Family-perceived distress from delirium-related symptoms of terminally ill cancer patients

Relationship between cognitive and non-cognitive symptoms of delirium

AIM

To study relationship between the cognitive and the non-cognitive symptoms of delirium.

METHODS

Eighty-four patients referred to psychiatry liaison services and met DSM-IVTR criteria of delirium were assessed using the Delirium Rating Scale Revised-1998 (DRSR-98) and Cognitive Test for Delirium (CTD).

RESULTS

The mean DRS-R-98 severity score was 17.19 and DRS-R-98 total score was 23.36. The mean total score on CTD was 11.75. The mean scores on CTD were highest for comprehension (3.47) and lowest for vigilance (1.71). Poor attention was associated with significantly higher motor retardation and higher DRS-R-98 severity scores minus the attention scores. There were no significant differences between those with and without poor attention. Higher attention deficits were associated with higher dysfunction on all other domains of cognition on CTD. There was significant correlation between cognitive functions as assessed on CTD and total DRS-R-98 score, DRS-R-98 severity score and DRS-R-98 severity score without the attention item score. However, few correlations emerged between CTD domains and CTD total scores with cognitive symptom total score of DRS-R-98 (items 9-13) and non-cognitive symptom total score of DRS-R-98 (items 1-8).

CONCLUSIONS

Our study suggests that in delirium, cognitive deficits are quite prevalent and correlate with overall severity of delirium. Attention deficit is a core symptom of delirium.

Experiences, understandings and support needs of family carers of older patients with delirium: a descriptive mixed methods study in a hospital delirium unit

BACKGROUND

Delirium is common in older patients. Little is known of support needs of families of older hospital patients with delirium.

AIMS AND OBJECTIVES

To inform nursing practice, we sought to describe families' experiences, understanding of delirium and delirium care, and support needs.

DESIGN

Descriptive mixed methods.

METHODS

Review of questionnaire items used with families of people with terminal delirium informed development of a new questionnaire to evaluate the support needs in our study population. In a tertiary hospital delirium unit, we recruited 17 family carers of older patients with (non-terminal) delirium to respond to this questionnaire. Twelve participants (11 female) also took part in interviews addressing the study's aims. Descriptive statistics were calculated and thematic analysis was undertaken.

RESULTS

From the survey, key family issues included distress about the patient's condition, worries about future care, and a need for more information about how the patient might feel and how families could support the patient. Themes from interviews included The admission experience, Worries and concerns, Feeling supported, and The discharge experience. Limited understanding of delirium underpinned all themes. Families experienced shock and sadness at the change in the patient; they were reassured by the specialist care but needed more information about delirium, its effects and outcomes, and how they could help with care. Meeting long-term postdischarge needs was a key concern.

CONCLUSIONS

In this study, families with a hospitalised older relative who had delirium described a distressing experience and needs for informational support. Further research is needed outside of delirium-specific units and in samples including a greater proportion of male relatives.

IMPLICATIONS FOR PRACTICE

Nurses should work within the interdisciplinary team to ensure a planned, sensitive and timely approach to informing the patient's family about delirium and its implications for their relative, recognising the family carer's role and likely distress.

The Use of Pentobarbital in Cases of Severe Delirium

Delirium is a common syndrome present at the end of life and causes significant distress for patients and families. Sleep disruption is a common precipitating factor for delirium and restoration of sleep may be instrumental in attenuating symptoms. In this cases series, we present three patients who were unresponsive to escalating doses of standard delirium medications, but whose delirium resolved once improved sleep was achieved using Pentobarbital. In a fourth patient, delirium was successfully treated where neuroleptics were contraindicated. Pentobarbital has been shown to reduce the time to sleep onset, decrease the number of body movements during sleep and spontaneous awakenings and increase the total sleep time. Pentobarbital may provide an additional treatment option for patients whose delirium is refractory to standard management approaches.

Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial

PURPOSE

The vast majority of patients with cancer at the end of life receive parenteral hydration in hospitals and no hydration in hospice, with limited evidence supporting either practice. In this randomized controlled trial, we determined the effect of hydration on symptoms associated with dehydration, quality of life, and survival in patients with advanced cancer.

