1
|
Abe H, Sumitani M, Matsui H, Inoue R, Fushimi K, Uchida K, Yasunaga H. Association between hospital palliative care team intervention volume and patient outcomes. Int J Clin Oncol 2024:10.1007/s10147-024-02574-4. [PMID: 38913218 DOI: 10.1007/s10147-024-02574-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/19/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND The benefits of palliative care in patients with advanced cancer are well established. However, the effect of the skills of the palliative care team (PCT) on patient outcomes remains unclear. Our aim was to evaluate the association between hospital PCT intervention volume and patient outcomes in patients with cancer. METHODS A retrospective cohort study was conducted using a nationwide inpatient database in Japan. Patients with cancer receiving chemotherapy and PCT intervention from 2015 to 2020 were included. The outcomes were incidence of hyperactive delirium within 30 days of admission, mortality within 30 days of admission, and decline in activities of daily living (ADL) at discharge. The exposure of interest was hospital PCT intervention volume (annual number of new PCT interventions in a hospital), which was categorized into low-, intermediate-, and high-volume groups according to tertiles. Multivariate logistic regression and restricted cubic-spline regression were conducted. RESULTS Of 29,076 patients, 1495 (5.1%), 562 (1.9%), and 3026 (10.4%) developed delirium, mortality, and decline in ADL, respectively. Compared with the low hospital PCT intervention volume group (1-103 cases/year, n = 9712), the intermediate (104-195, n = 9664) and high (196-679, n = 9700) volume groups showed significant association with lower odds ratios of 30-day delirium (odds ratio, 0.79 [95% confidence interval, 0.69-0.91] and 0.80 [0.69-0.93], respectively), 30-day mortality (0.73 [0.60-0.90] and 0.59 [0.46-0.75], respectively), and decline in ADL (0.77 [0.70-0.84] and 0.52 [0.47-0.58], respectively). CONCLUSION Hospital PCT intervention volume is inversely associated with the odds ratios of delirium, mortality, and decline in ADL among hospitalized patients with cancer.
Collapse
Affiliation(s)
- Hiroaki Abe
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
2
|
Tavares T, Almeida J, Gonçalves E, Abelha F. Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review. J Palliat Med 2024. [PMID: 38770684 DOI: 10.1089/jpm.2023.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Teresa Tavares
- Palliative Care Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Almeida
- Orthopedics and Traumatology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Edna Gonçalves
- Palliative Care Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Fernando Abelha
- Anesthesiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| |
Collapse
|
3
|
Kruize Z, van Campen I, Vermunt L, Geerse O, Stoffels J, Teunissen C, van Zuylen L. Delirium pathophysiology in cancer: neurofilament light chain biomarker - narrative review. BMJ Support Palliat Care 2024:spcare-2024-004781. [PMID: 38290815 DOI: 10.1136/spcare-2024-004781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
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.
Collapse
Affiliation(s)
- Zita Kruize
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Isa van Campen
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lisa Vermunt
- Department of Laboratory medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Olaf Geerse
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Josephine Stoffels
- Department of Internal Medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Charlotte Teunissen
- Department of Laboratory medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Allan L, O'Connell A, Raghuraman S, Bingham A, Laverick A, Chandler K, Connors J, Jones B, Um J, Morgan-Trimmer S, Harwood R, Goodwin VA, Ukoumunne OC, Hawton A, Anderson R, Jackson T, MacLullich AMJ, Richardson S, Davis D, Collier L, Strain WD, Litherland R, Glasby J, Clare L. A rehabilitation intervention to improve recovery after an episode of delirium in adults over 65 years (RecoverED): study protocol for a multi-centre, single-arm feasibility study. Pilot Feasibility Stud 2023; 9:162. [PMID: 37715277 PMCID: PMC10503099 DOI: 10.1186/s40814-023-01387-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Delirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible. METHODS The study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants' own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals. DISCUSSION Findings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care. TRIAL REGISTRATION The feasibility study was registered: ISRCTN15676570.
Collapse
Affiliation(s)
- Louise Allan
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Abby O'Connell
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Shruti Raghuraman
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alison Bingham
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Abigail Laverick
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Kirstie Chandler
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - James Connors
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Benjamin Jones
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jinpil Um
- University of Exeter Medical School, University of Exeter, Exeter, UK.
| | | | - Rowan Harwood
- School of Health Sciences, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Victoria A Goodwin
- Department of Ageing and Rehabilitation, University of Exeter, Exeter, UK
| | - Obioha C Ukoumunne
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter, EX1 2LU, UK
| | - Annie Hawton
- Health Economics Group, University of Exeter Medical School, Exeter, UK
| | - Rob Anderson
- Exeter HS&DR Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Thomas Jackson
- Institute of Inflammation and Ageing, University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WD, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing and Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah Richardson
- AGE Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Lesley Collier
- Faculty of Health and Well-Being, University of Winchester, Winchester, SO22 4NR, UK
| | - William David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5AX, UK
| | | | - Jon Glasby
- School of Social Policy, University of Birmingham, Birmingham, UK
| | - Linda Clare
- University of Exeter Medical School, University of Exeter, Exeter, UK
| |
Collapse
|
5
|
Stevens E, Scott EME. Delirium Among Patients With Cancer in the Intensive Care Unit: Prognostic Sign or Opportunity for Intervention. JCO Oncol Pract 2023:OP2300061. [PMID: 37075269 DOI: 10.1200/op.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Affiliation(s)
- Erin Stevens
- Division of Palliative Medicine, The Ohio State University, Columbus, OH
- Department of Internal Medicine, The Ohio State University, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Erin M E Scott
- Division of Palliative Medicine, The Ohio State University, Columbus, OH
- Department of Internal Medicine, The Ohio State University, Columbus, OH
| |
Collapse
|
6
|
Oya K, Morita T, Tagami K, Matsuda Y, Naito AS, Kashiwagi H, Otani H. Physicians' Beliefs and Attitudes Toward Hypoactive Delirium in The Last Days of Life. J Pain Symptom Manage 2022; 64:110-118. [PMID: 35490994 DOI: 10.1016/j.jpainsymman.2022.04.176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 12/31/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kiyofumi Oya
- Peace Home Care Clinic, Otsu, (K.O,) Shiga, Japan; Clinical Research Support Office, (K.O., T.M) Iizuka Hospital, Iizuka-shi, Fukuoka, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, (T.M.) Shizuoka Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai, (K.T.) Miyagi, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, (Y.M.) Osaka, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care, Miyazaki Medical Association Hospital, Miyazaki-shi, (A.S.N.) Miyazaki, Japan
| | - Hideyuki Kashiwagi
- Department of Transitional and Palliative Care, Iizuka Hospital, Iizuka-shi, (H.K.) Fukuoka, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Mitami-ku, (H.O.) Fukuoka Japan
| |
Collapse
|
7
|
Intervention of Coordination by Liaison Nurse Where Ward Staff Struggled to Establish a Therapeutic Relationship with a Patient Because of Failure to Recognize Delirium: A Case Study. Healthcare (Basel) 2022; 10:healthcare10071335. [PMID: 35885860 PMCID: PMC9319112 DOI: 10.3390/healthcare10071335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022] Open
Abstract
In this case study, ward staff found it difficult to establish a therapeutic relationship with a patient with advanced gastric cancer because they misdiagnosed delirium as a psychogenic reaction to the cancer diagnosis. This article reports on the process and effects of intervention by a liaison nurse. The liaison nurse recognized the misdiagnosis and approached the ward staff via a psychiatrist-led team. This enabled rapid revision of the treatment policy. The liaison nurse contributed to the continuation of treatment by enabling the ward staff and patient to understand each other better and to collaborate to build a relationship and control the patient’s mental health symptoms, including attention disorder and excessive demands. The patient and family had different views on discharge because of the patient’s mental health issues. The liaison nurse encouraged the ward staff to inform the family caregiver about the patient’s medical condition, the expected future course of the disease, and likely symptoms, and provide appropriate professional services. This enabled the patient to be discharged in line with their wishes. This case highlights the role of the liaison nurse in coordinating care and helping ward staff to recognize symptoms and provide appropriate care and support for patients and their families.
