50:17-20. [PMID: 22694782 DOI: 10.3928/02793695-20120605-05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Older adults with multiple pre-existing conditions are admitted to hospitals with acute illnesses and injuries every day. Delirium is not recognized by clinicians across health care settings. With awareness of risk factors and knowledge of delirium, nurses can play a pivotal role in the early identification, treatment, and, most important, prevention of delirium in older adults. Nurses often display a lack of knowledge related to delirium and the complex symptoms that appear differently in the presence of other complicating co-morbid conditions in aging adults. Nurses play a crucial role in keeping patients safe and ensuring optimal outcomes, regardless of the setting. With the growing population of older adults and the expected increases in chronic illness and dementia, delirium is a problem nurses are likely to experience in all practice settings. Knowing what to look for facilitates recognizing the risk and acting early to minimize (or even prevent) delirium.
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Affiliation(s)
- Melinda R Steis
- Orlando Veterans Affairs Medical Center, Viera, Florida 32940, USA.
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