Background:
Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed.
Aim:
Expanding on a 2013 review, ...this systematic review examines the incidence and prevalence of delirium across all palliative care settings.
Design:
This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment.
Data sources:
Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included.
Results:
Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%–12% in the community, 9%–57% across hospital palliative care consultative services, and 6%–74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%–88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29–0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used.
Conclusion:
Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
IMPORTANCE: Antipsychotics are widely used for distressing symptoms of delirium, but efficacy has not been established in placebo-controlled trials in palliative care. OBJECTIVE: To determine ...efficacy of risperidone or haloperidol relative to placebo in relieving target symptoms of delirium associated with distress among patients receiving palliative care. DESIGN, SETTING, AND PARTICIPANTS: A double-blind, parallel-arm, dose-titrated randomized clinical trial was conducted at 11 Australian inpatient hospice or hospital palliative care services between August 13, 2008, and April 2, 2014, among participants with life-limiting illness, delirium, and a delirium symptoms score (sum of Nursing Delirium Screening Scale behavioral, communication, and perceptual items) of 1 or more. INTERVENTIONS: Age-adjusted titrated doses of oral risperidone, haloperidol, or placebo solution were administered every 12 hours for 72 hours, based on symptoms of delirium. Patients also received supportive care, individualized treatment of delirium precipitants, and subcutaneous midazolam hydrochloride as required for severe distress or safety. MAIN OUTCOME AND MEASURES: Improvement in mean group difference of delirium symptom score (severity range, 0-6) between baseline and day 3. Five a priori secondary outcomes: delirium severity, midazolam use, extrapyramidal effects, sedation, and survival. RESULTS: Two hundred forty-seven participants (mean SD age, 74.9 9.8 years; 85 women 34.4%; 218 with cancer 88.3%) were included in intention-to-treat analysis (82 receiving risperidone, 81 receiving haloperidol, and 84 receiving placebo). In the primary intention-to-treat analysis, participants in the risperidone arm had delirium symptom scores that were significantly higher than those among participants in the placebo arm (on average 0.48 Units higher; 95% CI, 0.09-0.86; P = .02) at study end. Similarly, for those in the haloperidol arm, delirium symptom scores were on average 0.24 Units higher (95% CI, 0.06-0.42; P = .009) than in the placebo arm. Compared with placebo, patients in both active arms had more extrapyramidal effects (risperidone, 0.73; 95% CI, 0.09-1.37; P = .03; and haloperidol, 0.79; 95% CI, 0.17-1.41; P = .01). Participants in the placebo group had better overall survival than those receiving haloperidol (hazard ratio, 1.73; 95% CI, 1.20-2.50; P = .003), but this was not significant for placebo vs risperidone (hazard ratio, 1.29; 95% CI, 0.91-1.84; P = .14). CONCLUSIONS AND RELEVANCE: In patients receiving palliative care, individualized management of delirium precipitants and supportive strategies result in lower scores and shorter duration of target distressing delirium symptoms than when risperidone or haloperidol are added. TRIAL REGISTRATION: ACTRN12607000562471.
Delirium is acknowledged as a common complication of cancer that frequently results in a visit to the emergency department, yet it is often poorly assessed, and the diagnosis is missed as a result. ...Because age is a major risk factor for delirium and population demographics are changing, there is a critical need to develop optimal delirium screening strategies for cancer patients who access this point of care. See also pages 2918–24.
Delirium is a frequent neurocognitive complication in patients with cancer, particularly in patients with advanced-stage disease (in whom a combination of factors might trigger an episode) and in ...patients with a high degree of predisposing vulnerability, such as the elderly or patients with dementia. The communicative impediments associated with delirium generate distress for the patient and their family, and substantive challenges for health-care practitioners, who might have to contend with agitation, and difficulty in assessing pain and other symptoms. Validated assessment tools exist for screening, diagnosing and monitoring the severity of delirium in cancer care. The level of investigative and therapeutic intervention in a delirium episode is determined by the patient's estimated prognosis and the agreed goals of care. Although delirium is ominously associated with the terminal phase of life, part or complete reversal can be possible depending on the nature of the precipitating factors, and on whether investigation and treatment of these factors is consistent with the established goals of care. Pharmacological treatment for symptom control is indicated for most patients with delirium, and antipsychotics are the drugs of choice, but some patients with refractory and nonreversible delirium can require continuous deep sedation with agents such as midazolam.
