Symptom Expression in Patients with Advanced Cancer Admitted to an Acute Supportive/Palliative Care Unit With and Without Delirium

Delirium Motor Subtypes and Severity of Physical Symptoms in Patients with Advanced Cancer in Inpatient Hospice/Palliative Care Units: A Multicenter Prospective Cohort Study

Background: Altered cognitive function due to delirium changes the threshold or tolerance of symptoms. The impacts of delirium motor subtypes on symptoms remain unknown. Objectives: Determining whether delirium motor subtypes are associated with the severity of physical symptoms in a palliative care setting. Design: A secondary analysis of a multicenter prospective observational study. Setting/Subjects: We included consecutive patients with advanced cancer admitted to 23 inpatient hospices in Japan in 2017. Measurements: Occurrence of delirium, motor subtype, and severity of pain and dyspnea (Integrated Palliative Care Outcome Scale) were assessed at admission (T1) and on the day of Palliative Performance Scale declined to 20 (T2). Results: T1 and T2 data were obtained from 1896 and 1396 patients, respectively. Using patients without delirium as a reference, the odds ratio (OR) for moderate-to-overwhelming pain among those with hyperactive or mixed delirium was significantly higher at T1 and T2 (OR, 95% confidence interval [CI]: 1.49, 1.15-1.92, and 1.71, 1.26-2.32, respectively). A similar trend was observed for dyspnea at T1 and T2 (OR, 95% CI: 1.54, 1.16-2.06, and 1.88, 1.39-2.55, respectively). However, patients with hypoactive delirium did not have higher odds of developing severe symptoms. Patients without delirium at T1, who developed hyperactive or mixed delirium, had a higher severity of both pain and dyspnea than those who were delirium-free (OR, 95% CI; 1.60, 1.08-2.37, and 1.86, 1.27-2.72, respectively) at T2. Conclusion: Hyperactive delirium is associated with the intensity of pain and dyspnea in patients receiving palliative care.

Increasing Awareness and Access to Integrated Behavioral Health and Palliative Care: An Introduction to the American Journal of Hospice and Palliative Medicine's

Mental health symptoms are common in the general population and are overrepresented in patients receiving palliative care and hospice services. This introduction to the special issue on Mental Health in Palliative Care and Hospice highlights the ongoing need for research and training to prepare our palliative care workforce to address the concerns of patients experiencing serious illness and mental health concerns. Multilevel approaches are needed to enhance understanding of mental health needs among people with serious illness. Public health outreach is needed within our communities, targeted support is needed for family caregivers, and structured training for palliative care and hospice clinicians is needed to enhance competent mental health in these settings.

Pharmacological Strategies for Providing Patients With Delirium Relief From Terminal Dyspnea: A Secondary Data Analysis

INTRODUCTION

Systemic opioids are recommended as a pharmacological treatment for dyspnea, and antipsychotics are widely used for delirium. Because little is known about optimal palliative pharmacological strategies for dyspnea in patients with delirium, this study explored the symptom course in such cases, including the use of opioids and antipsychotics.

METHODS

This was a secondary analysis of a multicenter prospective and observational study. We consecutively enrolled adult patients with advanced cancer at palliative care units in Japan. The eligibility criteria for their participation were a dyspnea Integrated Palliative care Outcome Scale (IPOS) score ≥ 2 and the presence of delirium. We investigated pharmacological strategies, IPOS for dyspnea, and delirium symptoms using item 9 of the Memorial Delirium Assessment Scale.

RESULTS

Of the 1896 patients, 141 were found eligible and were analyzed. Eighty-two (58%) patients had agitated delirium, and the median survival period was 4 days. Regarding pharmacological strategy, 31 (22%) received opioid initiation or dose escalation, whereas 92 (65%) used regular antipsychotics. Although mean dyspnea IPOS scores significantly decreased from Day 1 to Day 2 (0.44, 95% CI: 0.24-0.64), the proportion of responders (IPOS score ≤ 1) was 21% (30/141). In the agitated delirium group, the proportion of remaining agitation symptoms at Day 2 was 74% (61/82).

CONCLUSIONS

The combined distressing symptoms of dyspnea and delirium during the last days of life are likely to be refractory suffering, which shows a poor response to pharmacological interventions, including opioids and antipsychotics.

