Abstract
Background
Delirium is one of the most common neuropsychiatric complications in advanced cancer patients with a frequency of up to 85 % before death. It is associated with adverse clinical outcomes such as increased morbidity and mortality as well as significant family and patient distress. The aim of our study is to determine at the frequency of missed delirium (MD) and identify factors associated with MD.
Methods
Seven hundred seventy-one consecutive palliative care inpatient consults from August 1, 2009 to January 31, 2010 were reviewed. Demographics, Memorial Delirium Assessment Scale (MDAS), Edmonton Symptom Assessment Scale (ESAS), primary referral symptom, Eastern Cooperative Oncology Group (ECOG), and physician diagnosis of delirium were collected along with delirium etiology, subtype, and reversibility. Delirium was diagnosed with a MDAS score of ≥7 or by a palliative medicine specialist using Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV TR) Criteria. MD was reported in those patients found to have delirium by the palliative medicine specialists but were referred by the primary team for other reasons besides delirium. Chi-squared test and Wilcoxon-Mann-Whitney test were used to examine the difference on measurements among or between different groups. Univariate logistic regression model was applied to assess for associations for MD.
Results
Two hundred fifty-two (33 %) had a diagnosis of delirium by the palliative medicine specialist. One hundred fifty-three (61 %) were missed by the primary referring team. Females comprised 53 % (n = 81), white 62 % (n = 95), and pain was the most common referral symptom (n = 77, 50 %). Hypoactive delirium was the most common subtype of delirium in MD (n = 47, 63 %). Opioid-related delirium was the most common etiology of MD (n = 47, 31 %). Patients referred for pain were more likely to have MD (odds ratio (OR) = 2.57, p = 0.0109). Of the 82 patients with delirium that was reversed, 67 % (n = 55) had a diagnosis of MD.
Conclusion
Sixty-one percent of patients with a diagnosis of delirium by a palliative care specialist were missed by the primary referring team. Patients with MD were frequently referred for pain. Universal screening of cancer patients for delirium is recommended.
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References
Casarett DJ, Inouye SK (2001) Diagnosis and management of delirium near the end of life. Ann Intern Med 135(1):32–40
Alici-Evcimen Y, Breitbart W (2008) An update on the use of antipsychotics in the treatment of delirium. Palliat Support Care 6(2):177–182
Breitbart W, Gibson C, Tremblay A (2002) The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 43(3):183–194
Bruera E, Bush SH, Willey J et al (2009) Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 115(9):2004–2012
Ely EW, Gautam S, Margolin R et al (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27(12):1892–1900
Fick DM, Kolanowski AM, Waller JL, Inouye SK (2005) Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization. J Gerontol A Biol Sci Med Sci 60(6):748–753
Rudolph JL, Inouye SK, Jones RN et al (2010) Delirium: an independent predictor of functional decline after cardiac surgery. J Am Geriatr Soc 58(4):643–649
Cohen MZ, Pace EA, Kaur G, Bruera E (2009) Delirium in advanced cancer leading to distress in patients and family caregivers. J Palliat Care 25(3):164–171
Lawlor PG, Gagnon B, Mancini IL et al (2000) Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 160(6):786–794
Delgado-Guay MO, Yennurajalingam S, Bruera E (2008) Delirium with severe symptom expression related to hypercalcemia in a patient with advanced cancer: an interdisciplinary approach to treatment. J Pain Symptom Manag 36(4):442–449
Centeno C, Sanz A, Bruera E (2004) Delirium in advanced cancer patients. Palliat Med 18(3):184–194
Caraceni A, Simonetti F (2009) Palliating delirium in patients with cancer. Lancet Oncol 10(2):164–172
Reddy SK, Nguyen N, El Osta B, Bruera E (2008) Opioids masquerading as delirium in a patient with cancer pain and obstructive sleep apnea. J Palliat Med 11(7):1043–1045
Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S (1997) The memorial delirium assessment scale. J Pain Symptom Manag 13(3):128–137
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113(12):941–948
Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001) Validation of the delirium rating scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 13(2):229–242
Collins N, Blanchard MR, Tookman A, Sampson EL (2010) Detection of delirium in the acute hospital. Age Ageing 39(1):131–135
Mittal D, Majithia D, Kennedy R, Rhudy J (2006) Differences in characteristics and outcome of delirium as based on referral patterns. Psychosomatics 47(5):367–375
Kishi Y, Kato M, Okuyama T et al (2007) Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation. Gen Hosp Psychiatry 29(5):442–445
Bush SH, Kanji S, Pereira JL et al (2014) Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development. J Pain Symptom Manag 48(2):231–248
Lawlor PG, Bruera ED (2002) Delirium in patients with advanced cancer. Hematol Oncol Clin North Am 16(3):701–714
Yennurajalingam S, Braiteh F, Bruera E (2005) Pain and terminal delirium research in the elderly. Clin Geriatr Med 21(1):93–119, 1
Armstrong SC, Cozza KL, Watanabe KS (1997) The misdiagnosis of delirium. Psychosomatics 38(5):433–439
Irwin SA, Rao S, Bower KA et al (2008) Psychiatric issues in palliative care: recognition of delirium in patients enrolled in hospice care. Palliat Support Care 6(2):159–164
Swigart SE, Kishi Y, Thurber S, Kathol RG, Meller WH (2008) Misdiagnosed delirium in patient referrals to a university-based hospital psychiatry department. Psychosomatics 49(2):104–108
de Stoutz ND, Bruera E, Suarez-Almazor M (1995) Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manag 10(5):378–384
Bruera E, Franco JJ, Maltoni M, Watanabe S, Suarez-Almazor M (1995) Changing pattern of agitated impaired mental status in patients with advanced cancer: association with cognitive monitoring, hydration, and opioid rotation. J Pain Symptom Manag 10(4):287–291
Bush SH, Bruera E, Lawlor PG et al (2014) Clinical practice guidelines for delirium management: potential application in palliative care. J Pain Symptom Manag 48(2):249–258
Fang CK, Chen HW, Liu SI, Lin CJ, Tsai LY, Lai YL (2008) Prevalence, detection and treatment of delirium in terminal cancer inpatients: a prospective survey. Jpn J Clin Oncol 38(1):56–63
Stagno D, Gibson C, Breitbart W (2004) The delirium subtypes: a review of prevalence, phenomenology, pathophysiology, and treatment response. Palliat Support Care 2(2):171–179
Farrell KR, Ganzini L (1995) Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med 155(22):2459–2464
Farrell TW, Dosa D (2007) The assessment and management of hypoactive delirium. Med Health R I 90(12):393–395
Kean J, Ryan K (2008) Delirium detection in clinical practice and research: critique of current tools and suggestions for future development. J Psychosom Res 65(3):255–259
Wada Y, Yamaguchi N (1993) Delirium in the elderly: relationship of clinical symptoms to outcome. Dementia 4(2):113–116
Wada T, Wada M, Onishi H (2010) Characteristics, interventions, and outcomes of misdiagnosed delirium in cancer patients. Palliat Support Care 8(2):125–131
Kiely DK, Marcantonio ER, Inouye SK et al (2009) Persistent delirium predicts greater mortality. J Am Geriatr Soc 57(1):55–61
Leonard M, Raju B, Conroy M et al (2008) Reversibility of delirium in terminally ill patients and predictors of mortality. Palliat Med 22(7):848–854
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The authors indicated no financial relationships. The authors have full control of primary data, which is welcome for review if appropriate.
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de la Cruz, M., Fan, J., Yennu, S. et al. The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center. Support Care Cancer 23, 2427–2433 (2015). https://doi.org/10.1007/s00520-015-2610-3
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DOI: https://doi.org/10.1007/s00520-015-2610-3