The incidence and prevalence of delirium across palliative care settings: A systematic review

Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study

Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.

Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice

End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.

Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study

BACKGROUND

Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.

AIM

To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.

DESIGN

A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.

SETTING/PARTICIPANTS

Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years.

RESULTS

A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).

CONCLUSION

The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings.

TRIAL REGISTRY

ISCRTN 97417474.

Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): Feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care

BACKGROUND

Delirium is a complex condition, stressful for all involved. Although highly prevalent in palliative care settings, it remains underdiagnosed and associated with poor outcomes. Guideline-adherent delirium care may improve its detection, assessment and management.

AIM

To inform a future definitive study that tests whether an implementation strategy designed to improve guideline-adherent delirium care in palliative care settings improves patient outcomes (reduced proportion of in-patient days with delirium).

DESIGN

With Patient Involvement members, we conducted a feasibility study to assess the acceptability of and engagement with the implementation strategy by hospice staff (intervention), and whether clinical record data collection of process (e.g. guideline-adherent delirium care) and clinical outcomes (evidence of delirium using a validated chart-based instrument;) pre- and 12-weeks post-implementation of the intervention would be possible.

SETTING/PARTICIPANTS

In-patient admissions in three English hospices.

RESULTS

Between June 2021 and December 2022, clinical record data were extracted from 300 consecutive admissions. Despite data collection during COVID-19, target clinical record data collection (n = 300) was achieved. Approximately two-thirds of patients had a delirium episode during in-patient stay at both timepoints. A 6% absolute reduction in proportion of delirium days in those with a delirium episode was observed. Post-implementation improvements in guideline-adherent metrics include: clinical delirium diagnosis 15%-28%; delirium risk assessment 0%-16%; screening on admission 7%-35%.

CONCLUSIONS

Collection of data on delirium outcomes and guideline-adherence from clinical records is feasible. The signal of patient benefit supports formal evaluation in a large-scale study.

"Beyond Feasibility": A Qualitative Study of Patients, Their Whānau (Family) and Staff Perspectives and Experiences of a Non- Pharmacological Delirium-Prevention Intervention in Two Aotearoa/New Zealand Hospices

CONTEXT

Delirium is prevalent in the hospice population. Despite causing significant distress to patients and families, delirium is under-recognised. There is a need to better understand delirium prevention and outcomes in this population including people's experiences of delirium-prevention strategies in different cultural contexts.

OBJECTIVES

To determine whether the "PRESERVE Aotearoa" delirium prevention intervention was feasible and acceptable for Māori (indigenous peoples of Aotearoa/ New Zealand) and non-Māori patients with advanced cancer, their families (called whānau in this paper), and clinical staff.

METHODS

A qualitative semistructured interview substudy of a cohort PRESERVE Aotearoa feasibility study codesigned with a Māori partner to ensure inclusion of Māori-centred values. The study was underpinned conceptually by He Awa Whiria (braided rivers)-combining Western and Māori knowledges. Data were analysed using Hopwood and Srivasta's framework.

RESULTS

Twenty-six patients and their whānau, 21 clinical staff and five researchers from two stand-alone hospices in the North Island, Aotearoa/New Zealand. Finding showed that, for the most part, participants considered the study interventions feasible and acceptable. Inductive analysis resulted in four themes highlighting the importance to whānau of their participation in the study: benefits of learning about delirium; the affirmation of the caregiver role and whānau-centred care; valuing fundamentals of care; and research as legacy.

CONCLUSION

This qualitative study found that it is feasible and acceptable to study multicomponent nonpharmacological delirium-prevention interventions in Aotearoa/New Zealand hospice inpatient units. The study also highlights the value of Māori-centred approaches and whānau involvement in these settings.

Assessment and management of delirium in a tertiary hospital-Improvements in cognitive screening and use of non-pharmacological strategies with a multidisciplinary approach

OBJECTIVE

This series of audits aimed to determine current best practice in delirium management in a tertiary teaching hospital and to identify strategies to improve the quality of care in delirium with a focus on prevention.

METHODS

We completed a series of audits following the formation of the Cognitive Impairment Reference Group, a multidisciplinary team that was created to implement delirium management guidelines and monitor compliance. Audit 1 focused on antipsychotic use in patients aged 66 years and older. Audit 2 reviewed delirium care in the Acute Medical Ward. Audit 3 included ethnographic data and investigated the use of non-pharmacological methods to prevent and manage delirium in the Geriatric Ward. Two years on, Audit 4 is a repeat of Audit 1.

