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Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care

Published online by Cambridge University Press:  20 February 2014

Maxine de la Cruz ,
Antonio Noguera ,
Maria Teresa San Miguel-Arregui ,
Janet Williams ,
Gary Chisholm  and
Eduardo Bruera
Maxine de la Cruz*
Affiliation:
The University of Texas MD Anderson Cancer Center, Department of Palliative and Rehabilitation Medicine. Houston, Texas
Antonio Noguera
Affiliation:
Laguna Hospital Centro de Cuidados, Palliative Care, Madrid, Spain
Maria Teresa San Miguel-Arregui
Affiliation:
The University of Texas MD Anderson Cancer Center, Department of Palliative and Rehabilitation Medicine. Houston, Texas
Janet Williams
Affiliation:
The University of Texas MD Anderson Cancer Center, Department of Palliative and Rehabilitation Medicine. Houston, Texas
Gary Chisholm
Affiliation:
The University of Texas MD Anderson Cancer Center, Department of Palliative and Rehabilitation Medicine. Houston, Texas
Eduardo Bruera
Affiliation:
The University of Texas MD Anderson Cancer Center, Department of Palliative and Rehabilitation Medicine. Houston, Texas The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas
*
Address correspondence and reprint requests to: Maxine de la Cruz, The University of Texas MD Anderson Cancer Center, Department of Palliative Care and Rehabilitation Medicine, 1515 Holcombe Boulevard, Unit 1414, Houston, Texas 77030. E-Mail: [email protected].
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Abstract

Objective:

Knowledge of symptom prevalence and adequate assessment of such symptoms at the end of life is important in clinical practice. We determined the frequency and severity of symptom distress and delirium using the Edmonton Assessment Scale (ESAS) and the Memorial Delirium Assessment Scale (MDAS) and evaluated the clinical utility of the Nursing Delirium Screening Scale (Nu-DESC) as scored by a caregiver as a screening tool for delirium.

Method:

We conducted a secondary analysis of the data from a previous randomized controlled trial on parenteral hydration at the end of life of patients admitted to home hospice. Only patients that had assessments within the last week of life were included. We collected the ESAS, MDAS, Nu-DESC, and Richmond Agitation Sedation Scale (RASS) results. The sensitivity and specificity of the Nu-DESC were then calculated.

Results:

Some 78 of 261 patients were included in our study, 62 (80%) of which had moderate-to-severe symptoms corresponding to an ESAS score >4. These symptoms include: 73 (94%) anorexia, 63 (81%) fatigue, 56 (73%) drowsiness, 58 (75%) decreased well-being, and 39 (51%) pain. Delirium was diagnosed in 34 (44%) of patients using the MDAS. The Nu-DESC was found to have a sensitivity of 35%, a specificity of 80%, a positive predictive value (PPV) of 58%, and an negative predictive value (NPV) of 61% when used by caregivers.

Significance of Results:

Hospice patients at the end of life have a high rate of symptom distress and delirium. The Nu-DESC is not a reliable tool for screening delirium when scoring is conducted by a caregiver. Our study illustrates the need for routine use of assessment tools to improve care.

Keywords

DeliriumAdvanced cancerSymptom distress
Type
Original Articles
Information
Palliative & Supportive Care , Volume 13 , Issue 2 , April 2015 , pp. 211 - 216
Copyright
Copyright © Cambridge University Press 2014 