Collapse
|
8
|
Arbabi M, Ziaei E, Amini B, Ghadimi H, Rashidi F, Shohanizad N, Moradi S, Beikmarzehei A, Hasanzadeh A, Parsaei A. Delirium risk factors in hospitalized patient: a comprehensive evaluation of underlying diseases and medications in different wards of a large Urban Hospital Center in Iran. BMC Anesthesiol 2022; 22:147. [PMID: 35578181 PMCID: PMC9109388 DOI: 10.1186/s12871-022-01690-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is a neurobehavioral syndrome, which is characterized by a fluctuation of mental status, disorientation, confusion and inappropriate behavior, and it is prevalent among hospitalized patients. Recognizing modifiable risk factors of delirium is the key point for improving our preventive strategies and restraining its devastating consequences. This study aimed to identify and investigate various factors predisposing hospitalized patients to develop delirium, focusing mostly on underlying diseases and medications. METHOD In a prospective, observational trial, we investigated 220 patients who had been admitted to the internal, emergency, surgery and hematology-oncology departments. We employed the Confusion Assessment Method (CAM) questionnaire, The Richmond Agitation Sedation Scale (RASS), the General Practitioner Assessment of Cognition (GPCOG), demographic questionnaire, patient interviews and medical records. Multivariate logistic regression models were used to analyze the predictive value of medications and underlying diseases for daily transition to delirium.; demographics were analyzed using univariate analysis to identify those independently associated with delirium. RESULTS Two hundred twenty patients were enrolled; the emergency department had the most incident delirium (31.3%), and the surgery section had the least (2.4%); delirium was significantly correlated with older ages and sleep disturbance. Among multiple underlying diseases and the medications evaluated in this study, we found that a history of dementia, neurological diseases and malignancies increases the odds of transition to delirium and the use of anticoagulants decreases the incident delirium. CONCLUSION Approximately 1 out of 10 overall patients developed delirium; It is important to evaluate underlying diseases and medications more thoroughly in hospitalized patients to assess the risk of delirium.
Collapse
Affiliation(s)
- Mohammad Arbabi
- Brain & Spinal Cord Injury Research Centre, Tehran University of Medical Sciences, Tehran, Iran.,Psychosomatic Medicine Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Ziaei
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Behnam Amini
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Hamidreza Ghadimi
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Fatemeh Rashidi
- Faculty of Medicine, Tehran University of Medical Science, Tehran, Iran
| | | | - Soroush Moradi
- Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Jalal Street, Tehran, 1411713139, Iran
| | | | | | - Amirhossein Parsaei
- Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Jalal Street, Tehran, 1411713139, Iran.
| |
Collapse
|
9
|
Abe H, Sumitani M, Matsui H, Inoue R, Konishi M, Fushimi K, Uchida K, Yasunaga H. Gabapentinoid Use Is Associated With Reduced Occurrence of Hyperactive Delirium in Older Cancer Patients Undergoing Chemotherapy: A Nationwide Retrospective Cohort Study in Japan. Anesth Analg 2022; 135:362-369. [PMID: 35560025 DOI: 10.1213/ane.0000000000006093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is unclear whether gabapentinoids affect the development of delirium. We aimed to determine the association between gabapentinoid use and hyperactive delirium in older cancer patients undergoing chemotherapy. METHODS We conducted propensity score-matched analyses using data from a nationwide inpatient database in Japan. We included cancer patients with pain ≥70 years of age undergoing chemotherapy between April 2016 and March 2018. Patients receiving gabapentinoids were matched with control patients using propensity scores. The primary outcome was occurrence of hyperactive delirium during hospitalization, and the secondary outcomes were length of hospital stay, in-hospital fractures, and in-hospital mortality. Hyperactive delirium was identified by antipsychotic use or discharge diagnoses from the International Classification of Diseases, 10th Revision. RESULTS Among 143,132 identified patients (59% men; mean age, 76.3 years), 14,174 (9.9%) received gabapentinoids and 128,958 (90.1%) did not (control group). After one-to-one propensity score matching, 14,173 patients were included in each group. The occurrence of hyperactive delirium was significantly lower (5.2% vs 8.5%; difference in percent, -3.2% [95% confidence interval, -3.8 to -2.6]; odds ratio, 0.60 [0.54-0.66]; P < .001), the median length of hospital stay was significantly shorter (6 days [interquartile range, 3-15] vs 9 days [4-17]; subdistribution hazard ratio, 1.22 [1.19-1.25]; P < .001), and the occurrence of in-hospital mortality was significantly lower in the gabapentinoid group than in the control group (1.3% vs 1.8%; difference in percent, -0.6% [-0.9 to -0.3]; odds ratio, 0.69 [0.57-0.83]; P < .001). Gabapentinoid use was not significantly associated with the occurrence of in-hospital fractures (0.2% vs 0.2%; difference in percent, 0.0% [-0.1 to 0.1]; odds ratio, 1.07 [0.65-1.76]; P = .799). The results of sensitivity analyses using stabilized inverse probability of treatment weighting were consistent with the results of the propensity score-matched analyses. CONCLUSIONS Our findings suggest that gabapentinoid use is associated with reduced hyperactive delirium in older cancer patients undergoing chemotherapy, with no evidence of an increase in the fracture rate, length of hospital stay, or in-hospital death.
Collapse
Affiliation(s)
- Hiroaki Abe
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Mitsuru Konishi
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
10
|
Mayer RS, Engle J. Rehabilitation of Individuals With Cancer. Ann Rehabil Med 2022; 46:60-70. [PMID: 35508925 PMCID: PMC9081390 DOI: 10.5535/arm.22036] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 01/02/2023] Open
Abstract
The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.
Collapse
Affiliation(s)
- Robert Samuel Mayer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica Engle
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
11
|
Abe H, Sumitani M, Matsui H, Inoue R, Fushimi K, Uchida K, Yasunaga H. Use of naldemedine is associated with reduced incidence of hyperactive delirium in cancer patients with opioid-induced constipation: a nationwide retrospective cohort study in Japan. Pharmacotherapy 2021; 42:241-249. [PMID: 34967450 DOI: 10.1002/phar.2658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/10/2021] [Accepted: 11/24/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Medical benefits of peripherally-acting mu-opioid receptor antagonists other than improving opioid-induced constipation remain unclear. Our aim was to evaluate the association between the use of naldemedine and incidence of hyperactive delirium in cancer patients receiving chemotherapy and opioid therapy. METHODS We conducted a propensity score-matched analysis using a nationwide inpatient database in Japan. Cancer patients receiving both inpatient chemotherapy and opioid therapy from June 1, 2017 to March 31, 2018 were included. Patients receiving naldemedine were matched to control patients by propensity score. Our primary outcome was the incidence of hyperactive delirium during hospitalization, and secondary outcomes were the length of hospital stay, hospital costs, in-hospital mortality, and incidence of ileus. RESULTS Of 34,031 patients receiving inpatient chemotherapy and opioid therapy, 1905 (5.6%) were included in the naldemedine group. After one-to-four propensity score matching, 1904 patients were included in the naldemedine group and 7616 in the control group. Naldemedine users had significantly reduced incidence of hyperactive delirium compared with the control patients (19.4% vs 23.3%; risk difference, -3.9 [95% confidence interval, -5.9 - -1.9]; risk ratio, 0.83 [0.75-0.92]; P<0.001; subdistribution hazard ratio, 0.85 [0.75-0.97]; P=0.015). The median length of hospital stay was significantly shorter in the naldemedine group compared with the control group (12 days [interquartile range, 6-23] vs 14 days [6-26]; P=0.001). The median hospital costs were also significantly lower in the naldemedine group compared with the control group (US $6179 [3351-10,026] vs US $6576 [3436-11,107]; P<0.001). No significant differences were found for in-hospital mortality or incidence of ileus between the groups. CONCLUSIONS Our findings suggest that the use of naldemedine may have benefits in preventing hyperactive delirium, shortening hospital stay, and decreasing hospital costs in cancer patients receiving chemotherapy and opioid therapy.
Collapse
Affiliation(s)
- Hiroaki Abe
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
12
|
A decision tree prediction model for a short-term outcome of delirium in patients with advanced cancer receiving pharmacological interventions: A secondary analysis of a multicenter and prospective observational study (Phase-R). Palliat Support Care 2021; 20:153-158. [DOI: 10.1017/s1478951521001565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective
There is no widely used prognostic model for delirium in patients with advanced cancer. The present study aimed to develop a decision tree prediction model for a short-term outcome.
Method
This is a secondary analysis of a multicenter and prospective observational study conducted at 9 psycho-oncology consultation services and 14 inpatient palliative care units in Japan. We used records of patients with advanced cancer receiving pharmacological interventions with a baseline Delirium Rating Scale Revised-98 (DRS-R98) severity score of ≥10. A DRS-R98 severity score of <10 on day 3 was defined as the study outcome. The dataset was randomly split into the training and test dataset. A decision tree model was developed using the training dataset and potential predictors. The area under the curve (AUC) of the receiver operating characteristic curve was measured both in 5-fold cross-validation and in the independent test dataset. Finally, the model was visualized using the whole dataset.