RESULTS

There were improved rates of cognitive screening between Audits 2 and 3 from 65% n = 40 to 86% n = 102, respectively. Most patients had one form of non-pharmacological strategy in place to prevent delirium however few had a multicomponent approach. Fewer patients were prescribed benzodiazepines alongside antipsychotics 28.57% n = 35 in Audit 1 compared to Audit 4 12.5% n = 32.

CONCLUSIONS

Improved quality of care in delirium management is achievable via a co-ordinated multidisciplinary approach. These audits demonstrated improvements in both rates of cognitive screening, and use of non-pharmacological strategies prior to antipsychotic medication use and better adherence to guidelines for antipsychotic prescribing. Areas for further development in delirium prevention include the uptake of screening and individualised non-pharmacological strategies.

Delirium pathophysiology in cancer: neurofilament light chain biomarker - narrative review

Background Delirium is a debilitating disorder with high prevalence near the end of life, impacting quality of life of patients and their relatives. Timely recognition of delirium can lead to prevention and/or better treatment of delirium. According to current hypotheses delirium is thought to result from aberrant inflammation and neurotransmission, with a possible role for neuronal damage. Neurofilament light chain (NfL) is a protein biomarker in body fluids that is unique to neurons, with elevated levels when neurons are damaged, making NfL a viable biomarker for early detection of delirium. This narrative review summarises current research regarding the pathophysiology of delirium and the potential of NfL as a susceptibility biomarker for delirium and places this in the context of care for patients with advanced cancer.Results Six studies were conducted exclusively on NfL in patients with delirium. Three of these studies demonstrated that high plasma NfL levels preoperatively predict delirium in older adult patients postoperatively. Two studies demonstrated that high levels of NfL in intensive care unit (ICU) patients are correlated with delirium duration and severity. One study found that incident delirium in older adult patients was associated with increased median NfL levels during hospitalisation.Conclusions Targeted studies are required to understand if NfL is a susceptibility biomarker for delirium in patients with advanced cancer. In this palliative care context, better accessible matrices, such as saliva or urine, would be helpful for repetitive testing. Improvement of biological measures for delirium can lead to improved early recognition and lay the groundwork for novel therapeutic strategies.

[Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol]

INTRODUCTION

Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice.

METHODS

A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters.

RESULTS

Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024.

CONCLUSIONS

Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences.

Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients

Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.

Effectiveness of sleep interventions to reduce delirium in critically ill patients: A systematic review and meta-analysis

PURPOSE

To analyze the effectiveness of sleep interventions in reducing the incidence and duration of delirium in the ICU.

MATERIALS AND METHODS

We searched the PubMed, Embase, CINAHL, Web of Science, Scopus, and Cochrane databases for relevant randomized controlled trials from inception to August 2022. Literature screening, data extraction, and quality assessment were performed independently by two investigators. Data from the included studies were analyzed using Stata and TSA software.

RESULTS

Fifteen randomized controlled trials were eligible. Meta-analysis showed that the sleep intervention was associated with a reduced incidence of delirium in the ICU (RR = 0.73, 95% CI = 0.58 to 0.93, p < 0.001) compared to the control group. The results of the trial sequence analysis further confirm that sleep interventions are effective in reducing the occurrence of delirium. Pooled data from the three dexmedetomidine trials showed significant differences in the incidence of ICU delirium between groups (RR = 0.43, 95% CI = 0.32 to 0.59, p < 0.001). The respective pooled results of other sleep interventions (e.g., light therapy, earplugs, melatonin, and multicomponent nonpharmacologic treatments) did not find a significant effect on reducing the incidence and duration of ICU delirium (p > 0.05).

CONCLUSIONS

The current evidence suggests that non-pharmacological sleep interventions are not effective in preventing delirium in ICU patients. However, limited by the number and quality of included studies, future well-designed multicenter randomized controlled trials are still needed to validate the results of this study.

Best Practices in End of Life and Palliative Care in the Emergency Department

Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.

A Core Outcome Set for Interventions to Prevent and/or Treat Delirium in Palliative Care

CONTEXT

Delirium is a serious neurocognitive syndrome which is highly prevalent in people approaching the end of life. Existing trials of interventions to prevent or treat delirium in adults receiving palliative care report heterogeneous outcomes.

OBJECTIVES

To undertake an international consensus process to develop a core outcome set for trials of interventions, designed to prevent and/or treat delirium, for adults receiving palliative care.

METHODS

The core outcome set development process included a systematic review, qualitative interviews, modified Delphi method and virtual consensus meetings using nominal group technique (Registration http://www.comet-initiative.org/studies/details/796). Participants included family members, clinicians, and researchers with experience of delirium in palliative care.

