The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses

A questionnaire to determine nurses' knowledge of delirium and its risk factors

Delirium is a frequent complication of hospital admission, especially among the elderly. It can have serious consequences in terms of morbidity, mortality and decreased quality of life. Nevertheless, an extensive literature review found that it is poorly recognised and poorly managed by medical and nursing staff. Although some researchers have found that education programs for nurses can improve outcomes for patients with delirium, no research assessing nurses' knowledge was found. The objective of this research was to determine nurses' level of knowledge regarding delirium and its risk factors. A questionnaire survey sent to nurses at a teaching hospital found that nurse's knowledge of delirium was generally inadequate, although one ward which had had in-service education attained better results. It is recommended that cognitive assessment in general and delirium in particular be incorporated into nursing education. Improved education could potentially lead to improved health outcomes and considerable cost savings.

The opportunity for psychiatry in palliative care

The need for psychiatrists to work with patients and families living with chronic life-threatening illnesses has never been greater. Further, psychiatrists may find exciting work within the relatively new field of palliative care, which is devoted to the prevention and relief of all suffering. Increasingly, individuals are living longer with multiple issues that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To ensure state-of-the-art care for patients and families throughout an illness and any ensuing bereavement period, many experienced psychiatrists are needed as consultants to, and as members of, interdisciplinary palliative care teams. This need presents limitless opportunities for psychiatrists to care for patients, provide education, and engage in research. The potential to make a difference is great.

Psychiatric aspects of organ transplantation in critical care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

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.

Drug treatment of delirium: past, present and future

OBJECTIVE

The aim of this review was to summarize and critically evaluate the current literature regarding the safety and efficacy of drug therapy in delirium. We also identified recent research developments and highlighted some ongoing clinical trials to explore future directions in drug treatment and prevention of delirium.

METHODS

We conducted a literature search of Medline, Embase, PsychInfo, and Cochrane Review databases, which included both prospective and retrospective clinical trials and case studies on delirium and drug therapy in adult patients up to March 2008. Abstracts from recent topical conferences were also reviewed. Ongoing delirium drug studies were identified via the WHO International Clinical Trials Registry Platform Search Portal, accessed March 12, 2008.

RESULTS

The evidence base for effective drug treatment of delirium is restricted by limitations in many of the studies conducted to date. However, there has been an increase in the quantity and quality of delirium drug studies in recent years; preliminary reports and ongoing studies add to this trend. Although efficacy rates between typical and atypical antipsychotic agents are similar, the latter are associated with fewer extrapyramidal side effects. Prophylactic interventions with antipsychotic and cholinesterase inhibitors in high-risk patients provide an opportunity to improve postoperative patient care. Alternative techniques and medication opportunities could be explored in attempts to minimize drug induced delirium potential.

CONCLUSIONS

Appropriate drug therapy should be considered part of systematic approaches to delirium treatment and prevention. There is a need for well-designed randomized, double-blind placebo-controlled trials investigating the drug management of various aspects of delirium, including delineating treatment by delirium subtype, dose ranging studies, and optimal duration of therapy.

Delirium issues in palliative care settings

OBJECTIVE

The objective of this study is to provide an expert review of delirium in the context of palliative care.

METHODS

Based on a primary selection criterion, firstly, studies were included for review if the population studied either had a diagnosis of advanced cancer or was receiving palliative care; alternatively, in the absence of data derived from these populations, studies conducted in other populations were included. Secondly, from the studies meeting the primary selection criterion, we selected those that examined specific standard outcome measures. Thirdly, we selected studies and literature reviews that identified delirium research issues.

RESULTS

Delirium occurs commonly in the context of palliative care where it is likely to cause heightened distress for patients, carers, and families alike, and make interpretation of pain and other symptoms extremely difficult. There is a profound dearth of rigorous studies on delirium in this setting. Ambiguous terminology, varying definitions in internationally recognized classification systems, and failure to use validated assessment tools lead to wide-ranging incidence and prevalence of delirium episodes in such populations. Episodes are usually multifactorial in origin and may portend poor prognosis by preceding death in many cases. Despite this, many are often at least partially reversible with relatively low-burden interventions. The patient's disease status, previous quality of life, and prior expressed wishes regarding goals of care should all be taken into account. Antipsychotics are the pharmacotherapeutic agents most commonly used to control symptoms despite limited evidence either supporting their efficacy or examining their adverse event profile. Often, symptomatic control alone is indicated. In cases with refractory symptoms, deeper or "palliative" sedation may be required.