Results
Altogether, 668 records were included, of which 141 had a DRS-R98 severity score of <10 on day 3. The model achieved an average AUC of 0.698 in 5-fold cross-validation and 0.718 (95% confidence interval, 0.627–0.810) in the test dataset. The baseline DRS-R98 severity score (cutoff of 15), hypoxia, and dehydration were the important predictors, in this order.
Significance of results
We developed an easy-to-use prediction model for the short-term outcome of delirium in patients with advanced cancer receiving pharmacological interventions. The baseline severity of delirium and precipitating factors of delirium were important for prediction.
Collapse
|
13
|
Wu J, Gao S, Zhang S, Yu Y, Liu S, Zhang Z, Mei W. Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia. Perioper Med (Lond) 2021; 10:3. [PMID: 33531068 PMCID: PMC7856719 DOI: 10.1186/s13741-020-00174-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022] Open
Abstract
Background Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery. Methods RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD. Results Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]). Conclusions Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.
Collapse
Affiliation(s)
- Jiayi Wu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shaojie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shuang Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yao Yu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhiguo Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
| |
Collapse
|
14
|
Delirium Rates in Advanced Cancer Patients Admitted to Different Palliative Care Settings: Does It Make the Difference? J Palliat Med 2020; 23:1227-1232. [DOI: 10.1089/jpm.2019.0414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
15
|
Vidal M, Rodriguez-Nunez A, Hui D, Allo J, Williams JL, Park M, Liu D, Bruera E. Place-of-death preferences among patients with cancer and family caregivers in inpatient and outpatient palliative care. BMJ Support Palliat Care 2020; 12:e501-e504. [DOI: 10.1136/bmjspcare-2019-002019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 11/04/2022]
Abstract
ObjectiveMeeting the preferences of patients is considered an important palliative care outcome. Prior studies reported that more than 80% of patients with terminally ill cancer prefer to die at home. The purpose of this study was to determine place-of-death preference among palliative care patients in the outpatient centre and the palliative care unit (PCU) of a comprehensive cancer centre.MethodsA cross-sectional anonymous questionnaire was administered to patients with advanced cancer and caregivers (PCU and outpatient centre) between August 2012 and September 2014. PCU patients responded when there was no delirium and the primary caregiver responded when the patient was unable to respond. In the case of outpatients, dyads were assessed. The survey was repeated 1 month later.ResultsOverall, 65% preferred home death. There was less preference for home death among PCU patients (58%) than among outpatients (72%). Patient and caregiver agreement regarding preferred place of death for home was 86%. After 1 month, outpatients were significantly more likely than PCU patients to have the same preferred place of death as they had 1 month earlier (96% vs 83%; p=0.003).ConclusionsAlthough home was the preferred place of death in our group of patients with advanced cancer and their caregivers, a substantial minority preferred hospital death or had no preference. We speculate that PCU patients’ higher preference for hospital death is likely related to more severe distress because they had already tried home care. Personalised assessment of place of death preference for both patient and caregiver is needed.
Collapse
|
16
|
Mercadante S, Masedu F, Maltoni M, De Giovanni D, Montanari L, Pittureri C, Bertè R, Russo D, Ursini L, Marinangeli F, Aielli F. Symptom expression in advanced cancer patients admitted to hospice or home care with and without delirium. Intern Emerg Med 2019; 14:515-520. [PMID: 30334235 DOI: 10.1007/s11739-018-1969-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
The aim of this study is to investigate the relationship between delirium and symptom expression in advanced cancer patients admitted to palliative care services. This is a secondary analysis of a consecutive sample of advanced cancer patients who were admitted to home care and hospices, and prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after seven days of home care or hospice care (T7). Of the eight hundred and forty-eight patients screened in the period, 585 were not considered in the analysis for various reasons. The mean age was 72.1 years (SD 13.7), and 146 patients were males (55.5%). The mean Karnofsky status recorded at T0 is 34.1 (SD = 6.69). The mean duration palliative care assistance is 38.4 days (SD = 48, range 2-220). Of 263 patients who had a MDAS available at T0, 110 patients (41.8%) had a diagnosis of delirium. Of them, 167 patients had complete data regarding MDAS measurement, either at T0 and T7. A larger number of patients (n 167, 63.5%) had delirium after a week of palliative care. Patients with delirium are likely to be older, to have a lower Karnofsky level at T0, and to be home care patients. At T0, weakness, nausea, drowsiness, lack of appetite, and well-being are associated with delirium. At T7, weakness, poor appetite, and poor well-being are significantly associated with delirium. 27% of patients who had a normal cognitive status at T0 developed delirium at T7. In patients with delirium, an improvement in the cognitive status corresponds to a significant improvement in weakness, depression, and appetite. Conversely, the occurrence of delirium in patients who had a normal cognitive status at admission significantly increases the level depression, while the level of weakness and appetite decrease. Symptom expression is amplified in patients with delirium admitted to home care or hospices, while patients without delirium can be more responsive to palliative treatments with a significant decrease in intensity of ESAS items.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain relief and supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90145, Palermo, Italy.
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | | | | | | | - Raffaella Bertè
- Palliative Care, Oncology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01, Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Franco Marinangeli
- Anesthesiology and Pain Medicine, Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| |
Collapse
|
17
|
The Patient with Difficult Cancer Pain. Cancers (Basel) 2019; 11:cancers11040565. [PMID: 31010249 PMCID: PMC6521083 DOI: 10.3390/cancers11040565] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 11/17/2022] Open
Abstract
Most patients with cancer pain can be managed with relatively simple methods using oral analgesics at relatively low doses, even for prolonged periods of time. However, in some clinical conditions pain may be more difficult to manage. Various factors can interfere with a desirable and favorable analgesic response. Data from several studies assessing factors of negative pain prognosis have indicated that neuropathic pain, incident pain, psychological distress, opioid addiction, and baseline pain intensity were associated with more difficult pain control. In this narrative review, the main factors that make the therapeutic response to opioids difficult are examined.
Collapse
|
18
|
Stefanczyk-Sapieha L, Fainsinger RL. Hepatocellular Carcinoma: Misdiagnosis or Spontaneous Remission? J Palliat Care 2019. [DOI: 10.1177/082585970802400108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Robin L. Fainsinger
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
19
|
Nadimi F, Currow DC. Transitions in Parenting Responsibilities for Sole Parents who are Dying. J Palliat Care 2019. [DOI: 10.1177/082585970802400306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fariba Nadimi
- Southern Adelaide Palliative Services, Repatriation General Hospital, Daw Park, South Australia
| | - David C. Currow
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
20
|
Matuoka JY, Kurita GP, Nordly M, Sjøgren P, de Mattos-Pimenta CA. Validation of a Battery of Neuropsychological Tests for Patients With Metastatic Cancer. Clin Nurs Res 2019; 29:607-615. [PMID: 30793636 DOI: 10.1177/1054773819831210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate the psychometric properties of Trail Making Test (TMT), Continuous Reaction Time (CRT), Finger Tapping Test (FTT), Digit Span Test (DST), and Mini-Mental State Examination (MMSE) in Brazilian patients with metastatic cancer. Cognitive performance of 178 patients with metastatic cancer and 79 controls was assessed using the TMT, CRT, FTT, DST, and MMSE. Discriminant validity, concurrent validity, and reliability (39 patients were retested after 3-7 days) were investigated. Discriminant validity between groups was observed in TMT, DST, and MMSE. Measures of concurrent validity and cognitive performance were positively correlated with physical performance, education level, and better performance on MMSE. Negative correlations were observed between cognitive function, pain, anxiety, and depression. All tests but FTT demonstrated very good reliability. Thus, all neuropsychological tests but FTT showed psychometric properties that permit their use in clinical and research purposes in patients with metastatic cancer.