RESULTS

Forty outcomes were generated from the systematic review and interviews informing the Delphi Round one survey. The international Delphi panel comprised 92 participants including clinicians (n = 71, 77%), researchers (n = 13, 14%), and family members (n = 8, 9%). Delphi Round two was completed by 77 (84%) participants from Round one. Following the consensus meetings, four outcomes were selected for the core outcome set: 1) delirium occurrence (incidence and prevalence); 2) duration of delirium until resolution defined as either no further delirium in this episode of care or death; 3) overall delirium symptom profile (agitation, delusions or hallucinations, delirium symptoms and delirium severity); 4) distress due to delirium (person with delirium, and/or family and/or carers [including healthcare professionals]).

CONCLUSION

Using a rigorous consensus process, we developed a core outcome set comprising four delirium-specific outcomes for inclusion in future trials of interventions to prevent and/or treat delirium in palliative care.

Preventing and treating delirium in clinical settings for older adults

Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.

Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused

Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.

Biomarkers of delirium risk in older adults: a systematic review and meta-analysis

Delirium is a neuropsychiatric syndrome associated with increased morbidity and mortality in older patients. The aim of this study was to review predictive biomarkers of delirium in older patients to gain insights into the pathophysiology of this syndrome and provide guidance for future studies. Two authors independently and systematically searched MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases up to August 2021. A total of 32 studies were included. Only 6 studies were eligible for the meta-analysis, pooled results showed a significant increase in some serum biomarkers (C-reactive protein [CRP], tumour necrosis factor alpha [TNF-α] and interleukin-6 [IL-6]) among patients with delirium (odds ratio = 1.88, 95% CI 1.01 to 1.637; I2 = 76.75%). Although current evidence does not favour the use of any particular biomarker, serum CRP, TNF-α, and IL-6 were the most consistent biomarkers of delirium in older patients.

'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

BACKGROUND

Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting.

AIM(S)

To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care.

DESIGN

Qualitative interview study using behaviour change theory from a critical realist stance.

SETTING/PARTICIPANTS

Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices.

RESULTS

We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this.

CONCLUSIONS

Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

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.

Improving Delirium Assessment in Palliative Homecare - A Quality Improvement Project at CanSupport

Objectives

Delirium increases distress in patients and caregivers and often leads to hospitalisation and increased health-care costs. It is early diagnosis and management improves the quality of life (QoL) of advanced cancer patients as well as their families. This quality improvement (QI) project aimed at increasing delirium assessment in poor performance advanced cancer patients receiving palliative homecare.

Material and Methods

The A3 methodology for QI was used. Our SMART goal was to increase the assessment of delirium in poor performance advanced cancer patients from 25% to 50%. The Fishbone and Pareto analysis helped to determine the reasons for low assessment rates. A validated screening tool for delirium assessment was selected and the homecare team doctors and nurses were trained to use it. A flier was designed to help educate families about delirium.

Results

Regular use of the tool helped to increase delirium assessment from an initial 25-50% at the time of project completion. The homecare teams learnt the importance of early delirium diagnosis and the need for regular delirium screening. Family caregivers were empowered through education and use of fliers.

Conclusion

The QI project helped to improve delirium assessment and leading to improved QoL of patients and their caregivers. Regular training and awareness and continued use of a validated screening tool should help to sustain the results.

Palliative care for people with dementia

Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.

Neurological consultations via telemedicine for specialized outpatient palliative care (SOPC) at home and in hospice (TANNE project): study protocol for a randomized controlled trial

BACKGROUND

Neurological diseases cause numerous challenges in palliative care. Telemedicine may improve the access to specialized expertise in neurology for patients, their relatives, and palliative care physicians. The TANNE study offers teleconsultations by a hospital-based neuropalliative center for specialized outpatient palliative care (SOPC) and hospices. A prospective, partially randomized, controlled trial aims at generating evidence for clinical improvements, quality of life, and cost efficiency.

METHODS

SOPC and hospice teams in Bavaria, Germany, are partially randomized to one of two study arms, namely a treatment group with teleconsultations by specialists for neurology and palliative medicine or to a control group with interventions after a 12-months delay. Individual and population-based measures are assessed with a mixed-methods design in order to evaluate the medical effects, the potential for implementation in standard care, and health economic aspects. The primary outcome consists of the mean change difference between groups in the Integrated Palliative Care Outcome Scale (IPOS), which physicians assess before and after treatment of a neurological event. Besides, several secondary outcomes are investigated, including quality of life, which is measured with the revised McGill Quality of Life Questionnaire (McGill QOL-R) as well as items regarding general and health-related quality of life. Further secondary outcomes include the concrete progress of the neurological signs and symptoms; the subjective change in well-being since the start of the treatment of the neurological diseases from the perspectives of patients, their relatives, as well as medical and nursing professionals; as well as patient, professional, and caregiver satisfaction with the teleconsultations. Moreover, a health economic evaluation compares group differences regarding hospital visits and emergency calls with utilization measurements.

