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Predisposing and precipitating risk factors for delirium in palliative care patients

Published online by Cambridge University Press:  14 November 2019

Annina Seiler Open the ORCID record for Annina Seiler [Opens in a new window] ,
Maria Schubert ,
Caroline Hertler ,
Markus Schettle ,
David Blum ,
Matthias Guckenberger ,
Michael Weller ,
Jutta Ernst ,
Roland von Känel  and
Soenke Boettger Open the ORCID record for Soenke Boettger [Opens in a new window]
Annina Seiler*
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
Maria Schubert
Affiliation:
University of Applied Science, School of Health Professions, Zurich, Switzerland
Caroline Hertler
Affiliation:
Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
Markus Schettle
Affiliation:
Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
David Blum
Affiliation:
Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
Matthias Guckenberger
Affiliation:
Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
Michael Weller
Affiliation:
Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
Jutta Ernst
Affiliation:
Center of Clinical Nursing Science, University Hospital Zurich and University of Zurich, Zurich, Switzerland
Roland von Känel
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
Soenke Boettger
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
*
Author for correspondence: Annina Seiler, Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Culmannstrasse 8, 8091Zurich, Switzerland. E-mail: [email protected]
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Abstract

Objective

Delirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.

Method

In this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.

Results

The prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).

Significance of results

Our study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.

Keywords

DeliriumPalliative care patientsPalliative treatmentPrecipitating factorsPredisposing factorsRisk factors
Type
Original Article
Information
Palliative & Supportive Care , Volume 18 , Special Issue 4: Palliative and Supportive Care During The COVID-19 Pandemic , August 2020 , pp. 437 - 446
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Copyright
Copyright © Cambridge University Press 2019