Characterizing Difficulties and Management of Sleep Disturbances in a Tertiary Palliative Care Unit-A Retrospective Review

Objective: Difficulty sleeping is common in palliative care, however often unrecognized by palliative care physicians. This retrospective review aims to gain a better understanding of the causes and treatment of sleeping disturbances in a tertiary palliative care unit. Methods: This study included 200 palliative care inpatients admitted between January 1, 2015, and August 31, 2020. Patients with sleep disturbances were placed into 3 subgroups: insomnia, delirium, and those with an unclear diagnosis. These categories were analyzed by bivariate analysis (ANOVA, Kruskal-Wallis) to determine statistical significance. Results: A total of 156 (78%) patients had symptoms suggestive of sleep disturbance and 163 (81.5%) patients were prescribed a sedative for sleep disturbance. Most patients were prescribed lorazepam (52 [26%]), followed by haloperidol (47 [23.5%]), and zopiclone (33 [16.5%]). Benzodiazepine and zopiclone prescribing decreased over time, while antipsychotic prescribing remained stable. When analyzed according to the most likely cause of the sleep disturbance, patients with insomnia had a higher Palliative Performance Score (P < .035) and were more likely to have a previous medical history of insomnia (P < .0003) than those with delirium. Both insomnia and delirium were quickly diagnosed but patients with unclear sleep disturbances took longer to recognize and treat. Conclusion: These results suggest that sleep disturbances are common at the end of life and can be challenging to categorize. Using specific criteria may be helpful in differentiating insomnia versus delirium and ultimately lead to more consistent approaches to management.

Severity of Symptoms as an Independent Predictor of Poor Outcomes in Patients with Advanced Cancer Presenting to the Emergency Department: Secondary Analysis of a Prospective Randomized Study

Background/Objectives: Patients with advanced cancer often present to the emergency department (ED) with pain and distressing symptoms that are not systematically evaluated. The current study investigated the association of symptom severity with the diagnosis of delirium and short-term survival. Methods: In this secondary analysis of a prospective randomized study of delirium among advanced cancer patients in the ED, in which symptoms were assessed by the MD Anderson Symptom Inventory (MDASI), we analyzed the distribution of MDASI item scores by 90-day mortality (Kolmogorov-Smirnov), the association of MDASI item scores with short-term mortality (logistic regression models), and the symptoms in those with or without delirium (Mann-Whitney U test or chi-square test). Results: Of the 243 patients included, 222 (91.4%) had complete MDASI scores. The MDASI median symptom scores for pain, fatigue, and interference with work were the highest. A significant difference in MDASI item score distribution with 90-day mortality was observed for fatigue (p = 0.018), shortness of breath (p < 0.001), difficulty remembering (p = 0.038), lack of appetite (p = 0.035), drowsiness (p < 0.001), feeling sad (p = 0.031), and interference with walking (p < 0.001). In multivariable logistic regression models, shortness of breath (adjusted OR 1.15, 95% CI 1.04-1.26, p = 0.005) and drowsiness (adjusted OR 1.17, 95% CI 1.05-1.33, p = 0.008) were associated with 90-day mortality, adjusting for age, race, performance status, and cancer type. The median total MDASI score was significantly higher in patients with delirium than in those without (88, IQR 83-118 vs. 80, IQR 55-104; p < 0.001). Conclusions: Patients with advanced cancer presenting to the ED had severe symptoms, some of which were associated with shorter survival. These findings underscore the necessity of systematic symptom assessment, focusing on shortness of breath, drowsiness, fatigue, difficulty remembering, lack of appetite, feeling sad, and feeling distressed, to enhance clinical decision-making and improve the care of patients with advanced cancer. Additional longitudinal studies are needed to evaluate the improvement in symptoms and quality of life for these patients.

Development of a Prediction Model for Delirium in Hospitalized Patients with Advanced Cancer

PURPOSE

Delirium is a common neurocognitive disorder in patients with advanced cancer and is associated with poor clinical outcomes. As a potentially reversible phenomenon, early recognition of delirium by identifying the risk factors demands attention. We aimed to develop a model to predict the occurrence of delirium in hospitalized patients with advanced cancer.