PATIENTS AND METHODS

We randomly assigned 129 patients with cancer from six hospices to receive parenteral hydration (normal saline 1 L per day) or placebo (normal saline 100 mL per day) daily over 4 hours. The primary outcome was change in the sum of four dehydration symptoms (fatigue, myoclonus, sedation and hallucinations, 0 = best and 40 = worst possible) between day 4 and baseline. Secondary outcomes included Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Nursing Delirium Screening Scale (NuDESC), Unified Myoclonus Rating Scale (UMRS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Dehydration Assessment Scale, creatinine, urea, and overall survival. Intention-to-treat analysis was conducted to examine the change by day 4 ± 2 and day 7 ± 2 between groups.

RESULTS

The hydration (n = 63) and placebo (n = 66) groups had similar baseline characteristics. We found no significant differences between the two groups for change in the sum of four dehydration symptoms (-3.3 v -2.8, P = .77), ESAS (all nonsignificant), MDAS (1 v 3.5, P = .084), NuDESC (0 v 0, P = .13), and UMRS (0 v 0, P = .54) by day 4. Results for day 7, including FACIT-F, were similar. Overall survival did not differ between the two groups (median, 21 v 15 days, P = .83).

CONCLUSION

Hydration at 1 L per day did not improve symptoms, quality of life, or survival compared with placebo.

Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology

BACKGROUND

Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delirium when caring for people with cancer, the elderly or older people requiring psychiatric care in the inpatient setting.

METHODS

Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses' views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective.

RESULTS

A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others.

DISCUSSION

Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.

Neurolytic celiac plexus block reduces occurrence and duration of terminal delirium in patients with pancreatic cancer

PURPOSE

WHO's three step ladder sometimes cannot provide adequate pain relief for pancreatic cancer. Some patients develop terminal delirium (TD). The aim of this study was to test if the addition of a celiac plexus block (CPB) to pharmacotherapy could reduce the incidence of TD.

METHODS

Pancreatic cancer patients under the care of our palliative-care team were investigated with regard to the duration and occurrence of TD, pain scores [numerical rating score (NRS)] and daily opioid dose. Between August 2007 to September 2008, 17 patients received only pharmacotherapy (control group). Then, we modified our guideline for analgesia, performing CPB 7 days after the first intervention of our team. Between October 2008 to September 2009, 19 patients received CPB.

RESULTS

The opioid doses in CPB group were significantly lower both at 10 days after the first intervention (3 days after CPB) (27 ± 11 vs. 66 ± 82 mg; p = 0.029) and 2 days before death (37 ± 25 vs. 124 ± 117 mg; p = 0.009). NRS in the CPB group were significantly lower both at 10 days after the first intervention (0 [0-2] vs. 3 [2-5], p < 0.0001) and 2 days before death (1 [0-2] vs. 3 [1-4.5], p = 0.018). The occurrence and duration of TD in CPB group were both reduced (42 vs. 94 %, p = 0.019; and 1.8 ± 2.9 vs. 10.4 ± 7.5 days, p = 0.0003).

CONCLUSION

The duration and occurrence of TD and the pain severity were significantly less in pancreatic cancer patients who underwent neurolytic CPB.

Providing delirium education for family caregivers of older adults

Using the Knowledge to Action Process, an education session was developed to teach families of older adults about delirium. Seven sessions were held with 16 eligible participants. A significant increase in delirium knowledge was found following education, and many participants believed others should receive similar education. At follow up, most participants were able to recall information related to risk factors and signs of delirium. Families of older adults form a common communication link for their relatives between health care providers across settings; providing education to family caregivers may in part provide a solution to the problem of delirium.

Postoperative delirium: a 76-year-old woman with delirium following surgery

Delirium (acute confusion) complicates 15% to 50% of major operations in older adults and is associated with other major postoperative complications, prolonged length of stay, poor functional recovery, institutionalization, dementia, and death. Importantly, delirium may be predictable and preventable through proactive intervention. Yet clinicians fail to recognize and address postoperative delirium in up to 80% of cases. Using the case of Ms R, a 76-year-old woman who developed delirium first after colectomy with complications and again after routine surgery, the diagnosis, prevention, and treatment of delirium in the postoperative setting is reviewed. The risk of postoperative delirium can be quantified by the sum of predisposing and precipitating factors. Successful strategies for prevention and treatment of delirium include proactive multifactorial intervention targeted to reversible risk factors, limiting use of sedating medications (especially benzodiazepines), effective management of postoperative pain, and, perhaps, judicious use of antipsychotics.