DISCUSSION

The TANNE trial provides a comprehensive and complex evaluation design for teleconsultations in neuropalliative care. Ethical considerations need to take the patients' vulnerability into account. The project promises to substantially broaden the width of health care services and to improve the quality of life for deserving patients.

TRIAL REGISTRATION

German Clinical Trials Register ( www.germanctr.de [July 17, 2022], DRKS ID: DRKS00027436. Registered February 10th, 2022, retrospectively registered. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027436 [July 17, 2022].

Delirium: Prevalence and outcome in the very old in 27 medical departments during a one-year prospective study

OBJECTIVE

The prevalence and effects of delirium in very old individuals aged ≥80 years have not yet been systematically evaluated. Therefore, this large single-center study of the one-year prevalence of delirium in 3,076 patients in 27 medical departments of the University Hospital of Zurich was conducted.

METHODS

Patient scores on the Delirium Observation Screening scale, Intensive Care Delirium Screening Checklist, Diagnostic and Statistical Manual, 5th edition, and electronic Patient Assessment-Acute Care (nursing tool) resulted in the inclusion of 3,076 individuals in 27 departments. The prevalence rates were determined by simple logistic regressions, odds ratios (ORs), and confidence intervals.

RESULTS

Of the 3,076 patients, 1,285 (41.8%) developed delirium. The prevalence rates in the 27 departments ranged from 15% in rheumatology (OR = 0.30) to 73% in intensive care (OR = 5.25). Delirious patients were more likely to have been admitted from long-term care facilities (OR = 2.26) or because of emergencies (OR = 2.24). The length of their hospital stay was twice as long as that for other patients. Some died before discharge (OR = 24.88), and others were discharged to nursing homes (OR = 2.96) or assisted living facilities (OR = 2.2).

CONCLUSION

This is the largest study to date regarding the prevalence of delirium in patients aged ≥80 years and the medical characteristics of these patients. Almost two out of five patients developed delirium, with a high risk of loss of independence and mortality.

Exploration of delirium assessment and management in a hospice inpatient unit

Background: Delirium is common across all palliative care settings. Guidelines exist to support the care of terminally ill people who develop delirium; yet the evidence base is limited. Recent surveys of palliative care specialists have suggested clinical practice is variable. Aim: To explore delirium assessment and management in a hospice inpatient setting. Methods: A mixed-methods study comprising a retrospective case note review of 21 patients admitted to a hospice inpatient unit and semi-structured interviews with seven hospice inpatient doctors and nurses. Results: A total of 62% of patients were screened for delirium on admission using the 4 As tool (4AT). The period prevalence of delirium was 76% during the 2-week study period. The term ‘delirium’ was documented infrequently in case notes, compared to other more ambiguous terms. Interview data suggested that nurses were unfamiliar with delirium screening tools. Conclusion: Lack of awareness about delirium screening tools and the infrequent use of the term ‘delirium’ may suggest that delirium goes under-recognised and under-treated. Further education and research are required to support the care of terminally ill people with delirium.

A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study

OBJECTIVE

This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner.

METHODS

This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic.

RESULTS

In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values.

CONCLUSION

Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.

Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study

BACKGROUND

Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials.

AIM

To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'.

DESIGN

A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework.

SETTING/PARTICIPANTS

Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer.

RESULTS

Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention).

CONCLUSION

This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.

Cytokine profiles in intensive care unit delirium

Background

Neuroinflammation causing disruption of the blood-brain barrier and immune cell extravasation into the brain parenchyma may cause delirium; however, knowledge of the exact pathophysiologic mechanism remains incomplete. The purpose of our study was to determine whether cytokine profiles differ depending on whether delirium occurs in the setting of sepsis, coronavirus disease 2019 (COVID-19), or recent surgery.

Methods

This prospective observational cohort study involved 119 critically ill patients admitted to a multidisciplinary intensive care unit (ICU) during 2019 and 2020. Delirium was identified using the validated confusion assessment method for the ICU. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. Serums samples were collected within 12 hours of ICU admission and cytokine levels were measured.

Results:

The following proinflammatory cytokines were elevated in our delirium population: tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-18, C-C motif ligand (CCL) 2, CCL3, C-X-C motif chemokine ligand (CXCL)1, CXCL10, IL-8, IL-1 receptor antagonist, and IL-10. Analysis of relative cytokine levels in those patients that developed delirium in the setting of sepsis, COVID-19, and recent surgery showed elevations of CCL2, CXCL10, and TNF-α in both the sepsis and COVID-19 group in comparison to the postsurgical population. In the postsurgical group, granulocyte colony-stimulating factor was elevated and CXCL10 was decreased relative to the opposing groups.

