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Dai Y, Walpole G, Ding J, Scanlon C, Ho L, Khoo RH, Huang C, Cook A, William L, Johnson CE. Symptom trajectories for palliative care inpatients with and without hyperactive delirium in the last week of life. J Adv Nurs 2021; 78:142-153. [PMID: 34252213 DOI: 10.1111/jan.14966] [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] [Received: 01/11/2021] [Revised: 05/04/2021] [Accepted: 06/15/2021] [Indexed: 11/28/2022]
Abstract
AIMS Hyperactive delirium (HD) is a common and distressing symptom among palliative care patients. This study aimed to describe the characteristics of HD and associated symptoms among palliative care inpatients and evaluate relationships between HD development and symptom trajectories in this population. DESIGN A retrospective study was conducted. METHODS A retrospective review of medical records was conducted for all patients who died in a large Australian specialist palliative care unit between 1 January and 31 December 2019. Patients were assessed daily using the Symptoms Assessment Scale (SAS) and Palliative Care Problem Severity Scale (PCPSS). Multilevel models were used to estimate the differences in symptoms trajectories in the last 7 days of life between the two groups. RESULTS Of the 501 included patients, 64.5% (323) had an episode of HD. For 30% (95) of patients, HD occurred prior to admission. Compared with patients without HD, those with HD had significantly higher odds ratios (ORs) for four of the seven SAS symptoms (sleep problems, appetite, fatigue and pain; OR range: 1.94-4.48, p < .05), and all four PCPSS items (OR range: 2.00-3.00, p < .05) in the last week of life. CONCLUSIONS Palliative care inpatients commonly experience HD in their last week of life. There are higher levels of symptom distress, complexity, psychological concerns and family/carer concerns among patients with HD compared with those without HD. IMPACT The high prevalence of HD, and its association with higher levels of symptom distress, highlights the importance of routine screening and optimal management for HD among palliative care patients. Given the widely recognized challenges facing palliative care professionals in assessment and management of delirium, provision of relevant training among these professionals is recommended.
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Affiliation(s)
- Yunyun Dai
- School of Nursing, Guilin Medical University, Guilin, China
| | - Grace Walpole
- Supportive and Palliative Care Service, Eastern Health, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Cian Scanlon
- Supportive and Palliative Care Service, Eastern Health, Melbourne, VIC, Australia
| | - Luke Ho
- Supportive and Palliative Care Service, Eastern Health, Melbourne, VIC, Australia
| | - Ru Hui Khoo
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Chongmei Huang
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Angus Cook
- Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Leeroy William
- Supportive and Palliative Care Service, Eastern Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,Public Health Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Claire E Johnson
- Supportive and Palliative Care Service, Eastern Health, Melbourne, VIC, Australia.,Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia.,Monash Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
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2
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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.
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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.
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3
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Sampson EL, West E, Fischer T. Pain and delirium: mechanisms, assessment, and management. Eur Geriatr Med 2020; 11:45-52. [PMID: 32297242 DOI: 10.1007/s41999-019-00281-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Pain and delirium are common problems for older people. Both conditions are prevalent in acute hospital settings. In people living in the community, delirium often precipitates presentation to the emergency department. Pain and delirium are known to interact in a complex and multidirectional way. This can make it challenging for staff to recognize and treat pain in people with delirium. METHODS This paper aims to explore the complex relationship between pain and delirium and on pain assessment in delirium, drawing together evidence from a range of settings including acute medical, cardiac and orthopaedic post-operative cohorts, as well as from aged care. RESULTS A limited number of studies suggest there is an association between pain and delirium; however, this is a complex, particularly where analgesics which may-themselves cause delirium are prescribed. Factors acting on the pathway between pain and delirium may include depression, sleep deprivation and disturbance of the cholinergic system. Delirium affects the ability to self-report pain. The fluctuating nature of delirium as well as reduced awareness and attention may challenge practitioners in recognizing, assessing and treating pain. Evidence concerning the reliability and validity of current observational and self-assessment tools in people with delirium is unclear but some show promise in this population. CONCLUSION The current evidence base regarding assessing pain in people with delirium is lacking. Tentative recommendations, drawing on current guidelines require robust testing. Guidelines for people with pain and dementia require adaptations regarding the unique characteristics of delirium. The complex interplay between dementia, pain and delirium warrants further investigation across a range of settings.
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Affiliation(s)
- Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
- Barnet Enfield, Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK.
| | - Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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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: 101] [Impact Index Per Article: 20.2] [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.
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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
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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.