Evidence-based treatment of delirium in patients with cancer

Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

Delirium: a review

Delirium affects a diverse patient population, may present with highly variable clinical features, is a source of distress for patients and their caregivers, prolongs hospital stays and may herald a poor prognosis. Many cases of delirium are reversible and therefore a full history, physical examination and investigations should be performed. Ahigh degree of suspicion is required for detecting delirium and thorough investigations are necessary in order to determine the underlying etiology and to maximize the potential for reversibility. The following review outlines important aspects of a clinical approach to delirium, the differential diagnosis of delirium, investigation of a patient presenting with delirium, management of delirium, the pathophysiology of delirium and the prognosis accompanying delirium.

Delirium in older adults attending adult day care and family caregiver distress

BACKGROUND; Delirium is a critical, costly, frequently reversible problem in older adults. Findings of previous studies indicate that delirium occurs in up to 65% of hospitalised older adults and up to 80% of terminally ill patients. Few studies address the frequency of delirium in community dwelling older adults and the extent to which delirium symptoms create distress for their family caregivers.

AIMS

To determine the frequency of delirium in older people attending two adult day centers (ADC) in the United States and identify the extent to which delirium symptoms were associated with family caregivers' mental health symptoms, and ways of coping with the older adults' care.

METHOD

A descriptive, cross-sectional design was used. Thirty older adults and their family caregivers were randomly selected from the rosters of the ADC.

RESULTS

Only 6.7% of the older adults had a positive screen for delirium. The majority of family caregivers (96.6%) stated that they had no knowledge of delirium prior to participating in this study.

IMPLICATIONS FOR PRACTICE

Both older adults and their family caregivers need education about delirium symptoms and risks.

Determinants of the burden and positivity of family caregivers of terminally ill cancer patients in Korea

OBJECTIVE

Caregivers may experience positive or negative feelings about their role. The study investigated the determinants of the burden and positivity of family caregivers of Korean terminal cancer patients.

METHODS

A multicenter cross-sectional survey was conducted with 139 family caregivers. Determinants of caregiver's burden and positivity were assessed by the Caregiver Reaction Assessment Scale and by three questions based on a previous study, respectively. Two separate hierarchical multiple regression models were used.

RESULTS

Each domain of the caregiver's burden and positivity was explained by different factors, with the total explained variance ranging between 14.4-33.6% and 2.6-18.3%, respectively. Caregivers who were unmarried, less educated, and/or had low incomes were more likely to be negatively affected, while those who shared caregiving responsibilities were less prone to negative consequences. Caregivers who were male, religious practitioners, and who perceived a higher burden of schedule disruptions were more likely to have a positive perception of their role, while those who perceived a lack of family support were less likely.

CONCLUSIONS

Our results highlight the importance of sharing the caregiving burden with the other family members. Organizing a family meeting can provide an opportunity for other family members to acknowledge the feelings and reactions of the primary caregivers, and can prompt the sharing of caregiving responsibilities.

Subcutaneous olanzapine for hyperactive or mixed delirium in patients with advanced cancer: a preliminary study

CONTEXT

Oral olanzapine is effective in controlling agitation in patients with delirium, but often, parenteral administration is necessary. Intramuscular (IM) olanzapine is approved for managing agitation in schizophrenia, but this route is inappropriate for terminally ill patients.

OBJECTIVES

The purpose of this pilot study was to determine the safety and tolerability of subcutaneous (SC) olanzapine in the management of hyperactive or mixed delirium in patients with advanced cancer.

METHODS

We conducted a prospective open-label study in patients with advanced cancer who had agitated delirium (Richmond Agitation Sedation Scale [RASS] score ≥+1) that had not responded to a 10mg or higher dose of parenteral haloperidol over 24 hours. Patients received olanzapine 5mg SC every eight hours for three days and continued haloperidol for breakthrough agitation. For patients requiring more than 8mg of rescue haloperidol daily, the olanzapine dose was increased to 10mg SC every eight hours. Injection site, systemic toxicity, and efficacy (RASS score <+1 and total haloperidol dose <8mg per 24 hours on the last study day) were evaluated.

RESULTS

Twenty-four patients received at least one olanzapine injection, and 15 (63%) completed the study. Median age of evaluable patients was 58 years (range 49-79), and 67% were males. No injection site toxicity was observed after 167 injections. Probable systemic toxic effects were observed in four patients (severe hypotension [blood pressure <90/50mmHg], paradoxical agitation, diabetes insipidus, and seizure). Efficacy was achieved in nine (37.5%) patients.