Collapse
Affiliation(s)
| | | | - Mie Nordly
- Rigshospitalet Copenhagen University Hospital, Denmark
| | - Per Sjøgren
- Rigshospitalet Copenhagen University Hospital, Denmark.,University of Copenhagen, Denmark
| | | |
Collapse
|
21
|
Okuyama T, Yoshiuchi K, Ogawa A, Iwase S, Yokomichi N, Sakashita A, Tagami K, Uemura K, Nakahara R, Akechi T. Current Pharmacotherapy Does Not Improve Severity of Hypoactive Delirium in Patients with Advanced Cancer: Pharmacological Audit Study of Safety and Efficacy in Real World (Phase-R). Oncologist 2019; 24:e574-e582. [PMID: 30610009 DOI: 10.1634/theoncologist.2018-0242] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pharmacotherapy is generally recommended to treat patients with delirium. We sought to describe the current practice, effectiveness, and adverse effects of pharmacotherapy for hypoactive delirium in patients with advanced cancer, and to explore predictors of the deterioration of delirium symptoms after starting pharmacotherapy. SUBJECTS, MATERIALS, AND METHODS We included data of patients with advanced cancer who were diagnosed with hypoactive delirium and received pharmacotherapy for treatment of delirium. This was a pharmacovigilance study characterized by prospective registries and systematic data-recording using internet technology, conducted among 38 palliative care teams and/or units. The severity of delirium and other outcomes were assessed using established measures at days 0 (T0), 3 (T1), and 7 (T2). RESULTS Available data were obtained from 218 patients. The most frequently used agent was haloperidol (37%). A total of 67 and 42 patients (31% and 19%) had died or discontinued pharmacotherapy by T1 and T2, respectively. Delirium symptoms deteriorated between T0 and T1, but this trend did not reach statistical significance. The most prevalent adverse event was sedation (9%). Delirium severity worsened after starting pharmacotherapy in 121 patients (56%) at T1. In patients whose death was expected within a few days and those with delirium caused by organ failure, symptoms of delirium were significantly more likely to deteriorate after starting pharmacotherapy. CONCLUSION Current pharmacotherapy for hypoactive delirium in patients with advanced cancer is not recommended, especially in those whose death is expected within a few days and in those with delirium caused by organ failure. IMPLICATIONS FOR PRACTICE Delirium is common among patients with advanced cancer, and hypoactive delirium is the dominant motor subtype in the palliative care setting. Pharmacotherapy is recommended and regularly used to treat delirium. This article describes the effectiveness and adverse effects of pharmacotherapy for hypoactive delirium in patients with advanced cancer. The findings of this study do not support the use of pharmacotherapy for treatment of hypoactive delirium in the palliative care setting. Pharmacotherapy should especially be avoided in patients whose death is expected within a few days and in those with delirium caused by organ failure.
Collapse
Affiliation(s)
- Toru Okuyama
- Division of Psycho-Oncology and Palliative Care, Nagoya City University Hospital, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Asao Ogawa
- Department of Psycho-Oncology Service, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Satoru Iwase
- Department of Palliative Medicine, Saitama Medical University, Morohongo Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Naosuke Yokomichi
- Seirei Hospice, Seirei Mikatahara General Hospital, Mikatahara-cho, kita-ku, Hamamatsu, Shizuoka, Japan
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kusunoki-cho, chuoh-ku, Kobe, Hyogo, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Keiichi Uemura
- Department of Psychiatry, Hokkaido Medical Center, Yamanote, Nishi-ku, Sapporo, Hokkaido, Japan
| | - Rika Nakahara
- Department of Psycho-Oncology, National Cancer Center Hospital, Tsukiji, Chuou-ku, Tokyo, Japan
| | - Tatsuo Akechi
- Division of Psycho-Oncology and Palliative Care, Nagoya City University Hospital, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| |
Collapse
|
22
|
Nishioka M, Okuyama T, Uchida M, Aiki S, Ito Y, Osaga S, Imai F, Akechi T. What is the appropriate communication style for family members confronting difficult surrogate decision-making in palliative care?: A randomized video vignette study in medical staff with working experiences of clinical oncology. Jpn J Clin Oncol 2019; 49:48-56. [PMID: 30508206 DOI: 10.1093/jjco/hyy178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background The family members of terminally ill patients are often requested to make difficult surrogate decisions during palliative care. This study sought to clarify the appropriate communication style for physicians as perceived by family members confronting difficult surrogate decision-making. Methods This experimental psychological study used scripted videos. In the videos, the physician described treatment options including continuous deep sedation to the family members of patients with cancer and terminal delirium using an autonomous or paternalistic style. Medical professionals with clinical experience in oncology were randomly assigned to either group viewing the videos. The primary outcomes were physician compassion, decisional conflict and emotion scores. We also evaluated the communication style preference. Results In total, 251 participants completed this study. Although participants in both groups reported high physician compassion, participants in the autonomous style group reported lower compassion scores (reflecting higher physician compassion) (mean 15.0 vs. 17.3, P = 0.050), lower decisional conflicts scores (51.1 vs. 56.8, P = 0.002) and comparable emotions compared with those in the paternalistic style group. Seventy-six percent of participants preferred the autonomous style. Conclusions Regarding difficult surrogate decision-making, the autonomous style might be more appropriate than the paternalistic style. However, various factors, such as family members' communication style preferences, family members' values, physician-family relationships and ethnic cultures, should be considered.
Collapse
Affiliation(s)
- Masahiro Nishioka
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Toru Okuyama
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Sayo Aiki
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Department of Palliative Care, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan.,Department of Palliative Medicine, Higashi-Osaka Hospital, Chuo, Joto-ku, Osaka, Japan
| | - Yoshinori Ito
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Satoshi Osaga
- Clinical Research Management Center, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Fuminobu Imai
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| |
Collapse
|
23
|
Abstract
Emergency department (ED) use is a quality-of-care indicator for community-based end-of-life (EOL) care. This study examined ED use by EOL home care clients. The sample included all EOL home care clients who received care from one community care access centre in Ontario, Canada. Information on health was gathered using the interRAI instrument for palliative care. Data were collected between May 2009 and January 2010. The sample included 93 home care clients. Results showed that 35 percent of clients used the ED within 45 days of assessment. Multivariate analysis identified two determinants of ED use: excessive weight loss and previous hospitalization. Managing terminal illness is often a difficult task, and comprehensive, ongoing assessment of clients’ changing status is critical. Client care and service planning for clients who have lost excessive amounts of weight or who have been recently hospitalized need to be monitored closely to prevent any future avoidable ED use.