CONCLUSION

Further research is needed regarding delirium recognition, phenomenology, the development of low-burden instruments for assessment, family education, predictive models for reversibility, and evidence-based guidelines on the appropriate use of palliative sedation.

The delirium experience: a review

While the adverse medical complications and consequences of delirium has been well studied, the same is not true of the psychological morbidity associated with the condition. A better understanding of what it is like to be delirious has the potential to improve recognition, management and treatment of delirium. This article examines the literature relating to the experience of delirium from the perspective of patients, families, and staff. Finally, suggestions for further work that might advance might advance our understanding of these issues are outlined.

Delirium phenomenology: what can we learn from the symptoms of delirium?

OBJECTIVES

This review focuses on phenomenological studies of delirium, including subsyndromal and prodromal concepts, and their relevance to other elements of clinical profile.

METHODS

A Medline search using the keywords delirium, phenomenology, and symptoms for new data articles published in English between 1998 and 2008 was utilized. The search was supplemented by additional material not identified by Medline but known to the authors.

RESULTS

Understanding of prodromal and subsyndromal concepts is still in its infancy. The characteristic profile can differentiate delirium from other neuropsychiatric disorders. Clinical (motoric) subtyping holds potential but more consistent methods are needed. Studies are almost entirely cross-sectional in design and generally lack comprehensive symptom assessment. Multiple assessment tools are available but are oriented towards hyperactive features and few have demonstrated ability to distinguish delirium from dementia. There is insufficient evidence linking specific phenomenology with etiology, pathophysiology, management, course, and outcome.

CONCLUSIONS

Despite the major advancements of the past decade in many aspects of delirium research, further phenomenological work is crucial to targeting studies of causation, pathophysiology, treatment, and prognosis. We identified eight key areas for future studies.

Caring for hospitalized older adults at risk for delirium: the silent, unspoken piece of nursing practice

More than half of hospitalized older adults will experience delirium, which--if left untreated--can lead to detrimental outcomes. Despite the prevalence and severity of delirium, nurses recognize less than one third of cases. Because little is known about how nurses manage this problem, a qualitative study was conducted to explore how nurses care for hospitalized older adults at risk for delirium. The data revealed that nurses care for older adults byTaking a Quick Look, Keeping an Eye on Them, and Controlling the Situation. The context in which nurses choose their priorities and interventions was reflected in the themes of the Care Environment and Negative Beliefs and Attitudes about older adults. Nurses are caring for an older population whose care requirements are different than those of younger people and in a context where this challenging work is rarely addressed. To improve care, the older population must be acknowledged, and nurses must possess the knowledge and resources needed to meet this population's unique needs.

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.

An update on the use of antipsychotics in the treatment of delirium

Objective:

Delirium is the most common neuropsychiatric complication of medical illness, a medical emergency that needs to be identified and treated vigorously. Delirium is too frequently underdiagnosed and untreated in the medical setting, which leads to increased morbidity and mortality, interference in the management of symptoms such as pain, an increased length of hospitalization, increased health care costs, and distress for patients and their caregivers (Inouye, 2006; Breitbart et al., 2002a, 2002b). In this article, we present an update of the use of antipsychotics in management of delirium based on the available literature and our own clinical experience.

Methods:

We reviewed the current literature on the role of antipsychotics in the management of delirium using standard computer-based search methods (e.g., PubMed).

Results:

Antipsychotic medications, including the new atypical antipsychotics, have been demonstrated to effectively manage a wide spectrum of the symptoms of delirium and are an essential component in the multimodal approach to managing delirium.

Significance of results:

The standard approach to managing delirium includes identification and elimination of factors contributing to the delirium in addition to pharmacological and nonpharmacological treatment interventions (Trzepacz et al., 1999). Newer atypical antipsychotics can play an important role in the management of the symptoms of delirium.

Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside

BACKGROUND

While nurses play a key role in identifying delirium, several authors have noted variability in their ability to recognize delirium. We sought to measure the impact of a simple educational intervention on the ability of intensive care unit (ICU) nurses to clinically identify delirium and to use a standardized delirium scale correctly.

METHODS

Fifty ICU nurses from two different hospitals (university medical and community teaching) evaluated an ICU patient for pain, level of sedation and presence of delirium before and after an educational intervention. The same patient was concomitantly, but independently, evaluated by a validated judge (rho = 0.98) who acted as the reference standard in all cases. The education consisted of two script concordance case scenarios, a slide presentation regarding scale-based delirium assessment, and two further cases.

