JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

Concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer: A multicenter, retrospective, observational study

OBJECTIVES

There is concern that hydroxyzine exacerbates delirium, but a recent preliminary study suggested that the combination of haloperidol and hydroxyzine was effective against delirium. This study examined whether the concomitant use of hydroxyzine and haloperidol worsened delirium in patients with cancer.

METHODS

This retrospective, observational study was conducted at 2 general hospitals in Japan. The medical records of patients with cancer who received haloperidol for delirium from July to December 2020 were reviewed. The treatments for delirium included haloperidol alone or haloperidol combined with hydroxyzine. The primary outcome was the duration from the first day of haloperidol administration to the resolution of delirium, defined as its absence for 2 consecutive days. The time to delirium resolution was analyzed to compare the haloperidol group and hydroxyzine combination group using the log-rank test with the Kaplan-Meier method. Secondary outcomes were (1) the total dose of antipsychotic medications, including those other than haloperidol (measured in chlorpromazine-equivalent doses), and (2) the frequencies of detrimental incidents during delirium, specifically falls and self-removal of drip infusion lines. The unpaired t-test and Fisher's exact test were used to analyze secondary outcomes.

RESULTS

Of 497 patients who received haloperidol, 118 (23.7%) also received hydroxyzine. No significant difference in time to delirium resolution was found between the haloperidol group and the hydroxyzine combination group (log-rank test, P = 0.631). No significant difference between groups was found in either chlorpromazine-equivalent doses or the frequency of detrimental incidents.

SIGNIFICANCE OF RESULTS

This study showed that the concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer.

Risk Factors for Postoperative Delirium in Patients Undergoing Major Head and Neck Cancer Surgery: A Meta-analysis

BACKGROUND

Postoperative delirium (POD) is a common and serious complication after extensive surgery. Understanding the independent and potential modifiable risk factors leading to POD in patients with head and neck cancer (HNC) can provide information for future intervention trials aimed at reducing this risk.

OBJECTIVE

To systematically analyze influencing factors of POD in patients with HNC and identify high-risk individuals for delirium.

METHODS

PubMed, EMBASE, Scopus, OVID, and Cochrane Library were searched for publications prior to June 2023. Comparative studies in which POD risk factors were investigated were identified following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Newcastle-Ottawa Scale was used to evaluate the study quality. Pooled odds ratios or mean differences for individual risk factors were estimated using the Mantel-Haenszel and inverse-variance methods.

RESULTS

This review included 17 studies with a total of 4188 patients undergoing HNC surgery. The pooled prevalence of POD was 15.44%. Based on pooled analysis, 8 significant risk factors were identified including age older than 70 years, male sex, history of smoking, history of psychiatric disorder, American Society of Anesthesiologists score, albumin level, postoperative insomnia, and fluid intake.

CONCLUSION

In the present study, 8 factors that correlated with POD were identified: 6 preoperative, 1 intraoperative, and 1 postoperative.

IMPLICATIONS FOR PRACTICE

The influencing factors for POD in patients with HNC were identified that can provide a reference for improving the psychological state of the patient population and further development of effective treatment interventions.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

OBJECTIVE

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements.

RESULTS

This article provides a compendium of the recommendations along with their rationales, as well as a short summary.

CONCLUSIONS

These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Efficacy of blonanserin transdermal patch on terminal delirium in patients with respiratory diseases

BACKGROUND

Delirium is a common distressing symptom observed in patients with terminal respiratory diseases and is treated with antipsychotic medications such as haloperidol. Its management is difficult, especially in palliative home care, because its administration is limited to oral or injection methods. Recently, the blonanserin transdermal patch was developed as the first antipsychotic percutaneous agent. After it became available, we recognized its potential for the management of delirium and the alleviation of uncontrolled dyspnea in clinical practice. Thus, this study aimed to assess its efficacy in patients with terminal respiratory diseases.

METHODS

This retrospective study included 113 patients with respiratory diseases who were cared for at home. The efficacy was evaluated through the prevalence of terminal delirium before and after its treatment initiation for uncontrolled dyspnea.

RESULTS

Blonanserin transdermal patch treatment for uncontrolled dyspnea improved the prevalence and severity of terminal delirium (from 70.4% to 16.3%, p < 0.001) and reduced the number of doctors' visits to patients' homes within a week before their death (from 4.0 to 3.0, p = 0.086). A sub-group analysis of 23 patients with interstitial pneumonia revealed that the treatment prevented dyspnea progression by inhibiting terminal delirium.

CONCLUSIONS

Blonanserin transdermal patch performed similarly to haloperidol, as previously reported, for managing terminal delirium. Our study suggests that a blonanserin transdermal patch potentially prevents terminal delirium and alleviates uncontrolled dyspnea in patients with respiratory diseases. Our findings encourage clinical trials to evaluate the safety and efficacy of blonanserin transdermal patches for patients with terminal illnesses.

Influence of dosing pattern of antipsychotics on treatment outcome of delirium in patients with advanced cancer

BACKGROUND

Clinical guidelines recommend antipsychotics for the treatment of delirium; however, there has been no confirmed recommendation regarding their administrating patterns. This study aims to investigate whether different dosing patterns of antipsychotics (single or multiple administrations) influence the outcomes of delirium treatment.

METHODS

This is a secondary analysis of a prospective observational study involving patients with advanced cancer and delirium receiving antipsychotics. The Delirium Rating Scale Revised-98 was administered at baseline and after 72 h of starting pharmacotherapy. Patients were classified into single administration group (received a single dosage within 24 h before the assessment) and multiple administration group (received more than one dosage).