Collapse
Affiliation(s)
- Peter Brink
- P Brink (corresponding author) Department of Public Health, Lakehead University, 955 Oliver Road, Thunder Bay, Ontario, Canada P7B 5E1
| | - Lorraine Partanen
- North West Community Care Access Centre, Thunder Bay, Ontario, Canada
| |
Collapse
|
24
|
Hui D, De La Cruz M, Bruera E. Palliative Care for Delirium in Patients in the Last weeks of Life: The Final Frontier. J Palliat Care 2018. [DOI: 10.1177/082585971403000403] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, Texas, USA 77030
| | - Maxine De La Cruz
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
25
|
Hui D, Reddy A, Palla S, Bruera E. Neuroleptic Prescription Pattern for Delirium in Patients with Advanced Cancer. J Palliat Care 2018. [DOI: 10.1177/082585971102700210] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Neuroleptics are frequently used by palliative care specialists to treat delirium. In this study, we determined the median daily neuroleptic dose and prescription pattern in a cohort of unselected advanced cancer in-patients with delirium. Methods: We retrospectively reviewed the charts of 100 consecutive patients admitted to our acute palliative care unit with delirium for demographics, delirium characteristics, and neuroleptic use during the first five days of delirium. The dose of neuroleptics was expressed using the concept of haloperidol equivalent daily dose (HEDD). Results: The median delirium duration was six days, and the median Memorial Delirium Assessment Scale on day 1 was 13/30. Subtypes of delirium in cluded hypoactive (31 percent), mixed (59 percent), and hyperactive (10 percent). Haloperidol, olanzapine, and chlorpromazine were given to 94 (94 percent), 8 (8 percent), and 5 (5 percent) of patients, respectively. The median five-day average HEDD was 3.2 mg (interquartile range 1.5–6.0 mg). HEDD was not associated with any clinical characteristics except delirium subtype. Among the 31 occasions in which ≥3 breakthrough doses were given in a day, only 9 (29 percent) resulted in an increase in the scheduled neuroleptic dose, and 1 (3 percent) resulted in the addition of a new neuroleptic the next day. Among the 73 patients with ≥4 days of delirium, only 49 (67 percent) had an increase in the neuroleptic dose, and 2 (3 percent) had a new neuroleptic added. Conclusion: HEDD was lower than doses reported in previous studies involving cancer patients and was adjusted sparingly. Prospective clinical trials are necessary to identify the optimal neuroleptic dose for delirium.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative Care and Rehabilitation, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Shana Palla
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- E Bruera (corresponding author) Department of Palliative Care and Rehabilitation, Medicine Unit 1414, 1515 Holcombe Boulevard, Houston, Texas, USA 77030
| |
Collapse
|
26
|
Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication. Curr Opin Support Palliat Care 2018; 12:489-494. [PMID: 30239384 PMCID: PMC6261485 DOI: 10.1097/spc.0000000000000395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW To provide an evidence-based synopsis on the role of benzodiazepines in patients with agitated delirium. RECENT FINDINGS Existing evidence supports the use of benzodiazepines in two specific delirium settings: persistent agitation in patients with terminal delirium and delirium tremens. In the setting of terminal delirium, the goal of care is to maximize comfort, recognizing that patients are unlikely to recover from their delirium. A recent randomized trial suggests that lorazepam in combination with haloperidol as rescue medication was more effective than haloperidol alone for the management of persistent restlessness/agitation in patients with terminal delirium. In patients with refractory agitation, benzodiazepines may be administered as scheduled doses or continuous infusion for palliative sedation. Benzodiazepines also have an established role in management of delirium secondary to alcohol withdrawal. Outside of these two care settings, the role of benzodiazepine remains investigational and clinicians should exercise great caution because of the risks of precipitating or worsening delirium and over-sedation. SUMMARY Benzodiazepines are powerful medications associated with considerable risks and benefits. Clinicians may prescribe benzodiazepines skillfully by selecting the right medication at the right dose for the right indication to the right patient at the right time.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, USA
| |
Collapse
|
27
|
Mercadante S, Adile C, Ferrera P, Cortegiani A, Casuccio A. Symptom Expression in Patients with Advanced Cancer Admitted to an Acute Supportive/Palliative Care Unit With and Without Delirium. Oncologist 2018; 24:e358-e364. [PMID: 30355776 DOI: 10.1634/theoncologist.2018-0244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 09/18/2018] [Indexed: 11/17/2022] Open
Abstract
AIM The aim of this study was to investigate the relationship between delirium and symptom expression in patients with advanced cancer admitted to an acute supportive/palliative care unit (ASPCU). METHODS A consecutive sample of patients with advanced cancer who were admitted to an ASPCU was prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after 7 days of palliative care (T7). RESULTS Two hundred forty-six patients had complete data regarding MDAS measurements, at either T0 and T7. Of these, 75 (30.5%) and 63 patients (25.6%) had delirium at T0 and after a week of palliative care (T7), with a decrease in the frequency of delirium of 4.9% (from 30.5% to 25.6%); that means that 16% of patients with delirium improved their cognitive status after initiation of palliative care. Intensities of pain, depression, poor well-being, and global ESAS were significantly higher in patients with delirium. Patients who did not have delirium at T0 but developed delirium during admission after 1 week of palliative care had a higher level of symptom expression for pain, weakness, nausea, anxiety, dyspnea, appetite, and consequently global ESAS. Patients who did not develop delirium at any time had a relevant decrease in intensity of all ESAS items after 1 week of palliative care. The decrease of symptom intensity was significant for pain, insomnia, appetite, poor well-being, and global ESAS in patients with delirium either at T0 and T7, although these differences were less relevant than those observed in patients without delirium. In patients with delirium at T0 who improved their cognitive function at T7 (no delirium), significant changes were found in most ESAS items. CONCLUSION Symptom expression is amplified in patients with delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in intensity of ESAS items. IMPLICATIONS FOR PRACTICE Symptom expression is amplified in patients with cancer who have delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in symptom intensity.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center and Home Palliative Care Program SAMO, Palermo, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center and Home Palliative Care Program SAMO, Palermo, Italy
| | - Patrizia Ferrera
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center and Home Palliative Care Program SAMO, Palermo, Italy
| | - Andrea Cortegiani
- Department of Biopathology, Medical and Forensic Biotechnologies (DIBIMEF), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Department of Science for Health Promotion and Mother Child Care, University of Palermo, Palermo, Italy
| |
Collapse
|
28
|
Ogawa A, Okumura Y, Fujisawa D, Takei H, Sasaki C, Hirai K, Kanno Y, Higa K, Ichida Y, Sekimoto A, Asanuma C. Quality of care in hospitalized cancer patients before and after implementation of a systematic prevention program for delirium: the DELTA exploratory trial. Support Care Cancer 2018; 27:557-565. [DOI: 10.1007/s00520-018-4341-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
|
29
|
Barahona E, Pinhao R, Galindo V, Noguera A. The Diagnostic Sensitivity of the Memorial Delirium Assessment Scale-Spanish Version. J Pain Symptom Manage 2018; 55:968-972. [PMID: 29155289 DOI: 10.1016/j.jpainsymman.2017.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/01/2017] [Accepted: 11/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although Memorial Delirium Assessment Scale (MDAS) is a successful tool for delirium evaluation and monitoring, it is nevertheless important to determine whether cutoff scores vary according to the studied population. The main objective of this study was to evaluate the diagnostic sensitivity of the recently validated Spanish version of the MDAS. The secondary objective was to analyze possible diagnostic differences when used in a hospice or general hospital setting. METHODOLOGY A prospective study was conducted with advanced cancer patients in two settings (hospice and general hospital). A diagnosis of delirium was established according to clinical criteria and the Confusion Assessment Method. Sensitivity (S), specificity (Sp), positive predictive value, and negative predictive value were determined according to the receiver operating characteristics curve. The MDAS values for different centers were studied using nonparametric tests (Mann-Whitney). RESULTS A total of 67 patients were included, 28 of whom had been diagnosed with delirium (15/40 hospice and 13/27 general hospital). The mean MDAS scores were 13.6 and 5.5 for the delirium and nondelirium groups, respectively. A cutoff score of 7 gave the optimal screening diagnosis balance (S 92.6%, Sp 71.8%, positive predictive value 70.1%, and negative predictive value 93.3%). Diagnoses of anxiety and depression were not related with delirium (P ≤ 0.44). A diagnosis of dementia was related to delirium (P ≤ 0.052) but did not influence the diagnostic sensitivity of MDAS (P ≤ 0.26). No differences were found between hospice and general hospital settings as regards the diagnostic sensitivity of MDAS. CONCLUSION A screening cutoff of 7 appears to be optimal for MDAS Spanish version. No differences were found between advanced cancer patients cared for in a hospice or general hospital. However, more research is required to define the MDAS cutoff for patients with advanced cancer and dementia.
Collapse
Affiliation(s)
- Elena Barahona
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Rita Pinhao
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Victoria Galindo
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Antonio Noguera
- Primary Healthcare Centre Buenos Aires, Madrid, Spain; Primary Healthcare, Madrid, Spain; Palliative Care Unit, Fundación Jiménez Díaz, Madrid, Spain; Palliative Care Support Team, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.
| |
Collapse
|
30
|
Delgado-Guay MO, Ferrer J, Ochoa J, Cantu H, Williams JL, Park M, Bruera E. Characteristics and Outcomes of Advanced Cancer Patients Who Received Palliative Care at a Public Hospital Compared with Those at a Comprehensive Cancer Center. J Palliat Med 2018; 21:678-685. [PMID: 29451835 DOI: 10.1089/jpm.2017.0236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with advanced cancer experience severe physical, psychosocial, and spiritual distress requiring palliative care (PC). There are limited literature regarding characteristics and outcomes of patients evaluated by PC services at public hospitals (PHs). Objective, Design, Setting/Subjects, and Measurements: To compare the outcomes of advanced cancer patients undergoing PC at a PH and those at a comprehensive cancer center (CCC). We reviewed 359 consecutive advanced cancer patients (PH, 180; CCC, 179) undergoing PC. Symptoms and outcomes at consultation and first follow-up visit were assessed. Summary statistics were used to describe patient characteristics and outcomes. RESULTS The PH and CCC patients differed significantly according to race: 23% white, 39% black, and 36% Hispanic patients at the PH versus 66% white, 17% black, and 11% Hispanic patients at the CCC (p < 0.0001). Ninety-six (53%) patients at PH and 178 (99%) at the CCC had health insurance (p < 0.0001). Symptoms at consultation at PH and CCC were pain (85% and 91%, respectively; p = 0.0639), fatigue (81% and 94%, respectively; p = 0.0003), depression (51% and 69%, respectively; p = 0.0013), anxiety (47% and 75%, respectively; p < 0.0001), and well-being (63% and 93%, respectively; p < 0.0001). Multiple interventions provided: opioids, reviews for polypharmacy, constipation management, and interdisciplinary counseling. Median time from outpatient consultation to follow-up was 29 days(range, 1-119 days) at the PH and 21 days (range, 1-275 days) at the CCC (p = 0.0006). Median overall survival time from outpatient consultation was 473 days (95% confidence interval [CI], 205-699 days) at PH and 245 days (95% CI, 152-491 days) at CCC (p = 0.3408). CONCLUSIONS Advanced cancer patients at both institutions frequently had multiple distressing physical and emotional symptoms, although the frequency was higher at CCC. The median overall survival duration was higher at the PH. More research is needed.