RESULTS

Nurses' clinical recognition of delirium was poor in the before-education period as only 24% of nurses reported the presence or absence of delirium and only 16% were correct compared with the judge. After education, the number of nurses able to evaluate delirium using any scale (12% vs 82%, P < 0.0005) and use it correctly (8% vs 62%, P < 0.0005) increased significantly. While judge-nurse agreement (Spearman rho) for the presence of delirium was relatively high for both the before-education period (r = 0.74, P = 0.262) and after-education period (r = 0.71, P < 0.0005), the low number of nurses evaluating delirium before education lead to statistical significance only after education. Education did not alter nurses' self-reported evaluation of delirium (before 76% vs after 100%, P = 0.125).

CONCLUSION

A simple composite educational intervention incorporating script concordance theory improves the capacity for ICU nurses to screen for delirium nearly as well as experts. Self-reporting by nurses of completion of delirium screening may not constitute an adequate quality assurance process.

Individual delirium symptoms: do they matter?

OBJECTIVES

To evaluate the impact of individual manifestations of delirium on outcome, describe them in critically ill adults, and validate nurses' bedside item assessments from the Intensive Care Delirium Screening Checklist (ICDSC).

DESIGN

Prospective study.

SETTING

Single 16-bed medical/surgical university hospital intensive care unit.

PATIENTS

Six hundred consecutive patients admitted to the intensive care unit for >24 hrs.

INTERVENTIONS

All patients were evaluated with the eight-item ICDSC throughout their intensive care unit stay. In all patients scoring positive on any ICDSC item, individual checklist items were tallied throughout the intensive care unit stay and assessed for impact on mortality. In addition, when the ICDSC score indicated delirium (> or = 4 of 8), the subsequent overall frequency of each item was also independently documented to describe delirious patient symptoms. ICDSC items were tested for discrimination between delirious and nondelirious patients. Throughout the study, the validity of bedside delirium assessments was assessed in 30 nurses.

MEASUREMENTS AND MAIN RESULTS

We were able to assess 537 patients. In nondelirious patients, psychomotor agitation by ICDSC assessment was associated with a higher risk of mortality after adjustment for Acute Physiology and Chronic Health Evaluation, age, and the presence of coma. One hundred eight-nine patients (35.1%) developed delirium (i.e., ICDSC score > or = 4). On presentation (and throughout the intensive care unit stay), the most frequent features of delirium were inattention, disorientation, and psychomotor agitation. Each ICDSC item was highly discriminating between delirious vs. nondelirious patients. Correlation between gold standard adjudicators and nurses for the overall bedside evaluations of delirium were excellent (Pearson's correlation R = 0.924, p < .0005). Individual symptom evaluation by nurses varied: Alteration in level of consciousness was poorest (R = 0.681, p < .0005), and both disorientation and hallucinations evaluated best (R = 1.000).

CONCLUSIONS

In nondelirious patients, agitation was associated with a higher risk of mortality. Each of the eight ICDSC items is highly discriminating for the diagnosis of delirium, suggesting that any screening or diagnostic scales should incorporate them. Quality assurance and educational efforts should, therefore, emphasize independent assessment of the individual features of delirium.

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.

How to try this: detecting delirium

For patients and their loved ones, delirium can be a frightening experience. A fluctuating mental status is important to identify because it often signals a need for additional treatment. The Confusion Assessment Method (CAM) diagnostic algorithm enables nurses to assess for delirium by identifying the four features of the disorder that distinguish it from other forms of cognitive impairment. It can be completed in five minutes and is easily incorporated into ongoing assessments of hospitalized patients. (This screening tool is included in the series Try This: Best Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York University's College of Nursing.) For a free online video demonstrating the use of this tool, go to http://links.lww.com/A209.

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.

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.

Managing delirium in hospitalized elderly patients

This review highlights the key elements of guidelines developed for the management of delirium. Experts and expert panels in several countries have presented their own guidelines, which have similarities but also differences in their emphases. The essential elements in the management of delirium are appropriate detection and diagnosis, assessment and treatment of underlying conditions, symptom management, environmental and supportive interventions, post-delirium care and follow-up, and paying attention to risk factors and prevention. The level of evidence behind each recommendation of the guidelines is discussed, as well as some of the typical pitfalls in the care of patients with delirium. Although rigorous randomized intervention trials on full-blown delirium are still scarce, we have some trials suggesting how to manage each dimension of the care of delirium.