Conclusions

We identify several cytokines and precipitating factors known to be associated with delirium. However, our study suggests that the cytokine profile associated with delirium is variable and contingent upon delirium precipitating factors.

Proposing a Scientific and Technological Approach to the Summaries of Clinical Issues of Inpatient Elderly with Delirium: A Viewpoint

Background/rationale: Despite mounting evidence about delirium, this complex geriatric syndrome is still not well managed in clinical contexts. The aging population creates a very demanding area for innovation and technology in healthcare. For instance, an outline of an aging-friendly healthcare environment and clear guidance for technology-supported improvements for people at delirium risk are lacking. Objective: We aimed to foster debate about the importance of technical support in optimizing healthcare professional practice and improving the outcomes for inpatients’ at delirium risk. We focused on critical clinical points in the field of delirium worthy of being addressed by a multidisciplinary approach. Methods: Starting from a consensus workshop sponsored by the Management Perfectioning Course based at the Marco Biagi Foundation (Modena, Italy) about clinical issues related to delirium management still not addressed in our healthcare organizations, we developed a requirements’ analysis among the representatives of different disciplines and tried to formulate how technology could support the summaries of the clinical issues. We analyzed the national and international panorama by a PubMed consultation of articles with the following keywords in advanced research: “delirium”, “delirium management”, “technology in healthcare”, and “elderly population”. Results: Despite international recommendations, delirium remains underdiagnosed, underdetected, underreported, and mismanaged in the acute hospital, increasing healthcare costs, healthcare professionals’ job distress, and poor clinical outcomes. Discussion: Although all healthcare professionals recognize delirium as a severe and potentially preventable source of morbidity and mortality for hospitalized older people, it receives insufficient attention in resource allocation and multidisciplinary research. We synthesized how tech-based tools could offer potential solutions to the critical clinical points in delirium management.

Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit

BACKGROUND

Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit.

METHODS

The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach.

RESULTS

Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements.

CONCLUSIONS

Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.

Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): protocol for a co-design and feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care

INTRODUCTION

Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection.

METHODS AND ANALYSIS

Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate.

ETHICS AND DISSEMINATION

Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN55416525.

The Dilemma of Treating Delirium: the Conundrum of Drug Management

OPINION STATEMENT

Delirium is a common medical complication in people living with cancer, particularly with more advanced disease. Delirium is associated with significant symptom burden which causes distress and impacts quality of life. As recommended by international guidelines, a high degree of suspicion is needed to ensure delirium is detected early. Attention to collateral history can provide clues to changes in cognition and attention. Non-pharmacological approaches that can be considered essential elements of care are effective in reducing the risk of delirium. Delirium screening using a validated measure is recommended as even expert clinicians can underdiagnose or miss delirium. The diagnostic assessment requires consideration of the cancer diagnosis and comorbidities, in the context of potential reversibility, goals of care, and patient preferences. The gold standard approach based on expert consensus is to institute management for delirium precipitants supported by non-pharmacological essential care, with the support of an interdisciplinary team. Medication management should be used sparingly and for a limited period of time wherever possible for severe perceptual disturbance or agitation which has not improved with non-pharmacological approaches. Clinicians should be familiar with the registered indication for medications and seek informed consent for off-label use. All interventions put in place to manage delirium need to consider net clinical benefit, including harms such as sedation and loss of capacity for meaningful interaction. Clear communication and explanation are needed regularly, with the person with delirium as far as possible and with surrogate decision makers. Delirium can herald a poor prognosis and this needs to be considered and be discussed as appropriate in shared decision-making. Recall after delirium has resolved is common, and opportunity to talk about this experience and the related distress should be offered during the period after recovery.

Palliative care for patients with advanced dementia

ABSTRACT

Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older adults globally. Its final stages are complicated by a multitude of problems that can cause immense suffering. This article explores the interconnection between advanced dementia and palliative care and the role of nurses in providing end-of-life care for these patients.

Risk factors for delirium in adult patients receiving specialist palliative care: A systematic review and meta-analysis

BACKGROUND

Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.

AIM

To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.

DESIGN

Systematic review and meta-analysis (PROSPERO CRD42019157168).

DATA SOURCES

CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.

RESULTS

Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.

POTENTIALLY MODIFIABLE RISK FACTORS

Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).

NON-MODIFIABLE RISK FACTORS

Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.

CONCLUSIONS

Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

The detection of delirium in admitted oncology patients: a scoping review

Aim

To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting.