CONCLUSIONS

IM olanzapine is well tolerated subcutaneously. Further research is needed to evaluate its efficacy in controlling agitated delirium.

[Using psychostimulants in end-of-life patients with hypoactive delirium and cognitive disorders: A literature review]

OBJECTIVE

To review the research about psychostimulant effects on cognitive functions in end-of-life patients diagnosed with hypoactive delirium or cognitive disorders.

METHOD

The MEDLINE (1966-March 2008), Embase (1974-March 2008), PsycINFO (1806-March 2008), IPA (1970-March 2008), CINAHL (1982-March 2008), ISI Web of Science (1945-March 2008), Current Contents (March 2007-March 2008), Access Medicine (2001-March 2008), and ProQuest Dissertations & Theses (1980-March 2008) databases were searched with keywords related to delirium, cognition, psychostimulants, and palliative care for French or English articles in a dementia-free and hyperactive delirium-free end-of-life population. Cognitive functions had to be assessed before and after initiation of the psychostimulant treatment. Moreover, treatment had to be initiated after the onset of cognitive impairments.

RESULTS

A total of 173 studies were screened. Five studies on methylphenidate and 1 study on caffeine met inclusion criteria and were included in this review. Two studies were case reports, 2 were open-label trials, and 2 were double-blind, crossover randomized placebo-controlled trials. Three studies were conducted with hypoactive delirium patients and all studies were conducted in an advanced cancer patient population.

CONCLUSIONS

The reviewed studies support the use of methylphenidate to improve end-of-life patient cognitive functions, particularly in the case of hypoactive delirium. Caffeine seems to have beneficial effects on psychomotor activity. Further well-designed studies are needed to consolidate these findings.

The recognition and documentation of delirium in hospital palliative care inpatients

Objective:

Delirium is a clinical syndrome that is known to be under recognized by palliative care teams. A wide variation in reported prevalence may reflect differences in definitions and assessment methods, patient characteristics, and study design. The aim of this study was to test an intervention to improve recognition of delirium in the inpatient palliative care setting.

Method:

We conducted a retrospective palliative care notes review of documented prevalence of delirium among 61 patients referred to the Specialist Palliative Care Advisory Team (SPCT). Subsequently, training in the use of the Confusion Assessment Method (CAM) was provided to the SPCT and a prospective survey of the prevalence of delirium measured by the CAM was undertaken with the next 59 patients referred.

Results:

In the retrospective chart review, the term “delirium” was not used, and synonyms were identified and used to establish a delirium prevalence of 11.5%. In the intervention utilizing the CAM in a prospective sample of 59 referred patients, a prevalence rate of 8.5–15.2% for delirium was found. Use of the CAM was received favorably by the SPCT.

Significance of Results:

The institution of the use of the CAM as a screening and assessment tool in the inpatient palliative care setting did not significantly increase the recognition of delirium. Reasons for the low prevalence of delirium are discussed.

The assessment and management of delirium in cancer patients

Delirium remains the most common and distressing neuropsychiatric complication in patients with advanced cancer. Delirium causes significant distress to patients and their families, and continues to be underdiagnosed and undertreated. The most frequent, consistent, and, at the same time, reversible etiology is drug-induced delirium resulting from opioids and other psychoactive medications. The objective of this narrative review is to outline the causes of delirium in advanced cancer, especially drug-induced delirium, and the diagnosis and management of opioid-induced neurotoxicity. The early symptoms and signs of delirium and the use of delirium-specific assessment tools for routine delirium screening and monitoring in clinical practice are summarized. Finally, management options are reviewed, including pharmacological symptomatic management and also the provision of counseling support to both patients and their families to minimize distress.

Delirium resolution in hospitalized older patients with cancer

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.

Eye tracking technology: a fresh approach in delirium assessment?