Cytokines and acute phase response in delirium

OBJECTIVE

This study aimed to examine the expression patterns of pro- and anti-inflammatory cytokines in elderly patients with and without delirium who were acutely admitted to the hospital.

METHODS

All consecutive patients aged 65 years and older, who were acutely admitted to the Department of Internal Medicine of the Academic Medical Center, Amsterdam, a tertiary university teaching hospital, were invited. Members of the geriatric consultation team completed a multidisciplinary evaluation for all study participants within 48 h after admission, including cognitive and functional examination by validated measures of delirium, memory, and executive function. C-reactive protein and cytokines (IL-1beta, IL-6, TNF-alpha, IL-8, and IL-10) were determined within 3 days after admission.

RESULTS

In total, 185 patients were included; mean age was 79 years; 42% were male; and 34.6% developed delirium within 48 h after admission. Compared to patients without delirium, patients with delirium were older and had experienced preexistent cognitive impairment more often. In patients with delirium, significantly more IL-6 levels (53% vs. 31%) and IL-8 levels (45% vs. 22%) were above the detection limit as compared with patients who did not have delirium. After adjusting for infection, age, and cognitive impairment, these differences were still significant.

CONCLUSIONS

Proinflammatory cytokines may contribute to the pathogenesis of delirium in acutely admitted elderly patients.

Palliative care in the surgical intensive care unit: where least expected, where most needed

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.

Interventions for preventing delirium in hospitalised patients

BACKGROUND

Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients.

OBJECTIVES

Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings.

SEARCH STRATEGY

We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 28th September, 2005. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials.

SELECTION CRITERIA

Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients.

DATA COLLECTION AND ANALYSIS

Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus.

MAIN RESULTS

Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer. Only one study of 126 hip fracture patients comparing proactive geriatric consultation with usual care was sufficiently powered to detect a difference in the primary outcome, incident delirium. Total cumulative delirium incidence during admission was reduced in the intervention group (OR 0.48 [95% CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to treat' of 5.6 patients to prevent one case. The intervention was particularly effective in preventing severe delirium. In logistic regression analyses adjusting for pre fracture dementia and Activities of Daily Living impairment, there was no reduction in effect size, OR 0.6, but this no longer remained significant [95% CI 0.3,1.3]. There was no effect on the duration of delirium episodes, length of hospital stay, and cognitive status or institutionalisation at discharge. There was also no significant difference in cumulative delirium incidence between treatment and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI 0.59, 1.36]). In another trial of low dose haloperidol prophylaxis, there was no difference in delirium incidence but the severity and duration of a delirium episode, and length of hospital stay were all reduced. We identified no completed studies in hospitalised medical, care of the elderly, general surgery, cancer or intensive care patients. In outcomes, no studies examined for death, use of psychotropic medication, activities of daily living, psychological morbidity, quality of life, carers or staff psychological morbidity, cost of intervention and cost to health care services. Outcomes were only reported up to discharge, with no studies reporting medium or longer-term effects.

AUTHORS' CONCLUSIONS

Research evidence on effectiveness of interventions to prevent delirium is sparse. Based on a single study, a programme of proactive geriatric consultation may reduce delirium incidence and severity in patients undergoing surgery for hip fracture. Prophylactic low dose haloperidol may reduce severity and duration of delirium episodes and shorten length of hospital admission in hip surgery. Further studies of delirium prevention are needed.

Impact of delirium on cognition, distress, and health-related quality of life after hematopoietic stem-cell transplantation

PURPOSE

To determine the impact of delirium during the acute phase of myeloablative hematopoietic stem-cell transplantation (HSCT) on health-related quality of life (HRQOL), distress, and neurocognitive functioning 30 and 80 days after transplantation.

PATIENTS AND METHODS

Ninety patients completed a battery assessing HRQOL, distress, and neuropsychological functioning before receiving their first HSCT. Delirium was assessed three times per week using the Delirium Rating Scale and the Memorial Delirium Assessment Scale from 7 days before transplantation through 30 days after transplantation. At 30 days after transplantation, distress and neurocognitive functioning were assessed. At 80 days after transplantation, HRQOL, distress, and neuropsychological functioning were re-evaluated.