Collapse
Affiliation(s)
- Marvin Omar Delgado-Guay
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Jeannette Ferrer
- 2 Division of Geriatrics and Palliative Medicine, The University of Texas Health Science Center at Houston , McGovern Medical School, Harris Health System, Lyndon B. Johnson Hospital, Houston, Texas
| | - Jewel Ochoa
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Hilda Cantu
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Janet L Williams
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Minjeong Park
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| |
Collapse
|
31
|
Neuroleptics in the management of delirium in patients with advanced cancer. Curr Opin Support Palliat Care 2018; 10:316-323. [PMID: 27661210 DOI: 10.1097/spc.0000000000000236] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Delirium is the most common and distressing neuropsychiatric syndrome in cancer patients. Few evidence-based treatment options are available due to the paucity of high quality of studies. In this review, we shall examine the literature on the use of neuroleptics to treat delirium in patients with advanced cancer. Specifically, we will discuss the randomized controlled trials that examined neuroleptics in the front line setting, and studies that explore second-line options for patients with persistent agitation. RECENT FINDINGS Contemporary management of delirium includes identification and management of any potentially reversible causes, coupled with nonpharmacological approaches. For patients who do not respond adequately to these measures, pharmacologic measures may be required. Haloperidol is often recommended as the first-line treatment option, and other neuroleptics such as olanzapine, risperidone, and quetiapine represent potential alternatives. For patients with persistent delirium despite first-line neuroleptics, the treatment strategies include escalating the dose of the same neuroleptic, rotation to another neuroleptic, or combination therapy (i.e., the addition of a second neuroleptic or other agent). We will discuss the advantages and disadvantages of each approach, and the available evidence to support each strategy. SUMMARY Adequately powered, randomized trials involving proper control interventions are urgently needed to define the optimal treatment strategies for delirium in the oncology setting.
Collapse
|
32
|
|
33
|
Thompson LMA, Bobonis Babilonia M. Distinguishing Depressive Symptoms From Similar Cancer-Related Somatic Symptoms: Implications for Assessment and Management of Major Depression after Breast Cancer. South Med J 2017; 110:667-672. [PMID: 28973709 DOI: 10.14423/smj.0000000000000705] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Prevalence rates of major depressive disorder (MDD) following breast cancer diagnosis are estimated to be ~5% to >20%, and these rates range from slightly below to somewhat above the expected prevalence rate for MDD in the general population of women in the United States. Women with a history of MDD are at increased risk for recurrence of MDD after breast cancer and need to be monitored closely. To properly diagnose and treat MDD, healthcare providers must be able to recognize depressive symptoms and distinguish them from similar somatic symptoms that are associated with breast cancer and breast cancer treatment. The National Comprehensive Cancer Network and the American Society of Clinical Oncology have published guidelines for the screening, assessment, and care of adult cancer patients with depressive symptoms. Use of a standardized and validated screening measure may help healthcare providers identify patients in need of further assessment or treatment. Evidence-based nonpharmacological interventions such as cognitive behavioral therapy and antidepressant medications are recommended treatment options.
Collapse
Affiliation(s)
- Lora M A Thompson
- From the Supportive Care Medicine Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Margarita Bobonis Babilonia
- From the Supportive Care Medicine Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| |
Collapse
|
34
|
Jorgensen SM, Carnahan RM, Weckmann MT. Validity of the Delirium Observation Screening Scale in Identifying Delirium in Home Hospice Patients. Am J Hosp Palliat Care 2017; 34:744-747. [PMID: 27413013 PMCID: PMC5236003 DOI: 10.1177/1049909116658468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Delirium is common in home hospice patients and conveys significant morbidity to both patients and caregivers. The Delirium Observation Screening Scale (DOS) was developed to improve delirium recognition but has yet to be validated in the home hospice setting. OBJECTIVE This pilot study aimed to explore the accuracy of the DOS for identifying delirium in home hospice patients. DESIGN Prospective delirium evaluation using a convenience sample. SETTING/PARTICIPANTS Community hospice patients were approached for study inclusion. MEASUREMENTS Participants were assessed using the Delirium Rating Scale-Revised-98 (DRS-R-98), with results being categorized as "delirium" or "no delirium." The Delirium Observation Screening Scale scores, completed by hospice nurses during weekly patient assessment visits, were compared to the DRS-R-98 results. RESULTS Within this population, 30/78 (38%) assessments were categorized as delirious. In the majority of assessments, 69/75 (92%), the DRS-R-98 and DOS provided congruent results. There were 5 false positives and 1 false negative, demonstrating the DOS to be a clinically useful tool with a sensitivity of 0.97 and specificity of 0.89. CONCLUSION The DOS appears to be an accurate way to screen for delirium in home hospice patients. Validation of the DOS may help to improve delirium recognition and treatment and has the potential to increase quality of life in this vulnerable population. This input will also be taken into consideration in the development of a systematic screening procedure for delirium diagnosis at our local hospice, which we hope will be generalizable to other hospice agencies.
Collapse
Affiliation(s)
- Shea M Jorgensen
- 1 University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ryan M Carnahan
- 2 University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michelle T Weckmann
- 3 Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
35
|
Lawley H, Hewison A. An integrative literature review exploring the clinical management of delirium in patients with advanced cancer. J Clin Nurs 2017; 26:4172-4183. [DOI: 10.1111/jocn.13960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hayley Lawley
- Ward 622; Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - Alistair Hewison
- University of Birmingham-School of Health Sciences; Birmingham UK
- The University of Birmingham; Birmingham UK
| |
Collapse
|
36
|
|
37
|
Franken LG, Mathot RAA, Masman AD, Baar FPM, Tibboel D, van Gelder T, Koch BCP, de Winter BCM. Population pharmacokinetics of haloperidol in terminally ill adult patients. Eur J Clin Pharmacol 2017; 73:1271-1277. [PMID: 28681176 PMCID: PMC5599451 DOI: 10.1007/s00228-017-2283-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/07/2017] [Indexed: 01/07/2023]
Abstract
Purpose Over 80% of the terminally ill patients experience delirium in their final days. In the treatment of delirium, haloperidol is the drug of choice. Very little is known about the pharmacokinetics of haloperidol in this patient population. We therefore designed a population pharmacokinetic study to gain more insight into the pharmacokinetics of haloperidol in terminally ill patients and to find clinically relevant covariates that may be used in developing an individualised dosing regimen. Methods Using non-linear mixed effects modelling (NONMEM 7.2), a population pharmacokinetic analysis was conducted with 87 samples from 28 terminally ill patients who received haloperidol either orally or subcutaneously. The covariates analysed were patient and disease characteristics as well as co-medication. Results The data were accurately described by a one-compartment model. The population mean estimates for oral bioavailability, clearance and volume of distribution for an average patient were 0.86 (IIV 55%), 29.3 L/h (IIV 43%) and 1260 L (IIV 70%), respectively. This resulted in an average terminal half-life of haloperidol of around 30 h. Conclusion Our study showed that the pharmacokinetics of haloperidol could be adequately described by a one-compartment model. The pharmacokinetics in terminally ill patients was comparable to other patients. We were not able to explain the wide variability using covariates.