The objective of this paper is to highlight the potential role of eye tracking technology (ETT) in the assessment of delirious patients. Delirium occurs in one in five general hospital admissions (Siddiqi, 2006) and its frequency will increase as society gets older. Despite its frequency and significant independent impact upon morbidity and mortality, delirium remains under studied and is frequently missed, detected late, or misdiagnosed (Farrell & Ganzani, 1995; Inouye, 2001; Kakuma, 2003). Detection is a key target for both clinical and research efforts. Assessment of attention is key to diagnosing delirium, yet nurses and non-research medical staff often fail to correctly identify inattention (Inouye et al., 2001; Lemiengre et al., 2006; Ryan et al., 2008). Eye tracking measures have been used in a plethora of key areas of psychiatric research (Crawford et al., 2005; Corden, Chilvers, & Skuse, 2008; Hardin, Schroth, Pine, & Ernst, 2007; Holzman, Leonard, Proctor, & Hughes, 1973), and provide an accurate and non-invasive method in the assessment of cognitive function. The potential of ETT for direct clinical applications in the assessment of attention and comprehension, key cognitive symptoms of delirium, are promising. This paper considers potential new approaches which recent advancements in non-invasive ETT may bring to the examination and understanding of delirium.

The virtual gateway: opening doors in delirium teaching and learning

Delirium is a common, serious and potentially preventable problem. It is argued here that knowledge and skills for effective assessment and treatment of delirium cannot be considered 'specialist'. Rather, delirium is a problem that requires a healthcare team approach to assessing patients, identifying risks or symptoms and reducing precipitating factors. Research from the preceding decade suggests that the clinical reality is falling short of this ideal with the result that many cases of delirium go undetected and many precipitating factors are not reduced where this is indeed possible. This presents a challenge for the education of nursing and medical students and for the development of qualified staff in practice. The current paper outlines an educational approach, e-learning, which increases access for learners, integrates knowledge and skill development and promotes active, problem-based learning.

Reversibility of delirium in terminally ill patients and predictors of mortality

In this study, factors related to reversibility and mortality in consecutive cases of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) delirium [n = 121] occurring in palliative care patients were evaluated. Delirium was assessed with the revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Patients were followed until recovery from delirium or death. In all, 33 patients (27%) recovered from delirium before death. Mean time until death was 39.7 +/- 69.8 days in patients with reversible delirium [n = 33] versus 16.8 +/- 10.0 days in those with irreversible delirium [n = 88; P < 0.01]. DRS-R98 and CTD scores were higher in irreversible delirium (P < 0.001) with greater disturbances of sleep, language, long-term memory, attention, vigilance and visuospatial ability. Irreversible delirium was associated with greater disturbance of CTD attention and higher DRS-R98 visuospatial function. Survival time was predicted by CTD score (P < 0.001), age (P = 0.01) and organ failure (P = 0.01). Delirium was not necessarily a harbinger of imminent death. Less reversible delirium involved greater impairment of attention, vigilance and visuospatial function. Survival time is related to age, severity of cognitive impairment and evidence of organ failure.

Evaluation of End-of-Life Cancer Care From the Perspective of Bereaved Family Members: The Japanese Experience

Surveying bereaved family members could enhance the quality of end-of-life cancer care in inpatient palliative care units (PCUs). We systematically reviewed nationwide postbereavement studies of PCUs in Japan and attempts to develop measures for evaluating end-of-life care from the perspective of bereaved family members. The Care Evaluation Scale (CES) for evaluating the structures and processes of care, and the Good Death Inventory (GDI) for evaluating the outcomes of care were considered suitable methods. We applied a shortened version of the CES to three nationwide surveys from 2002 to 2007. We developed the CES as an instrument to measure the structures and processes of care and the GDI as an outcomes measure for end-of-life cancer care from the perspective of bereaved family members. We conducted three nationwide surveys in 1997, 2001, and 2007 (n = 850, 853, and 5,301, respectively). Although six of the 10 areas of the CES showed significant improvements between the two time points investigated, we identified considerable potential for further progress. Feedback from surveys of bereaved family members might help to improve the quality of end-of-life cancer care in inpatient PCUs. However, the effectiveness of feedback procedures remains to be confirmed. Furthermore, there is a need to extend the ongoing evaluation process to home care hospices and general hospitals, including cancer centers, identify the limitations of end-of-life care in all settings, and develop strategies to overcome them.

Delirium in cancer patients: a focus on treatment-induced psychopathology

PURPOSE OF REVIEW

Delirium is a neuropsychiatric syndrome that occurs frequently in cancer patients, especially in those with advanced disease. Recognition and effective management of delirium is particularly important in supportive and palliative care, especially in view of the projected increase in the elderly population and the consequent potential for the number of patients both diagnosed and living longer with cancer to increase substantively.