RESULTS

A total of 555 patients (single administration 492 (88.6%); multiple administration 63 (11.4%)) were subjected to analyses. The patients in the multiple administration group were more likely to be male, in psycho-oncology consulting settings, with lower performance status, with hyperactive delirium and with severer delirium symptoms. In the multivariate analysis, single administration was significantly associated with better improvement of delirium (p < 0.01, 95% confidence interval: 1.83-5.87) even after controlling covariates. There were no significant differences in the mean dosages of antipsychotics per day in chlorpromazine equivalent (single administration 116.8 mg/day, multiple administration 123.5 mg/day) and the incidence of adverse events between the two groups.

CONCLUSIONS

In this observational study sample, Delirium Rating Scale severity score improvement in single administration was higher than that seen in multiple administration. There was no difference in adverse events between the two groups.

Physicians' Beliefs and Attitudes Toward Hypoactive Delirium in The Last Days of Life

CONTEXT

The perspective toward hypoactive delirium in the last days of life could be different among physicians.

OBJECTIVES

To clarify the attitudes, beliefs, and opinions of palliative care physicians and liaison psychiatrists toward hypoactive delirium in the last days of life and to explore the association among these factors.

METHODS

A nationwide cross-sectional questionnaire survey was conducted among 1667 physicians who were either certified palliative care specialists or liaison psychiatrists. Physicians' agreement with the appropriateness of pharmacological management (e.g., antipsychotics) (one item), their beliefs (11 items), and their opinions (four items) were measured.

RESULTS

787 (47%) physicians responded. 481 (62%) agreed to use of medications for hypoactive delirium in the last days of life, whereas 296 (38.1%) disagreed. More than 95% agreed with "hypoactive delirium at the end of life can be considered as a part of natural dying process." Multivariate analysis identified two belief subscales of "hypoactive delirium at the end of life is a natural dying process" and "antipsychotics are futile and harmful in managing hypoactive delirium" had a significant negative correlation with the use of medications. On the other hand, one belief subscale of "hypoactive delirium can be distressing even if patients' consciousness is impaired" had significant positive correlations with the use of medications.

CONCLUSION

Pharmacological management of hypoactive delirium in the last days of life differs depending on physicians' beliefs. Future research is needed to clarify the efficacy and safety of pharmacological management of hypoactive delirium.

An association between cancer type and delirium incidence in Japanese elderly patients: A retrospective longitudinal study

OBJECTIVE

There is not a known elevated prevalence of delirium in older adult cancer patients. However, it is unknown if the incidence of delirium varies by cancer type among older adult patients. Therefore, this study aimed to examine the association between the incidence of delirium and cancer type among older adult patients using a Japanese hospital-based administrative claims database.

METHODS

A total of 76,868 patients over 65 years of age or older, first diagnosed with cancer on an initial date of hospitalization between April 2008 and December 2019, were included in this retrospective longitudinal study. Delirium was defined by the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes or antipsychotic medication use. Cox proportional hazard models were performed to estimate the risk of delirium incidence according to 22 cancer types during the one-year hospitalization period.

RESULTS

The incidence rates of delirium were 17.1% for men and 15.3% for women. Compared to gastric cancer, the risk of delirium was significantly higher for pancreatic cancer (HR: 1.26, 95% CI: 1.11-1.42 for men; HR: 1.27, 95% CI: 1.11-1.45 for women), leukemia (HR: 1.24, 95% CI: 1.09-1.41 for men; HR: 1.20, 95% CI: 1.03-1.41 for women), and oropharyngeal cancer (HR: 1.30, 95% CI: 1.10-1.54 for men; HR: 1.32; 95% CI: 1.02-1.72 for women) after adjusting for age, initial hospitalization year, antipsychotic medications, and surgery.

CONCLUSIONS

As compared to gastric cancer, patients with pancreatic cancer, leukemia, oropharyngeal cancer were found to have a higher risk of developing delirium. Our study findings suggested that the risk of delirium incidence may vary by cancer type.

Association of Antipsychotic Dose With Survival of Advanced Cancer Patients With Delirium

CONTEXT

Delirium is common in patients with advanced cancer, and antipsychotics are widely used for its management.

OBJECTIVES

We aimed to explore the association of the antipsychotic dose with survival of terminally ill cancer patients with delirium.

METHODS

A secondary analysis of a multicenter prospective observational study was conducted. We enrolled adult advanced cancer patients who developed delirium and received antipsychotics at 14 palliative care units in Japan between September 2015 and May 2016. Hazard ratios of survival after starting antipsychotics between groups with different oral chlorpromazine equivalent doses: low: <100 mg, moderate: 100-200 mg, high: ≥200 mg, were calculated with adjustment for potential confounders using Cox regression. The antipsychotic dose-specific mortality risk was estimated with smooth splines.

RESULTS

Of 453 patients enrolled, 422 patients were analyzed. The median antipsychotic dose was 92.6 mg: low-dose (N = 231), moderate-dose (122), and high-dose (69). The median survival of all patients was 11 days. Compared with the low-dose group, the high-dose group showed a significantly shorter survival (HR: 1.46, 95%CI: 1.08-1.98). Smooth splines demonstrated that HR continuously increased as the antipsychotic dose increased. In patients treated with atypical antipsychotics, the high-dose group showed a significantly shorter survival than the low-dose group (HR: 2.86), while in patients treated with typical antipsychotics, survival was not significantly different (0.99).

CONCLUSIONS

Higher doses of antipsychotics were associated with increased mortality in terminally ill cancer patients with delirium. To minimize the potential mortality risk, antipsychotics should be started at low doses and titrated carefully.