Collapse
Affiliation(s)
- L G Franken
- Department of Hospital Pharmacy, Erasmus Medical Centre, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - R A A Mathot
- Hospital Pharmacy - Clinical Pharmacology, Academic Medical Centre, Amsterdam, The Netherlands
| | - A D Masman
- Palliative Care Centre, Laurens Cadenza, Rotterdam, The Netherlands.,Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - F P M Baar
- Palliative Care Centre, Laurens Cadenza, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Centre, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - B C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Centre, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - B C M de Winter
- Department of Hospital Pharmacy, Erasmus Medical Centre, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| |
Collapse
|
38
|
de la Cruz M, Yennu S, Liu D, Wu J, Reddy A, Bruera E. Increased Symptom Expression among Patients with Delirium Admitted to an Acute Palliative Care Unit. J Palliat Med 2017; 20:638-641. [PMID: 28157431 DOI: 10.1089/jpm.2016.0315] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Delirium is the most common neuropsychiatric condition in very ill patients and those at the end of life. Previous case reports found that delirium-induced disinhibition may lead to overexpression of symptoms. It negatively affects communication between patients, family members, and the medical team and can sometimes lead to inappropriate interventions. Better understanding would result in improved care. Our aim was to determine the effect of delirium on the reporting of symptom severity in patients with advanced cancer. METHODS We reviewed 329 consecutive patients admitted to the acute palliative care unit (APCU) without a diagnosis of delirium from January to December 2011. Demographics, Memorial Delirium Assessment Scale, Eastern Cooperative Oncology Group (ECOG) Performance status, and Edmonton Symptom Assessment Scale (ESAS) on two time points were collected. The first time point was on admission and the second time point for group A was day one (+two days) of delirium. For group B, the second time point was within two to four days before discharge from the APCU. Patients who developed delirium and those who did not develop delirium during the entire course of admission were compared using chi-squared test and Wilcoxon rank-sum test. Paired t-test was used to assess if the change of ESAS from baseline to follow-up was associated with delirium. RESULTS Ninety-six of 329 (29%) patients developed delirium during their admission to the APCU. The median time to delirium was two days. There was no difference in the length of stay in the APCU for both groups. Patients who did not have delirium expressed improvement in all their symptoms, while those who developed delirium during hospitalization showed no improvement in physical symptoms and worsening in depression, anxiety, appetite, and well-being. CONCLUSION Patients with delirium reported no improvement or worsening symptoms compared to patients without delirium. Screening for delirium is important in patients who continue to report worsening symptoms despite appropriate management.
Collapse
Affiliation(s)
- Maxine de la Cruz
- 1 Department of Palliative Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Sriram Yennu
- 1 Department of Palliative Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Diane Liu
- 2 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Jimin Wu
- 2 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Akhila Reddy
- 1 Department of Palliative Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| |
Collapse
|
39
|
Mailly M, Bénézech JP, Chevallier-Michaud J. [Observational study of delirium in palliative care]. REVUE DE L'INFIRMIERE 2017; 66:37-38. [PMID: 28160834 DOI: 10.1016/j.revinf.2016.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Caregivers know that the agitation and movements to reject sheets and clothes is found in some patients with cancer in the palliative phase. An observational study was carried out with the aim of refining the short-term prognosis clinical approach and to organise more suitably adapted care.
Collapse
Affiliation(s)
- Maryse Mailly
- CHU Montpellier, Hôpital Saint-Éloi, 80 avenue Augustin-Fliche, 34090 Montpellier, France.
| | - Jean-Pierre Bénézech
- CHU Montpellier, Hôpital Saint-Éloi, 80 avenue Augustin-Fliche, 34090 Montpellier, France
| | | |
Collapse
|
40
|
Park MA, Choi E. Nurses' Awareness of Psychological Distress and Delirium in Cancer Patients and Job Stress. ASIAN ONCOLOGY NURSING 2017. [DOI: 10.5388/aon.2017.17.4.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mi Ae Park
- Department of Nursing, National Cancer Center, Goyang, Korea
| | - Eunsook Choi
- Department of Nursing, National Cancer Center, Goyang, Korea
| |
Collapse
|
41
|
Plaschke K, Petersen KA, Frankenhauser S, Weigand MA, Kopitz J, Bardenheuer HJ. The Impact of Plasma Cholinergic Enzyme Activity and Other Risk Factors for the Development of Delirium in Patients Receiving Palliative Care. J Pain Symptom Manage 2016; 52:525-532. [PMID: 27401519 DOI: 10.1016/j.jpainsymman.2016.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/01/2016] [Accepted: 05/20/2016] [Indexed: 11/20/2022]
Abstract
CONTEXT Delirium is an important complication in palliative care patients. One of the potential risk factors for cognitive disorders is deterioration in cholinergic neurotransmission. Anticholinergic medications are known to be important owing to the association of their metabolites with significant morbidity, which is often the result of cumulative effects of medications (anticholinergic burden). Additionally, cholinergic enzymes are possible candidates reflecting the cholinergic situation in patients. However, the role of cholinesterases (CHE) for delirium in palliative care patients is unknown. OBJECTIVES Following local Ethics Board approval and written informed consent, we recruited a cohort of patients who had been admitted to the Heidelberg University Palliative Care Unit related to CHE and other factors at risk for delirium. METHODS Delirium was assessed using the Nursing Delirium Screening Scale once daily in all cancer patients (N = 100) during their stay on the palliative care unit. In a subgroup of 69 probes, blood samples were analyzed for acetyl- and butyrylcholinesterase activity spectrophotometrically. Furthermore, patients' medications were recorded. Logistic regression analysis was used to evaluate potential predictors of delirium. RESULTS Delirium was identified in 29% of patients. Karnofsky Performance Status Scale score was significantly lower (P = 0.021) and mortality higher (P = 0.018) in patients with delirium. Plasma CHE activity was not associated with delirium. However, a significant effect of anticholinergic medication on plasma CHE activity was detected; so far midazolam (P = 0.01) seems to play an important role in that process. CONCLUSION Special care might be necessary with anticholinergic medication to minimize risk for delirium in palliative cancer patients.
Collapse
Affiliation(s)
- Konstanze Plaschke
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany.
| | | | | | - Markus A Weigand
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Kopitz
- Department of Pathology, University of Heidelberg, Heidelberg, Germany
| | | |
Collapse
|
42
|
Grandahl MG, Nielsen SE, Koerner EA, Schultz HH, Arnfred SM. Prevalence of delirium among patients at a cancer ward: Clinical risk factors and prediction by bedside cognitive tests. Nord J Psychiatry 2016; 70:413-7. [PMID: 26882016 DOI: 10.3109/08039488.2016.1141982] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Delirium is a frequent psychiatric complication to cancer, but rarely recognized by oncologists. Aims 1. To estimate the prevalence of delirium among inpatients admitted at an oncological cancer ward 2. To investigate whether simple clinical factors predict delirium 3. To examine the value of cognitive testing in the assessment of delirium. Methods On five different days, we interviewed and assessed patients admitted to a Danish cancer ward. The World Health Organization International Classification of Diseases Version 10, WHO ICD-10 Diagnostic System and the Confusion Assessment Method (CAM) were used for diagnostic categorization. Clinical information was gathered from medical records and all patients were tested with Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test. Results 81 cancer patients were assessed and 33% were diagnosed with delirium. All delirious participants were CAM positive. Poor performance on the cognitive tests was associated with delirium. Medical records describing CNS metastases, benzodiazepine or morphine treatment were associated with delirium. Conclusions Delirium is prevalent among cancer inpatients. The Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test can be used as screening tools for delirium among inpatients with cancer, but even in synergy, they lack specificity. Combining cognitive testing and attention to nurses' records might improve detection, yet further studies are needed to create a more detailed patient profile for the detection of delirium.
Collapse
Affiliation(s)
| | - Svend Erik Nielsen
- b Department of Oncology and Palliation, North Zealand Hospital , Hilleroed, Denmar
| | | | - Helga Holm Schultz
- d Department of Cardiology, Nephrology and Endocrinology, North Zealand Hospital , Hilleroed, Denmark
| | - Sidse Marie Arnfred
- e Psychiatric Hospital Slagelse, Region Zealand, University of Copenhagen , Denmark
| |
Collapse
|
43
|
Şenel G, Uysal N, Oguz G, Kaya M, Kadioullari N, Koçak N, Karaca S. Delirium Frequency and Risk Factors Among Patients With Cancer in Palliative Care Unit. Am J Hosp Palliat Care 2016; 34:282-286. [PMID: 26722008 DOI: 10.1177/1049909115624703] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introductıon: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit. METHODS Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria. RESULTS The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%. CONCLUSION The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.