RECENT FINDINGS

Studies of delirium in a variety of settings have generated new insights into phenomenology, assessment tools, the psychomotor subtypes, potential patho-physiological markers, pathogenesis, reversibility, and the role of sedation in symptom control.

SUMMARY

Validated tools exist to assist in the assessment of delirium. Although our understanding of the pathogenesis of delirium has improved somewhat, there remains a compelling need to further elucidate the underlying pathophysiology, especially in relation to opioids and the other psychoactive medications that are used in supportive care. Further trials are needed, especially in patients with advanced disease to determine predictive models of reversibility, preventive strategies, outcomes, and to assess the role of antipsychotic and other medications in symptomatic management.

Differing management of people with advanced cancer and delirium by four sub-specialties

INTRODUCTION

Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer.

METHODS

A questionnaire was designed to identify investigations and treatment used, in relation to two cases.

RESULTS

Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists.

INVESTIGATIONS

85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium.

TREATMENT

Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium.

DISCUSSION

The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

A comparison of the phenomenology of pediatric, adult, and geriatric delirium

BACKGROUND

The phenomenology of delirium in childhood is understudied.

OBJECTIVE

The objective of the study is to compare the phenomenology of delirium in children, adults and geriatric patients.

POPULATION AND METHODS

Forty-six children [mean age 8.3, S.D. 5.6, range 0-17 years (inclusive)], admitted to the pediatric intensive care unit of Maastricht University Hospital, with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delirium, underwent assessment with the Delirium Rating Scale (DRS). The scores are compared with those of 49 adult (mean age 55.4, S.D. 7.9, range 18-65 years) and 70 geriatric patients (mean age 76.2, S.D. 6.1, range 66-91 years) with DSM-IV delirium, occurring in a palliative care unit. Score profiles across groups, as well as differences in individual item scores across groups are analysed with multiple analysis of variance, applying a Bonferroni correction.

RESULTS

Although the range of symptoms occurring in all three groups was similar, DRS score profiles differed significantly across the three groups (Wilks lambda=0.019, F=804.206, P<.001). On item level, childhood delirium is characterized by a more acute onset, more severe perceptual disturbances, more frequent visual hallucinations, more severe delusions, more severe lability of mood, greater agitation, less severe cognitive deficits, less severe sleep-wake cycle disturbance, and less variability of symptoms over time. Adult and geriatric delirium do not differ in their presentations, except for the presence of more severe cognitive symptoms in geriatric delirium (P=.001).

CONCLUSION

Childhood delirium has a different course and symptom profile than adult and geriatric delirium. Adult and geriatric delirium differ only in the severity of cognitive symptoms.

Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers

BACKGROUND

Delirium, a common complication of advanced cancer, may put caregivers at risk for poor mental health outcomes. We looked for a relationship between caregiver-perceived delirium in a patient with advanced cancer and rates of caregiver psychiatric disorders.

METHODS

Using cross-sectional data from 200 caregivers of patients with cancer with a life expectancy of less than 6 months, we determined the frequency of caregiver-perceived delirium, which was defined as caregivers who reported witnessing the patient "confused, delirious" on the Stressful Caregiving Response to Experiences of Dying (SCARED) weekly or more often. We tested for associations between caregiver-reported delirium and presence of caregiver mental disorders, using the Structured Clinical Interview for the DSM-IV to diagnose mental disorders and caregiver burden, as measured by the caregiver burden scale (CBS).

RESULTS

Of the 200 caregivers who completed the SCARED, 38 (19.0%) reported seeing the patient "confused, delirious" at least once per week in the month prior to study enrollment and 7 (3.5%) met criteria for generalized anxiety (GA). Caregivers of patients with caregiver-perceived delirium were 12 times more likely to have GA (odds ratio [OR] 12.12; p < 0.01). The relationship between caregiver-perceived delirium and caregiver GA persisted after adjusting for caregiver burden and exposure to other stressful patient experiences (OR = 9.99; p = 0.04).

CONCLUSIONS

This is the first report of an association between caregiver-perceived delirium and a caregiver mental health outcome. Further studies, using improved measures of delirium, are needed.