Findings

Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias.

Message

In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00586-1.

Purpose

Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients.

Methods

MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection.

Results

Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality.

Conclusion

The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00586-1.

Delirium in Critically Ill Cancer Patients With COVID-19

BACKGROUND

COVID-19 has been a devastating pandemic with little known of its neuropsychiatric complications. Delirium is one of the most common neuropsychiatric syndromes among hospitalized cancer patients with incidence ranging from 25% to 40% and rates of up to 85% in the terminally ill. Data on the incidence, risk factors, duration, and outcomes of delirium in critically ill cancer patients with COVID-19 are lacking.

OBJECTIVE

To report the incidence, risks and outcomes of critically ill cancer patients who developed COVID-19.

METHODS

This is a retrospective single-center study evaluating delirium frequency and outcomes in all critically ill cancer patients with COVID-19 admitted between March 1 and July 10, 2020. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit, performed twice daily by trained intensive care unit (ICU) nursing staff. Patients were considered to have a delirium-positive day if Confusion Assessment Method for Intensive Care Unit was positive at least once per day.

RESULTS

A total of 70 patients were evaluated. Of those 70, 53 (75.7%) were found to be positive for delirium. Patients with delirium were significantly older than patients without delirium (median age 67.5 vs 60.3 y, P = 0.013). There were no significant differences in demographic characteristics, chronic medical conditions, neuropsychiatric history, cancer type, or application of prone positioning between the 2 groups. Delirium patients were less likely to receive cancer-directed therapies (58.5% vs 88.2%, P = 0.038) but more likely to receive antipsychotics (81.1% vs 41.2%, P = 0.004), dexmedetomidine (79.3% vs 11.8%, P < 0.001), steroids (84.9% vs 58.8%, P = 0.039), and vasopressors (90.6% vs 58.8%, P = 0.006). Delirium patients were more likely to be intubated (86.8% vs 41.2%, P < 0.001), and all tracheostomies (35.9%) occurred in patients with delirium. ICU length of stay (19 vs 8 d, P < 0.001) and hospital length of stay (37 vs 12 d, P < 0.001) were significantly longer in delirium patients, but there was no statistically significant difference in hospital mortality (43.4% vs 58.8%, P = 0.403) or ICU mortality (34.0% vs 58.8%, P = 0.090).

CONCLUSIONS

Delirium in critically ill cancer patients with COVID-19 was associated with less cancer-directed therapies and increased hospital and ICU length of stay. However, the presence of delirium was not associated with an increase in hospital or ICU mortality.

Personalized sedation goal for agitated delirium in patients with cancer: Balancing comfort and communication

BACKGROUND

Agitated delirium is common and highly distressing. Medications are often needed to reduce agitation, but it is unclear what the desired level of sedation is. This study assessed personalized sedation goals (PSGs) and their predictors for patients in a delirium clinical trial and in clinical vignettes.

METHODS

This was a preplanned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated delirium. At the baseline, caregivers and nurses were independently asked to select the PSG for the trial patient from 5 choices corresponding to Richmond Agitation Sedation Scale (RASS) scores of 0 or higher (no sedation), -1 to -2, -3, -4, and -5 (deep sedation). Respondents also selected a PSG for 6 vignettes that differed by the level of agitation, ability to communicate, and survival.

RESULTS

Forty-two caregivers and 39 nurses answered questions regarding PSGs. For the trial patient, caregivers preferred RASS scores of -1 to -2 most often (36%), whereas nurses preferred an RASS score of -3 most often (51 %). Caregivers were significantly more likely than nurses to choose lighter sedation (odds ratio [OR], 4.8; P = .01) despite reporting greater delirium-related distress (P = .0006). Patients were undersedated 33% to 53% of the time and oversedated 0% to 15% of the time according to the PSG response criteria. In the case vignettes, deeper sedation was preferred by nurses (P < .0001) and for patients who were unable to communicate (OR, 3.1-4.4; P < .0001) and had a shorter life expectancy (OR, 1.7; P = .002).

CONCLUSIONS

Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' PSGs, and this highlights room for improvement.

LAY SUMMARY

In the last days of life, many patients with cancer develop delirium and become restless/agitated; this can be highly distressing. Caregivers and physicians alike are often concerned about the use of sedatives for agitated delirium and try to find a balance between maximizing comfort and maintaining communication. This study examined the concept of a personalized sedation goal for setting an individualized target for the level of sedation. Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' stated goals, and this highlights room for improvement.

Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review

BACKGROUND

Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement.

AIM

To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions.

DESIGN

Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions.

RESULTS

From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life.