Collapse
Affiliation(s)
- Gülcin Şenel
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Neşe Uysal
- 2 Nursing Department, Faculty of Health Science, Gazi University Ankara, Turkey
| | - Gonca Oguz
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Mensure Kaya
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nihal Kadioullari
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nesteren Koçak
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Serife Karaca
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| |
Collapse
|
44
|
Delgado-Guay MO, Rodriguez-Nunez A, De la Cruz V, Frisbee-Hume S, Williams J, Wu J, Liu D, Fisch MJ, Bruera E. Advanced cancer patients' reported wishes at the end of life: a randomized controlled trial. Support Care Cancer 2016; 24:4273-81. [PMID: 27165052 DOI: 10.1007/s00520-016-3260-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/03/2016] [Indexed: 12/29/2022]
Abstract
CONTEXT Conversations about end-of-life (EOL) wishes are challenging for many clinicians. The Go Wish card game (GWG) was developed to facilitate these conversations. Little is known about the type and consistency of EOL wishes using the GWG in advanced cancer patients. METHODS We conducted a randomized controlled trial to assess the EOL wishes of 100 patients with advanced cancer treated at The University of Texas MD Anderson Cancer Center. The purpose of this study was to determine the EOL wishes of patients with advanced cancer and to compare patients' preference between the GWG and List of wishes/statements (LOS) containing the same number of items. Patients were randomized into four groups and completed either the GWG or a checklist of 35 LOS and one opened statement found on the GWG cards; patients were asked to categorize these wishes as very, somewhat, or not important. After 4-24 h, the patients were asked to complete the same or other test. Group A (n = 25) received LOS-LOS, group B (n = 25) received GWG-GWG, group C (n = 26) received GWG-LOS, and group D (n = 24) received LOS-GWG. All patients completed the State-Trait Anxiety Inventory (STAI) for adults before and after the first test. RESULTS Median age (interquartile range = IQR): 56 (27-83) years. Age, sex, ethnicity, marital status, religion, education, and cancer diagnosis did not differ significantly among the four groups. All patients were able to complete the GWG and/or LOS. The ten most common wishes identified as very important by patients in the first and second test were to be at peace with God (74 vs. 71 %); to pray (62 vs. 61 %); and to have family present (57 vs. 61 %). to be free from pain (54 vs. 60 %); not being a burden to my family (48 vs. 49 %); to trust my doctor (44 vs. 45 %); to keep my sense of humor (41 vs. 45 %); to say goodbye to important people in my life (41 vs. 37 %); to have my family prepared for my death (40 vs. 49 %); and to be able to help others (36 vs. 31 %). There was significant association among the frequency of responses of the study groups. Of the 50 patients exposed to both tests, 43 (86 %) agreed that the GWG instructions were clear, 45 (90 %) agreed that the GWG was easy to understand, 31 (62 %) preferred the GWG, 39 (78 %) agreed that the GWG did not increase their anxiety and 31 (62 %) agreed that having conversations about EOL priorities was beneficial. The median STAI score after GWG was 48 (interquartile range, 39-59) vs. 47 (interquartile range, 27-63) after LOS (p = 0.2952). CONCLUSION Patients with advanced cancer assigned high importance to spirituality and the presence/relationships of family, and these wishes were consistent over the two tests. The GWG did not worsen anxiety.
Collapse
Affiliation(s)
- Marvin O Delgado-Guay
- Department of Palliative Care and Rehabilitation and Integrative Medicine , Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Alfredo Rodriguez-Nunez
- Programa de Medicina Paliativa y Cuidados Continuos, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vera De la Cruz
- Department of Palliative Care and Rehabilitation and Integrative Medicine , Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care and Rehabilitation and Integrative Medicine , Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Janet Williams
- Department of Palliative Care and Rehabilitation and Integrative Medicine , Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Jimin Wu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation and Integrative Medicine , Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| |
Collapse
|
45
|
Okamoto Y, Fukui S, Yoshiuchi K, Ishikawa T. Do Symptoms among Home Palliative Care Patients with Advanced Cancer Decide the Place of Death? Focusing on the Presence or Absence of Symptoms during Home Care. J Palliat Med 2016; 19:488-95. [DOI: 10.1089/jpm.2015.0184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Yuko Okamoto
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
| | - Sakiko Fukui
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takako Ishikawa
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
| |
Collapse
|
46
|
Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
Collapse
Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | | |
Collapse
|
47
|
Luijendijk HJ, de Bruin NC, Hulshof TA, Koolman X. Terminal illness and the increased mortality risk of conventional antipsychotics in observational studies: a systematic review. Pharmacoepidemiol Drug Saf 2015; 25:113-22. [PMID: 26601922 DOI: 10.1002/pds.3912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Numerous large observational studies have shown an increased risk of mortality in elderly users of conventional antipsychotics. Health authorities have warned against use of these drugs. However, terminal illness is a potentially strong confounder of the observational findings. So, the objective of this study was to systematically assess whether terminal illness may have biased the observational association between conventional antipsychotics and risk of mortality in elderly patients. METHODS Studies were searched in PubMed, CINAHL, Embase, the references of selected studies and articles referring to selected studies (Web of Science). Inclusion criteria were (i) observational studies that estimated (ii) the risk of all-cause mortality in (iii) new elderly users of (iv) conventional antipsychotics compared with atypical antipsychotics or no use. Two investigators assessed the characteristics of the exposure and reference groups, main results, measured confounders and methods used to adjust for unmeasured confounders. RESULTS We identified 21 studies. All studies were based on administrative medical and pharmaceutical databases. Sicker and older patients received conventional antipsychotics more often than new antipsychotics. The risk of dying was especially high in the first month of use, and when haloperidol was administered per injection or in high doses. Terminal illness was not measured in any study. Instrumental variables that were used were also confounded by terminal illness. CONCLUSIONS We conclude that terminal illness has not been adjusted for in observational studies that reported an increased risk of mortality risk in elderly users of conventional antipsychotics. As the validity of the evidence is questionable, so is the warning based on it.
Collapse
Affiliation(s)
- Hendrika J Luijendijk
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Geriatric Psychiatry, BAVO Europoort, Rotterdam, The Netherlands
| | - Niels C de Bruin
- Laurens Alzheimer's Care Research Center, Rotterdam, The Netherlands.,Novicare Geriatric Care Inc, Best, The Netherlands
| | - Tessa A Hulshof
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| |
Collapse
|
48
|
Delgado-Guay MO, Rodriguez-Nunez A, Shin SH, Chisholm G, Williams J, Frisbee-Hume S, Bruera E. Characteristics and outcomes of patients with advanced cancer evaluated by a palliative care team at an emergency center. A retrospective study. Support Care Cancer 2015; 24:2287-2295. [DOI: 10.1007/s00520-015-3034-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/15/2015] [Indexed: 11/30/2022]
|
49
|
Boettger S, Jenewein J, Breitbart W. Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences. Palliat Support Care 2015; 13:1087-92. [PMID: 25191904 PMCID: PMC5516527 DOI: 10.1017/s1478951514001060] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Our aim was to examine the characteristics of delirium in the severely medically ill cancer population on the basis of sociodemographic and medical variables, delirium severity, and phenomenology, as well as severity of medical illness. METHOD All subjects in the database were recruited from psychiatric referrals at Memorial Sloan Kettering Cancer Center (MSKCC). Sociodemographic and medical variables, as well as the Karnofsky Performance Status (KPS) scale and Memorial Delirium Assessment Scale (MDAS) scores were recorded at baseline. Subsequently, these variables were analyzed with respect to the severity of the medical illness. RESULTS Out of 111 patients, 67 qualified as severely medically ill. KPS scores were 19.7 and 30.7 in less severe illness. There were no significant differences with respect to age, history of dementia, and MDAS scores. Although the severity of delirium did not differ, an increased frequency and severity of consciousness disturbance, disorientation, and inability to maintain and shift attention did exist. With respect to etiologies contributing to delirium, hypoxia and infection were commonly associated with severe illness. In contrast, corticosteroid administration was more often associated with less severe illness. There were no differences with respect to opiate administration, dehydration, and CNS disease, including brain metastasis. SIGNIFICANCE OF RESULTS Delirium in the severely medically ill cancer population has been characterized by an increased disturbance of consciousness, disorientation, and an inability to maintain and shift attention. However, the severity of illness did not predict severity of delirium. Furthermore, hypoxia and infection were etiologies more commonly associated with delirium in severe illness, whereas the administration of corticosteroids was associated with less severe illness.
Collapse
Affiliation(s)
- Soenke Boettger
- Department of Psychiatry and Psychotherapy,University Hospital Zurich,Zurich,Switzerland
| | - Josef Jenewein
- Department of Psychiatry and Psychotherapy,University Hospital Zurich,Zurich,Switzerland
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences,Memorial Sloan Kettering Cancer Center,New York,New York
| |
Collapse
|
50
|
Abstract
An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.
Collapse
Affiliation(s)
- Reema D Mehta
- Fellow, Psychosomatic Medicine Psycho-Oncology, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center/New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Andrew J Roth
- Attending Psychiatrist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center/New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| |
Collapse
|