MATERIALS AND METHODS

This retrospective study included patients with advanced cancer admitted to the oncology ward of four tertiary cancer centers in Korea for supportive cares and excluded those discharged due to death. The primary endpoint was occurrence of delirium. Sociodemographic characteristics, clinical characteristics, laboratory findings, and concomitant medication were investigated for associating variables. The predictive model developed using multivariate logistic regression was internally validated by bootstrapping.

RESULTS

From January 2019 to December 2020, 2,152 patients were enrolled. The median age of patients was 64 years, and 58.4% were male. A total of 127 patients (5.9%) developed delirium during hospitalization. In multivariate logistic regression, age, body mass index, hearing impairment, previous delirium history, length of hospitalization, chemotherapy during hospitalization, blood urea nitrogen and calcium levels, and concomitant antidepressant use were significantly associated with the occurrence of delirium. The predictive model combining all four categorized variables showed the best performance among the developed models (area under the curve 0.831, sensitivity 80.3%, and specificity 72.0%). The calibration plot showed optimal agreement between predicted and actual probabilities through internal validation of the final model.

CONCLUSION

We proposed a successful predictive model for the risk of delirium in hospitalized patients with advanced cancer.

Risk factors for delirium in advanced cancer patients: A systematic review and meta-analysis

PURPOSE

To systematically collect published research in order to identify and quantify risk factors for delirium in advanced cancer patients.

METHODS

The Cochrane Library, PubMed, Proquest, CINAHL, Web of Science, Ovid MEDLINE, Embase, Scopus, Chinese Wanfang Data, Chinese Periodical Full-text Database (VIP), Chinese Biomedical Literature Database (CBM), and Chinese National Knowledge Infrastructure (CNKI) were systematically searched for cohort or case-control studies reporting individual risk factors for delirium among advanced-stage cancer patients published prior to March 2022. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. The pooled adjusted odds ratio (aOR) and its 95% confidence interval were calculated using the RevMan 5.4 software package.

RESULTS

A total of 15 studies with data from 3106 advanced cancer patients were included in our analysis. Nine studies were high-quality and six were of moderate quality. Pooled analyses revealed that 11 risk factors were statistically significant. High-intensity risk factors included sleep disturbance, infection, cachexia and the Palliative Prognostic Index; medium-intensity risk factors included male sex, renal failure, dehydration and drowsiness; low-intensity risk factors included age, total bilirubin and opioid use. Antibiotic use was found to have been a protective factor.

CONCLUSIONS

We identified 12 independent risk factors that were significantly associated with delirium in advanced cancer patients and provide an evidence-based foundation to implement appropriate preventive strategies.

Maddalena Opioid Switching Score in patients with cancer pain

ABSTRACT

Evaluation of opioid switching (OS) for cancer pain has not been properly assessed. The aim of this study was to assess an integrated score (Maddalena Opioid Switching Score) as a simple and repeatable tool to evaluate the outcomes of OS, facilitating the interpretation and comparison of studies, and information exchange among researchers. The integrated score took into account pain intensity, intensity of opioid-related symptoms, and cognitive function by using an author's formula. Physical and psychological symptoms were evaluated by the Edmonton Symptom Assessment Scale and Patient Global Impression (PGI) by the minimal clinically important difference. One hundred six patients were analyzed. Ninety-five patients were switched successfully, and 11 patients underwent a further OS and/or an alternative procedure. The Maddalena Opioid Switching Score significantly decreased after OS and was highly correlated to PGI of improvement ( P < 0.0005). In patients with unsuccessful OS, no significant changes in the Maddalena Opioid Switching Score and PGI were observed. A significant reduction in Edmonton Symptom Assessment Scale items intensity was observed after OS. The Maddalena Opioid Switching Score resulted to be a sensitive instrument for measuring the clinical improvement produced by OS.