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References

REFERENCES

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Washington, DC: American Psychiatric Association.Google Scholar
Boettger, S and Jenewein, J (2017) Placebo might be superior to antipsychotics in management of delirium in the palliative care setting. Evidence Based Medicine 22(4), 152–153.CrossRefGoogle ScholarPubMed
Boettger, S, Jenewein, J and Breitbart, W (2015) Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences. Palliative & Supportive Care 13(4), 1087–1092.CrossRefGoogle ScholarPubMed
Bush, SH, Tierney, S and Lawlor, PG (2017) Clinical assessment and management of delirium in the palliative care setting. Drugs 77(15), 1623–1643.CrossRefGoogle ScholarPubMed
Bush, SH, Lawlor, PG, Ryan, K, et al. (2018) Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Annals of Oncology 29(Suppl 4), iv143–iv165.CrossRefGoogle ScholarPubMed
Casarett, D (2005) Ethical considerations in end-of-life care and research. Journal of Palliative Medicine 8(Suppl 1), S148–160.CrossRefGoogle ScholarPubMed
Casarett, DJ and Inouye, SK (2001) Diagnosis and management of delirium near the end of life. Annals of Internal Medicine 135(1), 32–40.CrossRefGoogle ScholarPubMed
Charlson, ME, Pompei, P, Ales, KL, et al. (1987) A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases 40(5), 373–383.CrossRefGoogle ScholarPubMed
Cole, MG, Dendukuri, N, McCusker, J, et al. (2003) An empirical study of different diagnostic criteria for delirium among elderly medical inpatients. The Journal of Neuropsychiatry and Clinical Neurosciences 15(2), 200–207.CrossRefGoogle ScholarPubMed
Dani, M, Owen, LH, Jackson, TA, et al. (2017) Delirium, frailty, and mortality: Interactions in a prospective study of hospitalized older people. The Journals of Gerontology: Series A 73(3), 415–418.CrossRefGoogle Scholar
de la Cruz, M, Ransing, V, Yennu, S, et al. (2015) The frequency, characteristics, and outcomes among cancer patients with delirium admitted to an acute palliative care unit. The Oncologist 20(12), 1425–1431.CrossRefGoogle Scholar
de la Cruz, M, Yennu, S, Liu, D, et al. (2017) Increased symptom expression among patients with delirium admitted to an acute palliative care unit. Journal of Palliative Medicine 20(6), 638–641.CrossRefGoogle Scholar
Diwell, RA, Davis, DH, Vickerstaff, V, et al. (2018) Key components of the delirium syndrome and mortality: Greater impact of acute change and disorganised thinking in a prospective cohort study. BMC Geriatrics 18(1), 24–24.CrossRefGoogle ScholarPubMed
Elsayem, AF, Bruera, E, Valentine, AD, et al. (2016) Delirium frequency among advanced cancer patients presenting to an emergency department: A prospective, randomized, observational study. Cancer 122(18), 2918–2924.CrossRefGoogle Scholar
European Delirium Association and American Delirium Society (2014) The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer. BMC Medicine 12, 141.CrossRefGoogle Scholar
Finucane, AM, Lugton, J, Kennedy, C, et al. (2017) The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: An integrative literature review. Psycho-oncology 26(3), 291–300.CrossRefGoogle Scholar
Harris, MJ, Brovman, EY and Urman, RD (2019) Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture. Journal of Clinical Anesthesia 58, 61–71.CrossRefGoogle ScholarPubMed
Hosie, A, Davidson, PM, Agar, M, et al. (2013) Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review. Palliative Medicine 27(6), 486–498.CrossRefGoogle ScholarPubMed
Hosie, A, Phillips, J, Lam, L, et al. (2019) Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: Study protocol for a phase II cluster randomised controlled trial. BMJ Open 9(1), e026177.CrossRefGoogle ScholarPubMed
Hosker, CMG and Bennett, MI (2016) Delirium and agitation at the end of life. BMJ 353, i3085.CrossRefGoogle ScholarPubMed
Hui, D (2019) Delirium in the palliative care setting: “Sorting” out the confusion. Palliative Medicine 33(8), 863–864.CrossRefGoogle ScholarPubMed
Hui, D, Nooruddin, Z, Didwaniya, N, et al. (2014) Concepts and definitions for “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care”: A systematic review. Journal of Pain and Symptom Management 47(1), 77–89.CrossRefGoogle ScholarPubMed
Hui, D, Frisbee-Hume, S, Wilson, A, et al. (2017) Effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced cancer receiving palliative care: A randomized clinical trial. JAMA 318(11), 1047–1056.CrossRefGoogle ScholarPubMed
Hunstein, D, Sippel, B, Rode, D, et al. (2012) ePAAC©: Ergebnisorientiertes PflegeAssessment AcuteCare (Version 2.0). Germany: ePA-Competence Center (ePA-CC).Google Scholar
IBM Corp (Released 2017) IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.Google Scholar
Inouye, SK, Westendorp, RGJ and Saczynski, JS (2014) Delirium in elderly people. Lancet (London, England) 383(9920), 911–922.CrossRefGoogle ScholarPubMed