CONCLUSION

The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Evaluation and Management of Delirium

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

Clinicians' delirium treatment practice, practice change, and influences: A national online survey

BACKGROUND

Recent studies cast doubt on the net effect of antipsychotics for delirium.

AIM

To investigate the influence of these studies and other factors on clinicians' delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework.

DESIGN

Australia-wide online survey of relevant clinicians.

SETTING/PARTICIPANTS

Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals' organisations.

RESULTS

Most of the sample (n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents' delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001).

CONCLUSION

Clinicians' use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.

Effect of hypertension and medication use regularity on postoperative delirium after maxillofacial tumors radical surgery

The incidence of postoperative delirium (POD) after maxillofacial tumors radical surgery is relatively high. There are a number of evidences showing the relationship between hypertension and decreased cerebral blood flow, as well as the relationship between cerebral ischemia and postoperative cognitive impairment. However, the impact of hypertension in the process of POD and related mechanisms remain unclear.

This study included 98 elderly patients who underwent maxillofacial tumors radical surgery in our hospital, from June 2020 to December 2020. We collected the general condition of patients and related research factors before surgery, and also collected related intraoperative factors. After that, we would follow up the patients for POD evaluation.

The incidence of POD in the hypertension group was 41%, compared with 12% in the nonhypertension group (P < 0.05). The incidence of POD in the irregular medication group was 62%, compared with 26% in the regular medication group (P < 0.05). Both hypertension (OR = 2.45, 95% CI = 1.11–5.72) and irregular medication use (OR = 2.35, 95% CI = 0.87–5.69) were independent risk factors for POD after this type of surgery in elderly patients.

Hypertension and medication use regularity are closely related to POD. This may be related to the delayed postoperative response caused by intraoperative cerebral ischemia.

Factors for Timely Identification of Possible Occurrence of Delirium in Palliative Care: A Prospective Observational Study

Delirium occurs in 50–80% of end-of-life patients but is often misdiagnosed. Identification of clinical factors potentially associated with delirium onset can lead to a correct early diagnosis. To this aim, we conducted a prospective cohort study on patients from an Italian palliative care unit (PCU) admitted in 2018–2019. We evaluated the presence of several clinical factors at patient admission and compared their presence in patients who developed delirium and in those who did not develop it during follow-up. Among 503 enrolled patients, after a median follow-up time of 16 days (interquartile range 6–40 days), 95 (18.9%) developed delirium. Hazard ratios (HR) and corresponding 95% confidence intervals were computed using Cox proportional hazard models. In univariate analyses, factors significantly more frequent in patients with delirium were care in hospice, compromised performance status, kidney disease, fever, renal failure, hypoxia, dehydration, drowsiness, poor well-being, breathlessness, and “around the clock” therapy with psychoactive drugs, particularly haloperidol. In multivariate analyses, setting of care (HR 2.28 for hospice versus home care, 95% CI 1.45–3.60; p < 0.001), presence of breathlessness (HR 1.71, 95% CI 1.03–2.83, p = 0.037), and administration of psychoactive drugs, particularly haloperidol (HR 2.17 for haloperidol, 95% CI 1.11–4.22 and 1.53 for other drugs, 95% CI 0.94–2.48; p = 0.048) were significantly associated with the risk of developing delirium. The study indicates that some clinical factors are associated with the probability of delirium onset. Their evaluation in PC patients could help healthcare professionals to identify the development of delirium in those patients in a timely manner.

Symptom trajectories for palliative care inpatients with and without hyperactive delirium in the last week of life

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.

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients

Purpose

The aim of this study is to establish the prevalence, associated factors, and clinical impact of delirium in newly referred palliative care patients and the percentage of delirium diagnoses missed by primary medical teams.

Methods

Newly referred palliative care patients were evaluated and were reviewed for possible associated factors of delirium. Univariable and multivariable analysis were used to identify associated factors. Median overall survival and survival curves were analyzed. The percentage of missed diagnosis in IPD patients was identified.

Results

We included 350 palliative care patients. Nearly all patients had cancer diagnosis (96.6%). The overall prevalence of delirium was 44.0%. The independent associated factors of delirium were age ≥ 63 years (adjusted odds ratio [aOR], 7.0; 95% CI, 2.2–22.9), palliative performance scale ≤ 20% (aOR, 54.5; 95% CI, 13.1–228.0), brain metastasis (aOR, 15.6; 95% CI, 3.7–66.7), urinary tract infection (aOR, 18.8; 95% CI, 4.7–75.5), sepsis (aOR, 59.0; 95% CI, 4.4–797.8), hyponatremia (aOR, 8.8; 95% CI, 2.6–29.8), and hypercalcemia (not applicable). Interestingly, opioids and benzodiazepines were not associated with delirium. Delirious patients had significantly shorter survival (median survival 11 days). Delirium diagnoses were missed for 76.1%.