The Dilemma of Treating Delirium: the Conundrum of Drug Management

OPINION STATEMENT

Delirium is a common medical complication in people living with cancer, particularly with more advanced disease. Delirium is associated with significant symptom burden which causes distress and impacts quality of life. As recommended by international guidelines, a high degree of suspicion is needed to ensure delirium is detected early. Attention to collateral history can provide clues to changes in cognition and attention. Non-pharmacological approaches that can be considered essential elements of care are effective in reducing the risk of delirium. Delirium screening using a validated measure is recommended as even expert clinicians can underdiagnose or miss delirium. The diagnostic assessment requires consideration of the cancer diagnosis and comorbidities, in the context of potential reversibility, goals of care, and patient preferences. The gold standard approach based on expert consensus is to institute management for delirium precipitants supported by non-pharmacological essential care, with the support of an interdisciplinary team. Medication management should be used sparingly and for a limited period of time wherever possible for severe perceptual disturbance or agitation which has not improved with non-pharmacological approaches. Clinicians should be familiar with the registered indication for medications and seek informed consent for off-label use. All interventions put in place to manage delirium need to consider net clinical benefit, including harms such as sedation and loss of capacity for meaningful interaction. Clear communication and explanation are needed regularly, with the person with delirium as far as possible and with surrogate decision makers. Delirium can herald a poor prognosis and this needs to be considered and be discussed as appropriate in shared decision-making. Recall after delirium has resolved is common, and opportunity to talk about this experience and the related distress should be offered during the period after recovery.

Risk factors for delirium in adult patients receiving specialist palliative care: A systematic review and meta-analysis

BACKGROUND

Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.

AIM

To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.

DESIGN

Systematic review and meta-analysis (PROSPERO CRD42019157168).

DATA SOURCES

CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.

RESULTS

Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.

POTENTIALLY MODIFIABLE RISK FACTORS

Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).

NON-MODIFIABLE RISK FACTORS

Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.

CONCLUSIONS

Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

Factors Influencing Pain Expression in Patients with Cancer: An Expert Opinion

Pain is a multidimensional experience that requires an appropriate assessment, and simple numbering may not be enough for the different components that are involved in the clinical expression. In consideration of the subjectivity of the symptom, each assessment should start from the way in which the patients perceive the pain and from how they deal with it. Some factors related to individual patient characteristics may make pain management difficult because of interference with the clinical pain expression. These factors may amplify the reporting of pain. Cognitive disorders and psychological distress seem to strongly influence pain expression and may render the analgesic treatment more difficult. Aberrant behaviors, such as alcoholism, smoking, and opioid misuse, may play a role, although geographic differences were found in terms of prevalence of the phenomenon, especially in some countries. Finally, the assessment of patients' expectation and the meaning of the personal feeling of changes in pain intensity provide new concepts in pain assessment, which may allow better personalization of the analgesic therapy. A modern pain assessment should include a multitude of factors influencing the phenotype of pain.

Association between alcoholism and symptom expression, patient symptom goals, and clinical response in advanced cancer patients

AIM

The aim of this study was to determine the influence of alcoholism on symptom expression, personalized symptom goal (PSG) and patient goal response (PGR), and patient global impression (PGI) in advanced cancer patients.

METHODS

This was a secondary analysis of an international multicenter study. Advanced cancer patients who had a history of alcohol dependence positive, according to CAGE (cut down, annoy, guilt, eye-opener), were selected. Thirty patients (3.45%) were CAGE-positive. This sample was matched with 30 patients with similar characteristics who were CAGE-negative. Patients rated symptom intensity by using the Edmonton Symptom Assessment Score (ESAS) at admission (T0) and then after 1 week. For each symptom, patients reported their PSG. After a week of comprehensive palliative care, PSG was measured again (T7), as well as the achievement of PGR, and PGI. Minimal clinically important difference (MCID) was calculated by PGI of improvement or deterioration at T7 (bit better or a little worse, respectively).

RESULTS

A significant decrease in intensity was found for most symptoms in both groups. In CAGE-negative and CAGE-positive patients, most patients had a PSG of ≤ 3 for all ESAS items as a target at T0. All PSG targets did not changed significantly after 1 week of palliative care in both groups. Although CAGE-positive basically had unfavorable PGI and PGR, a statistical significance was achieved only for appetite (P = 0.037; ANOVA test). In CAGE-negative patients, Karnofsky was the only factor independently associated with PGI for pain and dyspnea. Factors independently associated with PGI for nausea were symptom intensity at T0 and home situation. In CAGE-positive patients, Karnofsky was independently associated with PGI for pain, nausea, and well-being. Symptom intensity at T0 was independently associated with PGI for weakness.

CONCLUSION

CAGE-positive advanced cancer patients favorably responded to a palliative care intervention. No greater differences have been found in comparison with CAGE-negative patients for PSG, PGR, and PGI, except for appetite. Further studies with large number of patients could confirm some trends observed in this study.