RESULTS

After adjusting for confounding factors, patients who experienced a delirium episode, versus patients who did not, reported significantly worse depression, anxiety, and fatigue symptoms at 30 days (linear regression beta(s) = 0.2, 0.3, and 0.5, respectively; P < .04). At 80 days, patients with a delirium episode had significantly worse executive functioning (beta = -1.1; P < .02), attention and processing speed (beta(s) = -4.7 and -5.4, respectively; P < .03), mental health on the Medical Outcomes Study Health Survey, 12-item short form (beta = -6.5; P < .02), and anxiety, fatigue, and cancer and treatment distress symptoms (beta(s) = 0.4, 0.6, and 0.3, respectively; P < .03).

CONCLUSION

Patients with a malignancy who experience delirium during myeloablative HSCT showed impaired neurocognitive abilities and persistent distress 80 days after transplantation. Effective prevention or treatment of delirium during HSCT may improve both cognitive and psychological outcomes.

Subsyndromal delirium in the ICU: evidence for a disease spectrum

OBJECTIVE

ICU delirium is common and adverse. The Intensive Care Delirium Screening Checklist (ICDSC) score ranges from 0 to 8, with a score of 4 or higher indicating clinical delirium. We investigated whether lower (subsyndromal) values affect outcome.

PATIENTS

600 patients were evaluated with the ICDSC every 8[Symbol: see text]h.

MEASUREMENTS AND RESULTS

Of 558 assessed patients 537 noncomatose patients were divided into three groups: no delirium (score = 0; n = 169, 31.5%), subsyndromal delirium (score = 1-3; n = 179, 33.3%), and clinical delirium (score >or=4; n = 189, 35.2%). ICU mortality rates were 2.4%, 10.6%, and 15.9% in these three groups, respectively. Post-ICU mortality was significantly greater in the clinical delirium vs. no delirium groups (hazard ratio = 1.67) after adjusting for age, APACHE II score, and medication-induced coma. Relative ICU length of stay was: no delirium < subsyndromal delirium < clinical delirium and hospital LOS: no delirium < subsyndromal delirium approximately clinical delirium. Patients with no delirium were more likely to be discharged home and less likely to need convalescence or long-term care than those with subsyndromal delirium or clinical delirium. ICDSC score increments higher than 4/8 were not associated with a change in mortality or LOS.

CONCLUSIONS

Clinical delirium is common, important and adverse in the critically ill. A graded diagnostic scale permits detection of a category of subsyndromal delirium which occurs in many ICU patients, and which is associated with adverse outcome.

Evaluation of the memorial delirium assessment scale (MDAS) for the screening of delirium by means of simulated cases by palliative care health professionals

BACKGROUND

Delirium is among the most common neuropsychiatric complications of advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a widely used and validated screening tool for delirium in cancer patients.

OBJECTIVE

The purpose of this study was to assess the use of the MDAS by different palliative care health professionals after receiving formal training and a guiding manual for administration and scoring.

MATERIALS AND METHODS

Thirty-one palliative care health professionals received a training session on the MDAS, including description of the tool, validation, and scoring. Participants also received copies of a proposed standardized manual for completion of the MDAS. Two of the investigators presented three simulated cases to the participants, who independently completed a scoring sheet for each case. The data were then analyzed according to the cases and the profession of the operators.

RESULTS

Thirty-one scoring sheets were analyzed (11 physicians, 12 nurses, and 8 others). A correct diagnosis was achieved by 30 (96.8%) of the 31 participants in case 1 (nondelirious, true score = 5, median = 5, range = 2-15), 28 of 31 (90.3%) in case 2 (severe mixed delirium, true score = 20, median = 18, range = 10-26), and 31 of 31 in case 3 (mild hypoactive delirium, true score = 14, median = 19, range = 13-25). Overall percentage of error was 31% for items 2, 3, and 4 (cognitive) and 45% for all other items (observational) (p < 0.001). The percentage of error did not differ between physicians and nurses and other palliative care professionals (p > 0.99).

CONCLUSIONS

Our preliminary results suggest that adequate training and a guiding manual can enhance the application of MDAS by palliative care health professionals in the teaching settings. Clinical studies to assess the utility of the MDAS as a screening tool are justified to further confirm these findings.

