The Frequency, Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit

Abstract

Background. Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency, characteristics, and outcomes of delirium in patients with advanced cancer admitted to an APCU. Methods. Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients’ demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score ≥7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. Results. Of 556 patients in the APCU, 323 (58%) had a diagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admission and 94 (29%) developed delirium after admission to the APCU. Delirium reversed in 85 of 323 episodes (26%). Half of patients with delirium (n = 162) died. Patients with the diagnosis of delirium had a lower median overall survival than those without delirium. Patients who developed delirium after admission to the APCU had poorer survival (p ≤ .0001) and a lower rate of delirium reversal (p = .03) compared with those admitted with delirium. Conclusion. More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one‐third of cases. Diagnosis of delirium was associated with poorer survival. Implications for Practice: Delirium is the most common neuropsychiatric condition in patients with severe medical illness and those at the end of life. It can be a source of distress for patients, their families, and the medical team. When missed, or if symptoms are misinterpreted, delirium may also lead to unnecessary interventions. This underlines the importance of diagnosis and detection of delirium in populations that are at increased risk. This study has important implications in practice, as it can assist clinicians in making decisions regarding other medical interventions, advance care planning, and communicating with families relating to end‐of‐life issues.

Delirium and its consequences in the specialized palliative care unit: Validation of the Korean version of Memorial Delirium Assessment Scale

“…We identified delirium as an independent predictor of short‐term mortality in palliative care patients. The predisposing effect of delirium on mortality in the advanced care setting has been repeatedly demonstrated . The reason is not completely understood; it may be a predictor of global vulnerability of the organs and brain and may contribute to an increase in the number of complications and morbidity, which in turn lead to death .…”

“…Based on the previous study reporting predictors of delirium in hospitalized cancer patients, we calculated the effect and sample sizes necessary to identify variables related to delirium using G*Power 3.1; with 10 predictors, the required sample size for a power of 0.80, and an alpha of 0.05 was at least 84 participants.…”

Delirium in terminal cancer inpatients: short-term survival and missed diagnosis

“…In oncology palliative care services, delirium is frequently present, with a prevalence varying from 13% to 42% on admission, 26-62% during admission, and up to 58-88% in the weeks or hours preceding death (Hosie, Davidson, Agar, Sanderson, & Phillips, 2013). In this population, delirium can be reversible in 30-50% of cases (Leonard et al, 2008), since its main etiologies include the use of medications (e.g., opiates, benzodiazepines), infections, electrolytic misbalance, and dehydration (de la Cruz, Ransing, et al, 2015). The frequency of each psychomotor subtype in palliative care patients varies among studies, probably due to different populations and classification criteria.…”

“…Delirium increases morbidity (Gustafson et al, 1988), causes distress to patients, family members, and health care professionals (Breitbart, Gibson, & Tremblay, 2002;Bruera et al, 2009). It increases also health expenditure (de la Cruz, Ransing, et al, 2015). Moreover, the presence of delirium diminishes survival in palliative care patients, even as early as 21 days after its onset (Caraceni et al, 2000;Lawlor et al, 2000), and next to performance scales (e.g., Karnofsky Performance Status, Eastern Cooperative Oncology Group Scale), it is an important factor in clinical indexes designed to predict mortality among the same population (Baba et al, 2015;Scarpi et al, 2011).…”

Advance Directives, Hospitalization, and Survival Among Advanced Cancer Patients with Delirium Presenting to the Emergency Department: A Prospective Study

“…Delirium in patients with cancer is associated with an increased risk of mortality and morbidity, functional decline, falls, and increased risk of institutionalization after discharge from the hospital . Most studies of delirium in cancer patients are limited to patients in palliative care services and intensive care units (ICUs) . In ICUs, delirium is associated with increased mortality, prolonged mechanical ventilation, prolonged hospital stays, and cognitive impairment in patients discharged alive .…”