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References

REFERENCES

Allen, R.S., Haley, W.E. Haley, et al. (2002). Pain reports by older hospice cancer patients and family caregivers: The role of cognitive functioning. Gerontologist, 42(4), 507–514.Google Scholar
Anderson, G.F. & Squires, D.A. (2010). Measuring the U.S. health care system: A cross-national comparison. Issue Brief (Commonwealth Fund), 90, 1–10.Google Scholar
Breitbart, W., Rosenfeld, B., Roth, A., et al. (1997). The Memorial Delirium Assessment Scale. Journal of Pain and Symptom Management, 13(3), 128–137.Google Scholar
Bruera, E. & Hui, D. (2010). Integrating supportive and palliative care in the trajectory of cancer: Establishing goals and models of care. Journal of Clinical Oncology, 28(25), 4013–4017.CrossRefGoogle ScholarPubMed
Bruera, E., Kuehn, N., Miller, M.J., et al. (1991). The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care, 7(2), 6–9.Google Scholar
Bruera, E., Miller, L., McCallion, J., et al. (1992). Cognitive failure in patients with terminal cancer: A prospective study. Journal of Pain and Symptom Management, 7(4), 192–195.Google Scholar
Bruera, E., Hui, D., Dalal, S., et al. (2013). Parenteral hydration in patients with advanced cancer: A multicenter, double-blind, placebo-controlled randomized trial. Journal of Clinical Oncology, 31(1), 111–118.Google Scholar
Casarett, D.J. & Inouye, S.K. (2001). Diagnosis and management of delirium near the end of life. Annals of Internal Medicine, 135(1), 32–40.Google Scholar
Chang, V.T., Hwang, S.S. & Feuerman, M. (2000). Validation of the Edmonton Symptom Assessment Scale. Cancer, 88(9), 2164–2171.Google Scholar
Cheung, W.Y., Le, L.W. & Zimmermann, C. (2009). Symptom clusters in patients with advanced cancers. Supportive Care in Cancer, 17(9), 1223–1230.CrossRefGoogle ScholarPubMed
Currow, D.C., Ward, A.M., Plummer, J.L., et al. (2008). Comfort in the last 2 weeks of life: Relationship to accessing palliative care services. Supportive Care in Cancer, 16(11), 1255–1263.Google Scholar
de Santiago, A., Portela, M.A., Ramos, L., et al. (2012). A new palliative care consultation team at the oncology department of a university hospital: An assessment of initial efficiency and effectiveness. Supportive Care in Cancer, 20(9), 2199–2203.Google Scholar
Donnelly, S. & Walsh, D. (1995). The symptoms of advanced cancer. Seminars in Oncology, 22(2, Suppl. 3), 67–72.Google Scholar
Fang, C.K., Chen, H.W., Liu, S.I., et al. (2008). Prevalence, detection and treatment of delirium in terminal cancer inpatients: A prospective survey. Japanese Journal of Clinical Oncology, 38(1), 56–63.Google Scholar
Gagnon, B., Lawlor, P.G., Mancini, I.L., et al. (2001). The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients. Journal of Pain and Symptom Management, 22(4), 826–833.Google Scholar
Gaudreau, J.D., Gagnon, P., Harel, F., et al. (2005). Fast, systematic, and continuous delirium assessment in hospitalized patients: The nursing delirium screening scale. Journal of Pain and Symptom Management, 29(4), 368–375.Google Scholar
Greer, D.S., Mor, V., Sherwood, S., et al. (1983). National hospice study analysis plan. Journal of Chronic Diseases, 36(11), 737–780.Google Scholar
Hui, D., Parsons, H., Nguyen, L., et al. (2010). Timing of palliative care referral and symptom burden in phase 1 cancer patients: A retrospective cohort study. Cancer, 116(18), 4402–4409.Google Scholar
Hutcheson, A. (2011). Hospice care in the United States. Primary Care, 38(2), 173–182.Google Scholar
Lawlor, P.G. & Bruera, E.D. (2002). Delirium in patients with advanced cancer. Hematology/Oncology Clinics of North America, 16(3), 701–714.Google Scholar
Lawlor, P.G., Gagnon, B., Mancini, I.L., et al. (2000). Occurrence, causes, and outcome of delirium in patients with advanced cancer: A prospective study. Archives of Internal Medicine, 160(6), 786–794.Google Scholar
McMillan, S.C. (1996 a). Pain and pain relief experienced by hospice patients with cancer. Cancer Nursing, 19(4), 298–307.Google Scholar
McMillan, S.C. (1996 b). The quality of life of patients with cancer receiving hospice care. Oncology Nursing Forum, 23(8), 1221–1228.Google Scholar
McMillan, S.C. & Small, B.J. (2002). Symptom distress and quality of life in patients with cancer newly admitted to hospice home care. Oncology Nursing Forum, 29(10), 1421–1428.Google Scholar
Nekolaichuk, C.L., Maguire, T.O., Suarez-Almazor, M., et al. (1999). Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients. Journal of Clinical Oncology, 17(11), 3621–3630.Google Scholar
Rodriguez, K.L., Hanlon, J.T., Perera, S., et al. (2010). A cross-sectional analysis of the prevalence of undertreatment of non-pain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients. American Journal of Geriatric Pharmacotherapy, 8(3), 225–232.Google Scholar
Sessler, C.N., Gosnell, M.S., Grap, M.J., et al. (2002). The Richmond Agitation–Sedation Scale: Validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338–1344.Google Scholar
Steinhauser, K.E., Christakis, N.A., Clipp, E.C., et al. (2000). Factors considered important at the end of life by patients, family, physicians, and other care providers. The Journal of the American Medical Association, 284(19), 2476–2482.CrossRefGoogle ScholarPubMed
Watanabe, S.M., Nekolaichuk, C.L., Beaumont, C., et al. (2011). A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. Journal of Pain and Symptom Management, 41(2), 456–468.Google Scholar
Watanabe, S.M., Nekolaichuk, C.L. & Beaumont, C. (2012). The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: Development and refinement. Psycho-Oncology, 21(9), 977–985.Google Scholar
Weitzner, M.A., Moody, L.N. & McMillan, S.C. (1997). Symptom management issues in hospice care. The American Journal of Hospice & Palliative Care, 14(4), 190–195.Google Scholar
Yang, F.M., Marcantonio, E.R., Inouye, S.K., et al. (2009). Phenomenological subtypes of delirium in older persons: Patterns, prevalence, and prognosis. Psychosomatics, 50(3), 248–254.Google Scholar
Yennurajalingam, S., Atkinson, B., Masterson, J., et al. (2012). The impact of an outpatient palliative care consultation on symptom burden in advanced prostate cancer patients. Journal of Palliative Medicine, 15(1), 20–24.Google Scholar
Yurk, R., Morgan, D., Franey, S., et al. (2002). Understanding the continuum of palliative care for patients and their caregivers. Journal of Pain and Symptom Management, 24(5), 459–470.Google Scholar