Phenomenology of delirium in cancer patients, as described by the Memorial Delirium Assessment Scale (MDAS) and the Delirium Rating Scale (DRS)

This study was based on the data collected on a consecutive sample of 106 cancer patients referred for mental status evaluation. All patients were evaluated by use of the Confusion Assessment Method (CAM) algorithm, the Delirium Rating Scale (DRS), the Memorial Delirium Assessment Scale (MDAS), and a question about the subjective perception of delirium. After comparing the diagnostic criteria of delirium on the DSM-III-R and DSM-IV, authors evaluated the ability of all DRS and MDAS items to discriminate delirium versus non-delirium patients, testing the difference in the distribution of the individual MDAS and DRS item scores. Authors also assessed the relationship between delirium diagnosis and the subjective perception of delirium. The MDAS showed a greater number of discriminating items. The items that proved to be less discriminating were "Hallucinations" and "Lability of Mood" on the DRS. Subjective perception only partially discriminated delirium from non-delirium patients. The way in which the DRS and MDAS reflected the DSM criteria are therefore partially different.

Life's Final Journey: The Oncology Nurse's Role

Despite advances in technology and science, many people diagnosed with cancer are likely to die from the disease. Because of the long-term relationships that oncology nurses develop with patients and their families during lengthy treatment periods, they are the most appropriate clinicians to provide care across the continuum and through the final journey. Care of patients in the final days of life requires a comprehensive knowledge of common syndromes, skillful assessment, and adept clinical management. Nurses cannot focus solely on the needs of patients; family members often are unaware of the dying process. Oncology nurses are uniquely qualified to provide education and support to families at the bedside witnessing the final days and hours of their loved ones. Finally, oncology nurses involved in the care of dying patients are at risk for burnout and need to provide care for their own needs to find balance between their professional and personal lives.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

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.

Opioid medications and longitudinal risk of delirium in hospitalized cancer patients

BACKGROUND

Delirium is an important problem in hospitalized cancer patients. The objective of this study was to determine whether exposure to corticosteroids, benzodiazepines, or opioids predicted delirium.

METHODS

A prospective cohort study was conducted in an oncology/internal medicine population. Patients were assessed continuously for the presence of delirium until they were discharged by using the Nursing Delirium Screening Scale (Nu-DESC). Follow-up for outcome began after incident delirium. The primary outcome was the presence of a delirium event, which was defined as a Nu-DESC score >1. Strengths of associations of medications with delirium were expressed as odds ratios (ORs) in univariate and multivariate analyses.

RESULTS

In total, 114 patients (1823 patient-days) met the inclusion criteria for the study. The mean follow-up from incident delirium was 16 days. The mean number of delirium events by patient was 6 (total number, 667 delirium events). Analysis by day on several occasions revealed significant associations between opioids and delirium. Corticosteroids and benzodiazepines were not associated significantly with an increased risk of delirium on any given day. Analysis by patient using generalized estimating equation (GEE) models showed an increased risk of delirium on any day of follow-up associated with opioid exposure in univariate analysis (OR of 1.70; P<.0001). The association remained significant after adjustment for corticosteroid, benzodiazepine, and antipsychotic exposure using GEE regressions (OR of 1.37; P=.0033). Truncating follow-up at 30 days did not affect the results (OR of 1.38; P<.032).

CONCLUSIONS

Exposure to opioids during hospitalization was associated significantly with an increased longitudinal risk of delirium.

Measurement of psychological distress in palliative care

Research investigating the psychological distress of palliative care patients has contributed to our understanding of the needs and experiences of individuals approaching death. This paper aims to provide a brief review of such measurement of psychological distress in palliative care, focusing on established psychiatric and psychological research tools, and quantitative research methods. This includes clinical screening and diagnostic assessment instruments used to identify key distress-related symptoms and the presence of common clinical syndromes, such as depression, anxiety, delirium, as well as the broader psychological dimensions of suffering, such as existential concerns, spirituality, hope and demoralisation. There are important considerations in undertaking psychological research in palliative care, such as maintaining a balance between the methods and measurements that will address key research questions, and sensitivity to the range of physical and emotional demands facing individuals at the point of receiving palliative care. The clinical application of psychological and psychiatric research tools and methods can aid the detection of psychological distress, aid the thorough assessment of the psychological dimension of the patients' illness and care, aid the identification of individuals who would benefit from specific psychotherapeutic or pharmacologic interventions, and the evaluation of response to treatments.

Incidence, risk factors and consequences of ICU delirium

OBJECTIVE

Delirium in the critically ill is reported in 11-80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes.