Conclusion

Nearly half of the palliative care patients had delirium, which was associated with noticeably short survivals. We identified the independent factors associated with the delirium. Despite having a remarkably high prevalence rate and being a well-known poor prognostic factor, there was still a very high rate of missed delirium diagnoses. Effective, routine, delirium screening of palliative care patients needs to be emphasized.

Association among rescue neuroleptic use, agitation, and perceived comfort: secondary analysis of a randomized clinical trial on agitated delirium

BACKGROUND

Few studies have examined how the use of rescue medications could be used to inform on the efficacy of interventions in delirium clinical trials. The objective of this study was to determine the association among rescue medication use, Richmond Agitation-Sedation Scale (RASS), and perceived comfort by the nurses and caregivers.

METHODS

This was a pre-planned secondary analysis of a double-blind, randomized clinical trial comparing the use of a single dose of lorazepam plus haloperidol versus placebo plus haloperidol in patients with agitated delirium. Rescue medications were considered the gold standard for this analysis. The optimal cutoff for RASS analysis was calculated by using general linear regression models and determining the area of the curve and using the top left approach. We used 2 × 2 tables to examine the association between rescue medication use and perceived comfort.

RESULTS

Fifty-eight patients received the study medications and 52 (89%) completed the 8-h observation period. There were 26 (50%) patients in each arm. The lorazepam/haloperidol arm required fewer rescue doses (4/26 (15%)) vs. 16/26 (62%), p = 0.004). Patients with a greater initial RASS reduction required fewer rescue doses. The cutoff value for RASS improvement was 4 points, area under the curve (AUC) 0.64 (95% CI 0.49-0.79) for those who required no rescue doses, and 3 points, AUC 0.74 (95% CI 0.52-0.96) for those who required more than one rescue dose.

CONCLUSIONS

Rescue medication use was responsive to change and associated with both RASS scores and perceived patient comfort by the nurse and caregiver.

The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis

BACKGROUND

Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting.

AIM

To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts.

DESIGN

Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417).

DATA SOURCES

The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers.

RESULTS

A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care.

CONCLUSIONS

Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.

Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study

CONTEXT

Delirium is a highly distressing neurocognitive disorder for patients at the end of life.

OBJECTIVES

To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life.

METHODS

Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium.

RESULTS

Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05).

CONCLUSION

In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.

Associations Between Hospice Care and Scary Family Caregiver Experiences

CONTEXT

Hospice deaths in the U.S. are increasing. Dying hospice patients may have rapidly emerging needs the hospice team cannot immediately meet, exposing family caregivers to fright-inducing (i.e., scary) situations.

OBJECTIVES

To examine relationships between hospice care and family caregiver exposures and psychological responses to witnessing common and distressing patient symptoms near the end of life.

METHODS

Secondary analysis of prospective cohort study of 169 patients with advanced cancer and their family caregivers was analyzed. Multivariable regression analyses modeled associations between hospice use and caregiver exposures and psychological responses (fear and helplessness) to witnessing distressing symptoms common near death, adjusting for potential confounding influences (e.g., home death, patient characteristics, and suffering). Caregiver self-reported exposures and responses to observing patient symptoms during the last month of life were assessed using the validated Stressful Caregiving Response to Experiences of Dying (SCARED) scale.

RESULTS

Hospice care was significantly positively associated with more exposures and negative psychological responses to distressing patient symptoms, adjusting for home death, patient characteristics, and physical and mental suffering. On average, hospice patients' caregivers scored 1.6 points higher on the SCARED exposure scale and 6.2 points higher on the SCARED psychological response scale than caregivers of patients without hospice (exposure: 10.53 vs. 8.96; psychological responses: 29.85 vs. 23.67). Patient pain/discomfort, delirium, and difficulty swallowing/choking were reported by three-fourths of caregivers and associated with the most fear and helplessness among caregivers.

CONCLUSION

Hospice care is associated with more exposures to and caregiver fear and helplessness in response to scary patient experiences. Research is needed to understand how better to support family caregivers of hospice patients to enable them to cope with common distressing symptoms of dying cancer patients. Hospice clinicians providing additional education and training about these symptoms might enable caregivers to better care for dying loved ones and reduce the stresses of end-of-life caregiving.

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]

BACKGROUND

Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients.

METHODS

240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium.

DISCUSSION

The findings will inform clinical practice regarding delirium assessment in palliative care settings.

TRIAL REGISTRATION

ISRCTN ISRCTN97417474 (21/02/2020).