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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
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Puntillo K, Naidu RK. Measurement of Chronic Pain and Opioid Use Evaluation in Community-Based Persons with Serious Illnesses. J Palliat Med 2018; 21:S43-S51. [PMID: 29091525 PMCID: PMC5756460 DOI: 10.1089/jpm.2017.0457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic pain associated with serious illnesses is having a major impact on population health in the United States. Accountability for high quality care for community-dwelling patients with serious illnesses requires selection of metrics that capture the burden of chronic pain whose treatment may be enhanced or complicated by opioid use. OBJECTIVE Our aim was to evaluate options for assessing pain in seriously ill community dwelling adults, to discuss the use/abuse of opioids in individuals with chronic pain, and to suggest pain and opioid use metrics that can be considered for screening and evaluation of patient responses and quality care. DESIGN Structured literature review. MEASUREMENTS Evaluation of pain and opioid use assessment metrics and measures for their potential usefulness in the community. RESULTS Several pain and opioid assessment instruments are available for consideration. Yet, no one pain instrument has been identified as "the best" to assess pain in seriously ill community-dwelling patients. Screening tools exist that are specific to the assessment of risk in opioid management. Opioid screening can assess risk based on substance use history, general risk taking, and reward-seeking behavior. CONCLUSIONS Accountability for high quality care for community-dwelling patients requires selection of metrics that will capture the burden of chronic pain and beneficial use or misuse of opioids. Future research is warranted to identify, modify, or develop instruments that contain important metrics, demonstrate a balance between sensitivity and specificity, and address patient preferences and quality outcomes.
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Affiliation(s)
- Kathleen Puntillo
- Department of Nursing, University of California, San Francisco, San Francisco, California
| | - Ramana K. Naidu
- Division of Pain Medicine, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
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Mah K, Rodin RA, Chan VWS, Stevens BJ, Zimmermann C, Gagliese L. Health-Care Workers’ Judgments About Pain in Older Palliative Care Patients With and Without Delirium. Am J Hosp Palliat Care 2016; 34:958-965. [DOI: 10.1177/1049909116672641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Delirium complicates pain assessment and management in advanced cancer. This retrospective cohort study compared health-care workers’ (HCWs) cancer pain judgments between older patients with advanced cancer with and without a diagnosis of delirium. We reviewed HCWs’ daily chart notations about pain presence and good pain control in 149 inpatients with advanced cancer, ≥65 years of age, admitted to a palliative care inpatient unit. Any day with 1 or more notations of pain presence was counted as 1 day with pain; days with notation(s) indicating good pain control were similarly counted. Proportions of days that HCWs judged inpatients to have pain and good pain control were calculated. Patients with and without a delirium diagnosis were compared on both pain outcomes. The moderating effect of highest analgesic class administered was examined. Although most patients received opioid analgesics, mean proportions of days with judged pain were high (39%-60%) and mean proportions of days with judged good pain control were low (<25%) across groups. Among patients receiving either opioid or nonopioid medication, patients with delirium demonstrated lower proportions of days with judged good pain control than patients without delirium ( P ≤ .001), even though groups did not differ in proportions of days with judged pain ( P = .62). Cancer pain is difficult to manage in advanced cancer, especially when delirium is present; however, misinterpretation of delirium symptoms as pain cues may inflate pain judgments. Findings require replication but suggest the need for better pain assessment in older patients with advanced cancer and delirium.
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Affiliation(s)
- Kenneth Mah
- Department of Anesthesia and Pain Management, Toronto General Hospital (K.M., R.A.R., and L.G.) and Toronto Western Hospital (V.W.S.C.), University Health Network, Toronto, Ontario, Canada
- Department of Supportive Care, Research Division, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Kenneth Mah and Rebecca A. Rodin contributed equally to this work and should be regarded as co-first authors
| | - Rebecca A. Rodin
- Department of Anesthesia and Pain Management, Toronto General Hospital (K.M., R.A.R., and L.G.) and Toronto Western Hospital (V.W.S.C.), University Health Network, Toronto, Ontario, Canada
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Kenneth Mah and Rebecca A. Rodin contributed equally to this work and should be regarded as co-first authors
| | - Vincent W. S. Chan
- Department of Anesthesia and Pain Management, Toronto General Hospital (K.M., R.A.R., and L.G.) and Toronto Western Hospital (V.W.S.C.), University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bonnie J. Stevens
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Research Division, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucia Gagliese
- Department of Anesthesia and Pain Management, Toronto General Hospital (K.M., R.A.R., and L.G.) and Toronto Western Hospital (V.W.S.C.), University Health Network, Toronto, Ontario, Canada
- Department of Supportive Care, Research Division, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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