DESIGN AND SETTING

Prospective study in a 16-bed medical-surgical intensive care unit (ICU).

PATIENTS

820 consecutive patients admitted to ICU for more than 24 h.

INTERVENTIONS

Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression.

RESULTS

Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3-2.6), alcoholism (2.03, 1.2-3.2), and severity of illness (1.25, 1.03-1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5-6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5+/-11.5 vs. 4.4+/-3.9 days), longer hospital stay (18.2+/-15.7 vs. 13.2+/-19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%).

CONCLUSION

Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs.

Artificial nutrition and hydration at the end of life: Ethics and evidence

The case of Terri Schiavo resulted in substantial media attention about the use of artificial nutrition and hydration (ANH) especially by percutaneous endoscopic gastrostomy (PEG). In this article, I review ethical and legal principles governing decisions to choose or forgo ANH at the end of life, including issues of autonomy and decision-making capacity, similarities and differences between ANH and other medical treatments, the role of proxies when patients lack decision-making capacity, and the equivalence of withholding and withdrawing treatment. Evidence for palliative or life-sustaining benefits for ANH are reviewed in three disease processes: amyotrophic lateral sclerosis (ALS), cancer, and dementias, including Alzheimer's disease. Although more recent studies suggest a possible palliative role for ANH in ALS and terminal cancer, feeding tubes do not appear to prolong survival or increase comfort in advanced dementia of the Alzheimer's type.

Psychologic issues in palliative care

As medical science progresses and the life spans of patients with serious illnesses increase, the process that leads to death is becoming more feared than death itself. This fear is particularly intense in technologically advanced cultures with access to advanced medical care. The lives of patients who previously would have died rapidly are now often extended. As a result, images of suffering, such as dying in isolation and experiencing great pain, often are at the forefront of concerns about those struggling with terminal illnesses. This article provides medical practitioners with an overview of the issues and symptoms common in terminal illness, to help them work most effectively with their mental health colleagues.

Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial

BACKGROUND

Delirium is a common syndrome with poor prognosis affecting elderly inpatients. Treatment is mainly based on common sense with wide variations in practice. We investigated whether intensified, multicomponent geriatric treatment could improve the prognosis of delirious patients.

METHODS

We performed a randomized, controlled trial of 174 patients with delirium in six general medicine units from an acute hospital in Helsinki, Finland. The intervention group received individually tailored geriatric treatment. The primary endpoint was the sum of those deceased individuals and the patients permanently institutionalized. Secondary endpoints included the number of days in hospitals and other institutions, delirium intensity, and cognition.

RESULTS

The mean age of patients was 83 years, and 31% had previous dementia. The intervention group (N = 87) received significantly more acetylcholinesterase inhibitors (58.6% vs 9.2%), atypical antipsychotics (69.8% vs 30.2%), specialist consultations (49.4% vs 28.7%), hip protectors (88.5% vs 3.4%), physiotherapy (87.4% vs 47.1%), and fewer conventional neuroleptics (8.0% vs 23.0%) than did the control group (N = 87). During the 1-year follow-up, 60.9% of the intervention group and 64.4% of controls were either deceased or permanently institutionalized (p =.638). The intervention group spent a mean of 126 days in institutions, and the control group 140 days (p =.688). Delirium was, however, alleviated more rapidly during hospitalization, and cognition improved significantly at 6 months in the intervention group.

CONCLUSIONS

Faster alleviation of delirium and improved cognition justify good, comprehensive geriatric care for these patients although treatment produced no significant improvements in hard endpoints of prognosis.

Caring for patients with terminal delirium: palliative care unit and home care nurses’ experiences

AIM

To explore palliative care unit and home care nurses' experiences of caring for patients with terminal delirium.

DESIGN

A qualitative exploratory design using individual interviews.

SAMPLE

Participants included five nurses working in an interdisciplinary palliative care unit located in a large Canadian city hospital, and four nurses from a palliative home care nursing team located in the same city.

RESULTS

Nurses in both sites experienced multiple challenges caring for delirious patients. Additional education on delirium and collaborative teamwork were viewed as key factors in enhancing their ability to care for and support this patient and family population. Four core themes reflected the participants' perceptions and experiences: experiencing distress; the importance of presence; valuing the team; and the need to know more.

CONCLUSION

Findings suggest the need for interdisciplinary educational initiatives focused on the identification and management of terminal delirium, and targeted to the specific context in which nurses practise.

Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care

Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.