Kang, JH, Shin, SH and Bruera, E (2013) Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treatment Reviews 39(1), 105–112.CrossRefGoogle ScholarPubMed
Laurila, JV, Laakkonen, ML, Tilvis, RS, et al. (2008) Predisposing and precipitating factors for delirium in a frail geriatric population. Journal of Psychosomatic Research 65(3), 249–254.CrossRefGoogle Scholar
Lawlor, PG, Gagnon, B, Mancini, IL, 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.CrossRefGoogle ScholarPubMed
Lawlor, PG, Davis, DHJ, Ansari, M, et al. (2014) An analytical framework for delirium research in palliative care settings: Integrated epidemiologic, clinician-researcher, and knowledge user perspectives. Journal of Pain and Symptom Management 48(2), 159–175.CrossRefGoogle ScholarPubMed
Lawlor, PG, Rutkowski, NA, MacDonald, AR, et al. (2019) A scoping review to map empirical evidence regarding key domains and questions in the clinical pathway of delirium in palliative care. Journal of Pain and Symptom Management 57(3), 661–681.e612.CrossRefGoogle ScholarPubMed
Ljubisavljevic, V and Kelly, B (2003) Risk factors for development of delirium among oncology patients. General Hospital Psychiatry 25(5), 345–352.CrossRefGoogle ScholarPubMed
Maltoni, M, Scarpi, E, Pittureri, C, et al. (2012) Prospective comparison of prognostic scores in palliative care cancer populations. The Oncologist 17(3), 446–454.CrossRefGoogle ScholarPubMed
Meagher, DJ, Maclullich, AM and Laurila, JV (2008) Defining delirium for the International classification of diseases, 11th revision. Journal of Psychosomatic Research 65(3), 207–214.CrossRefGoogle ScholarPubMed
Mercadante, S, Adile, C, Ferrera, P, et al. (2017) Delirium assessed by Memorial Delirium Assessment Scale in advanced cancer patients admitted to an acute palliative/supportive care unit. Current Medical Research and Opinion 33(7), 1303–1308.CrossRefGoogle Scholar
Moorhouse, P and Rockwood, K (2012) Frailty and its quantitative clinical evaluation. Journal of the Royal College of Physicians of Edinburgh 42(4), 333–340.CrossRefGoogle ScholarPubMed
Morita, T, Tei, Y, Tsunoda, J, et al. (2001) Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients. Journal of Pain and Symptom Management 22(6), 997–1006.CrossRefGoogle ScholarPubMed
Namba, M, Morita, T, Imura, C, et al. (2007) Terminal delirium: Families’ experience. Palliative Medicine 21(7), 587–594.CrossRefGoogle ScholarPubMed
National Cancer Institute (2019) NCI Dictionary of Cancer Terms. Bethesda, MD, USA: National Cancer Institute at the National Institutes of Health.Google Scholar
Ryan, DJ, O'Regan, NA, Caoimh, RO, Clare, J, O'Connor, M, Leonard, M, McFarland, J, Tighe, S, O'Sullivan, K, Trzepacz, PT, Meagher, D and Timmons, S (2013) Delirium in an adult acute hospital population: Predictors, prevalence and detection. BMJ Open 3(1), 1–9.CrossRefGoogle Scholar
Schubert, M (2013–2015) Delir-Path: Impact of a Multiprofessional, Multicomponent Delirium Management Proto-col on the Incidence of Hospital Acquired Delirium and Associated Costs in Surgical Intensive Care Patients. Zurich: Forschungsdatenbank, Universität Zürich.Google Scholar
Schubert, M, Schurch, R, Boettger, S, et al. (2018) A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients – A cohort study. BMC Health Services Research 18(1), 550.CrossRefGoogle ScholarPubMed
Schuurmans, MJ, Shortridge-Baggett, LM and Duursma, SA (2003) The Delirium Observation Screening Scale: A screening instrument for delirium. Research and Theory for Nursing Practice 17(1), 31–50.CrossRefGoogle ScholarPubMed
Stiefel, F, Fainsinger, R and Bruera, E (1992) Acute confusional states in patients with advanced cancer. Journal of Pain and Symptom Management 7(2), 94–98.CrossRefGoogle ScholarPubMed
STROBE (2009) Strengthening the Reporting of Observational Studies in Epidemiology. Bern: Institute of Social and Preventive Medicine (ISPM).Google Scholar
Tosun Tasar, P, Sahin, S, Akcam, NO, et al. (2018) Delirium is associated with increased mortality in the geriatric population. International Journal of Psychiatry in Clinical Practice 22(3), 200–205.CrossRefGoogle ScholarPubMed
Williams, GR, Mackenzie, A, Magnuson, A, et al. (2016) Comorbidity in older adults with cancer. Journal of Geriatric Oncology 7(4), 249–257.CrossRefGoogle ScholarPubMed
World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization.Google Scholar
World Medical Association (2013). Declaration of Helsinki: Ethical principles for research involving human subjects. Jama 310(20), 2191–2194.CrossRefGoogle Scholar
Zipser, CM, Deuel, J, Ernst, J, et al. (2019) The predisposing and precipitating risk factors for delirium in neurosurgery: A prospective cohort study of 949 patients. Acta Neurochirurgica (Wien) 161(7), 1307–1315.CrossRefGoogle ScholarPubMed