Identification of quality indicators of end-of-life cancer care from medical chart review using a modified Delphi method in Japan

End-of life care is one of the principle components of cancer care. Measurement of the quality of care provided for end-of-life cancer patients is an important issue. The aim of this study was to identify the quality indicators (QIs) for end-of-life cancer care for Japanese patients using a medical chart review. A modified Delphi method for the development of QIs was adopted. Seventeen multi-professional specialists participated by rating the appropriateness and feasibility of potential QIs. Thirty QIs for end-of-life cancer care were ultimately identified within 4 domains: (1) symptom control, (2) decision-making and preference of care, (3) family care, and (4) psychosocial and spiritual concerns. These QIs will be useful for monitoring and evaluating end-of-life care for Japanese cancer patients. The QIs are feasible for use in any clinical setting and cover a comprehensive area in accordance with the World Health Organization's (WHO) definition of palliative care including physical, psychosocial, and spiritual concerns.

Terminal delirium: recommendations from bereaved families' experiences

Although delirium is a common complication in terminally ill cancer patients and can cause considerable distress for family members, little is known about effective care strategies for terminal delirium. The primary aims of this study were 1) to clarify the distress levels of bereaved families and their perceived necessity of care; and 2) to explore the association between these levels and family-reported professional care practice, family-reported patient behavior, and their interpretation of the causes of delirium. A multicenter questionnaire survey was conducted on 560 bereaved family members of cancer patients who developed delirium during their final two weeks in eight certified palliative care units across Japan. We obtained 402 effective responses (response rate, 72%) and, as 160 families denied delirium episodes, 242 responses were analyzed. The bereaved family members reported that they were very distressed (32%) and distressed (22%) about the experience of terminal delirium. On the other hand, 5.8% reported that considerable or much improvement was necessary, and 31% reported some improvement was necessary in the professional care they had received. More than half of the respondents had ambivalent wishes, guilt and self-blame, and worries about staying with the patient. One-fourth to one-third reported that they felt a burden concerning proxy judgments, burden to others, acceptance, and helplessness. High-level emotional distress and family-perceived necessity of improvement were associated with a younger family age; male gender; their experience of agitation and incoherent speech; their interpretation of the causes of delirium as pain/physical discomfort, medication effects, or mental weakness/death anxiety; and their perception that medical staff were not present with the family, not respecting the patient's subjective world, not explaining the expected course with daily changes, and not relieving family care burden. In terminal delirium, a considerable number of families experienced high levels of emotional distress and felt some need for improvement of the specialized palliative care service. Control of agitation symptoms with careful consideration of ambivalent family wishes, providing information about the pathology of delirium, being present with the family, respecting the patient's subjective world, explaining the expected course with daily changes, and relieving family care burden can be useful care strategies.

Terminal delirium: families' experience

BACKGROUND

Although delirium is a common complication in terminally ill cancer patients and can cause considerable distress to family members, little is known about the actual experience of family members. The primary aims of this study were thus to explore: (1) what the family members of terminally ill cancer patients with delirium actually experienced, (2) how they felt, (3) how they perceived delirium and (4) what support they desired from medical staff.

METHODS

A single-center in-depth qualitative study on 20 bereaved family members of cancer patents who developed delirium during the last two weeks before death. Content analysis of transcribed text was performed.

RESULTS

Families experienced various events including other than psychiatric symptoms, such as ;patients talked about events that actually occurred in the past', ;patients were distressed as they noticed that they were talking strangely,' ;patients talked about uncompleted life tasks', and ;patients expressed physiologic desires such as excretion and thirst'. Family emotions were positive, neutral, or negative (eg, distress, guilt, anxiety and worry, difficulty coping with delirium, helplessness, exhaustion and feeling a burden on others). Families perceived the delirium to have different meanings, including positive meanings (eg, relief from real suffering), a part of the dying process, and misunderstanding of the causes of delirium (effects of drugs, mental weakness and pain). Families recommended several support measures specifically for delirium, in addition to information and general support: ;respect the patients' subjective world', ;treating patients as the same person as before', ;facilitating preparations for the patients' death', and ;relieving family's physical and psychological burden'.

CONCLUSIONS

From the results of this study, we generated a potentially useful care strategy for terminal delirium: respect the patients' subjective world, treat patients as the same persons as before, explore unmet physiological needs behind delirium symptoms, consider ambivalent emotions when using psychotropics, coordinate care to achieve meaningful communication according to changes in consciousness levels during the day, facilitate preparations for the patients' death, alleviate the feelings of being a burden on others, relieve family's physical and psychological burden and information support.

