The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center

Cruz, Maxine Grace De La; Fan, Joanna; Yennurajalingam, Sriram; Tanco, Kimberson; Shin, Seong-Hoon; Wu, Jimin; Liu, Diane; Bruera, Éduardo

doi:10.1007/s00520-015-2610-3

Cited by 131 publications

(103 citation statements)

References 36 publications

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“…Rates of unrecognized delirium, defined as delirium diagnosed by an expert assessor after the diagnosis was not made by the patient’s treating physicians and nurses, ranged from 55% to 70% in 2000–2001 2, 3 and still remain around 60% in 2015. 4 Delirium is a complex and challenging condition, and a synthesis of current evidence should optimize clinical care. The goals of this review were (1) to summarize the current approaches to diagnosis and treatment of delirium, (2) to highlight recent advances, and (3) to underscore critical gaps in knowledge where future research is needed to advance the field.…”

Section: Introductionmentioning

confidence: 99%

Delirium in Older Persons

Fong

Hshieh

et al. 2017

JAMA

691

306

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Importance-Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effect with substantial health care costs.Objective-To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.Evidence Review-We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.Findings-Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment, 4 A's test, and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of

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Section: Introductionmentioning

confidence: 99%

Delirium in Older Persons

Fong

Hshieh

et al. 2017

JAMA

691

306

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“…Hypoactive delirium is the most common subtype and is more likely to be underdiagnosed compared with hyperactive or mixed delirium. 4,74 Delirium can be clinically assessed using a variety of screening instruments, with the Confusion Assessment Method 75 being the most well-validated and widely used approach. The diagnosis is established according to DSM-5 60 or ICD-10 criteria.…”

Section: Gap 4: Patients With Cancer Are Not Routinely Screened Fomentioning

confidence: 99%

“…Delirium is also a common, often under-recognized 4 neuropsychiatric problem associated with substantial morbidity, mortality, and a high potential impact on decision-making ability. The vast majority of studies on the prevalence and impact of delirium have focused on hospitalized general medicine or postoperative patients, as opposed to older adults with cancer.…”

Section: Introductionmentioning

confidence: 99%

Understanding cognition in older patients with cancer

Karuturi

Wong

Hsu

et al. 2016

Journal of Geriatric Oncology

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Cancer and neurocognitive disorders, such as dementia and delirium, are common and serious diseases in the elderly that are accompanied by high degree of morbidity and mortality. Furthermore, evidence supports the under-diagnosis of both dementia and delirium in older adults. Complex questions exist regarding the interaction of dementia and delirium with cancer, beginning with guidelines on how best measure disease severity, the optimal screening test for either disorder, the appropriate level of intervention in the setting of abnormal findings, and strategies aimed at preventing the development or progression of either process. Ethical concerns emerge in the research setting, pertaining to the detection of cognitive dysfunction in participants, validity of consent, disclosure of abnormal results if screening is pursued, and recommended level of intervention by investigators. Furthermore, understanding the ways in which comorbid cognitive dysfunction and cancer impact both cancer and non-cancer-related outcomes is essential in guiding treatment decisions. In the following article, we will discuss what is presently known of the interactions of pre-existing cognitive impairment and delirium with cancer. We will also discuss identified deficits in our knowledge base, and propose ways in which innovative research may address these gaps.

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“…A retrospective review of 771 consecutive palliative care inpatient consults at a large cancer hospital found that 61% of delirium diagnoses were missed by the primary referring team and that hypoactive delirium was the most common subtype (63%). 16 Given this high prevalence, cancer patients should be screened with an appropriate assessment on admission and throughout their hospital course. 17 In the cancer patient hypoactive delirium due to hypoxia, infection, or metabolic encephalopathy is often missed and misinterpreted as fatigue, depression, or sedation from opioid pain medication.…”

Section: Introductionmentioning

confidence: 99%

“…Cancer predominately affects individuals age 65 and older, and older age and a pre-existing psychiatric condition are associated with a missed diagnosis of delirium which is often misinterpreted as dementia in this population. 16,18,19 …”

Section: Introductionmentioning

confidence: 99%

The confused oncologic patient: a rational clinical approach

Nolan

DeAngelis

2016

Current Opinion in Neurology

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Purpose of review The purpose of this review is to provide a practical clinical approach to confusion in the patient with cancer. Confusion in the cancer population has a broader differential diagnosis than in the general medical population. The clinician must consider the usual differential diagnoses as well as causes unique to the cancer patient including direct complications from the cancer and indirect complications related to cancer treatment. Recent findings In the recent age of precision medicine, the oncologist now utilizes the genomic profile of both the patient and the tumor to provide advanced biologic therapies including targeted anticancer drugs, antiangiogenic agents, and immunotherapy. Such advances carry with them an emerging pattern of neurotoxicity which, although less well described in the literature, is now an important consideration to the clinical approach to confusion in cancer patients. Summary Confusion is the most common neurologic complication in cancer and is associated with significant morbidity, mortality, and prolonged hospital stays resulting in increased health care costs. Early recognition and treatment of delirium is essential to improve clinical outcomes.

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The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center

Abstract: Sixty-one percent of patients with a diagnosis of delirium by a palliative care specialist were missed by the primary referring team. Patients with MD were frequently referred for pain. Universal screening of cancer patients for delirium is recommended.

Cited by 131 publications

References 36 publications

Delirium in Older Persons

Delirium in Older Persons

Understanding cognition in older patients with cancer

The confused oncologic patient: a rational clinical approach

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