Quality of life of caregivers of patients with advanced-stage cancer

There has been much research documenting the impact of having a loved one diagnosed with advanced cancer, but little is known about how to reduce care-giver burden. In this randomized controlled trial, the authors examined the potential relationship of an advanced cancer patient's participation in an 8-session, structured, multidisciplinary intervention on the care-giver's burden and quality of life (QOL). Although the patients randomly assigned to the intervention (n = 54) demonstrated improved QOL compared to the control condition (n = 49) participants (P < .05), there was no evidence that improving the patient's QOL made an impact on the caregiver's level of burden or the care-giver's QOL. Further investigation is warranted in this area, including interventions specifically designed and targeted to both reduce caregiver burden and to improve caregiver QOL.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES

To examine key aspects of delirium in a sample of hospitalized older patients with cancer.

DESIGN

Secondary analysis of data from studies on acute confusion in hospitalized older adults.

SETTING

Tertiary teaching hospital in the southeastern United States.

SAMPLE

76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses.

METHODS

Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission.

MAIN RESEARCH VARIABLES

Prevalent and incident delirium, etiologic risk patterns, and patient characteristics.

FINDINGS

Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium.

CONCLUSIONS

Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients.

IMPLICATIONS FOR NURSING

Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Coping and psychological well being in families of elderly cancer patients

This article reviews research directions on elderly cancer patients and the consequences of their disease for their partners and families. In a systematic review of the research literature, five research directions were identified: first, the relationship between the family and the etiology of the disease; second, the importance of the family as a source of social support; third, family caregivers as second order patients and the moderating role of psychological factors; fourth, cancer as a challenge for the family and fifth, ways of providing social and psychological support for the families of patients including examples for intervention programs. It is shown that the assumption of a "psychogenic" etiology may inhibit adaptive processes. Depending on its quality, social support can trigger adaptive coping in the patients. Elderly patients seem to be ambivalent in their attitudes towards social support because they may feel hindered with respect to their autonomy. Distress among family members is sometimes very similar to the distress experienced by patients. Several studies have shown that distress is differentially influenced by disease-related, personal and interpersonal factors as well as social resources. Interpersonal factors seem to have a specific impact on the adaptive capacities of patients and their family members. Open communication, a "healthy" family cohesion and adaptive competence seem to positively influence patients' coping. Support programs which actively include family members seem to be effective in reducing the distress of patients and their relatives. Some conclusions will be drawn including a discussion of future research directions.

Opioid rotation from morphine to fentanyl in delirious cancer patients: an open-label trial

Although recent studies suggest that opioid rotation could be an effective treatment strategy for morphine-induced delirium, there have been no prospective studies to investigate the treatment effects of opioid rotation using fentanyl. The primary aim of this study was to clarify the efficacy of opioid rotation from morphine to fentanyl in symptom palliation of morphine-induced delirium. Twenty-one consecutive cancer patients with morphine-induced delirium underwent opioid rotation to fentanyl. Physicians recorded the symptom severity of delirium (the Memorial Delirium Assessment Scale, MDAS), pain, and other symptoms (categorical verbal scale from 0: none to 3: severe) and the Schedule for Team Assessment Scale (STAS) (from 0: none to 4: extreme); and performance status at the time of study enrollment and three and seven days after. Of 21 patients recruited, one patient did not complete the study. In the remaining 20 patients, morphine was substituted with transdermal fentanyl in 9 patients and parenteral fentanyl in 11 patients. Total opioid dose increased from 64 mg oral morphine equivalent/day (Day 0) to 98 mg/day (Day 7), and the median increase in total opioid dose was 42%. Treatment success, defined as an MDAS score below 10 and pain score of 2 or less, was obtained in 13 patients on Day 3 and 18 patients on Day 7. The mean MDAS score significantly decreased from 14 (Day 0) to 6.4 and 3.6 (Days 3 and 7, respectively, P < 0.001). Pain scores significantly decreased from 2.2 (Day 0) to 1.3 and 1.1 on the categorical verbal scale (Days 3 and 7, respectively, P < 0.001); from 2.6 (Day 0) to 1.6 and 1.3 on the STAS (Days 3 and 7, respectively, P < 0.001). Symptom scores of dry mouth, nausea, and vomiting significantly decreased, and performance status significantly improved. Opioid rotation from morphine to fentanyl may be effective in alleviating delirium and pain in cancer patients with morphine-induced delirium.