Retrospective studies of inpatients with cancer suggest that a cancer diagnosis confers a high risk of falls. In adults with advanced cancer, we aimed to prospectively document the incidence of ...falls, identify the risk factors, and determine if falls in this population occur predominantly in older patients.
Patients admitted consecutively to community and inpatient palliative care services with metastatic or locoregionally advanced cancer who were mobile without assistance were recruited. Risk-factor assessment was conducted on initial encounter. Patients underwent follow-up via weekly telephone contact for 6 months or until time of fall or death. Relationship between covariates and time to fall was examined using hazard ratios (HRs) derived from univariate and multivariate Cox proportional hazards models.
Of 185 participants (52.4% men; mean age 68 ± standard deviation of 12.6 years), 50.3% fell; 35 (53%) of 66 participants age < 65 years and 58 (48.7%) of 119 age ≥ 65 years fell; 61.3% of falls occurred in the community; 42% resulted in injury. Median time to fall was 96 days (95% CI, 64.66 to 127.34). Primary brain tumor or brain metastasis (HR 2.5; P = .002), number of falls in the preceding 3 months (HR, 1.27; P = .005), severity of depression (HR, 1.12; P = .012), benzodiazepine dose (HR, 1.05; P = .004), and cancer-related pain (HR, 1.96; P = .024) were independently associated with time to fall in multivariate analysis.
Fifty percent of adults with advanced cancer, regardless of age, will experience a fall associated with high risk of physical injury. There is a compelling need to assess the efficacy of assessment and management of modifiable fall risk factors in patients with advanced cancer.
Abstract
Background
Physicians experience high rates of burnout, which may negatively impact patient care. Palliative care is an emotionally demanding specialty with high burnout rates reported in ...previous studies from other countries. We aimed to estimate the prevalence of burnout and degree of resilience among Canadian palliative care physicians and examine their associations with demographic and workplace factors in a national survey.
Methods
Physician members of the Canadian Society of Palliative Care Physicians and Société Québécoise des Médecins de Soins Palliatifs were invited to participate in an electronic survey about their demographic and practice arrangements and complete the Maslach Burnout Inventory for Medical Professionals (MBI-HSS (MP)), and Connor-Davidson Resilience Scale (CD-RISC). The association of categorical demographic and practice variables was examined in relation to burnout status, as defined by MBI-HSS (MP) score. In addition to bivariable analyses, a multivariable logistic regression analysis, reporting odds ratios (OR), was conducted. Mean CD-RISC score differences were examined in multivariable linear regression analysis.
Results
One hundred sixty five members (29%) completed the survey. On the MBI-HSS (MP), 36.4% of respondents reported high emotional exhaustion (EE), 15.1% reported high depersonalization (DP), and 7.9% reported low personal accomplishment (PA). Overall, 38.2% of respondents reported a high degree of burnout, based on having high EE or high DP. Median CD-RISC resilience score was 74, which falls in the 25th percentile of normative population. Age over 60 (OR = 0.05; CI, 0.01–0.38), compared to age ≤ 40, was independently associated with lower burnout. Mean CD-RISC resilience scores were lower in association with the presence of high burnout than when burnout was low (67.5 ± 11.8 vs 77.4 ± 11.2, respectively,
p
< 0.0001). Increased mean CD-RISC score differences (higher resilience) of 7.77 (95% CI, 1.97–13.57), 5.54 (CI, 0.81–10.28), and 8.26 (CI, 1.96–14.57) occurred in association with age > 60 as compared to ≤40, a predominantly palliative care focussed practice, and > 60 h worked per week as compared to ≤40 h worked, respectively.
Conclusions
One in three Canadian palliative care physicians demonstrate a high degree of burnout. Burnout prevention may benefit from increasing resilience skills on an individual level while also implementing systematic workplace interventions across organizational levels.
Background
The impact of delirium on cognition has not been well‐studied in long‐term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC ...residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia.
Methods
We conducted a population‐based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument‐Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0–6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models.
Results
Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval CI 1.35–1.99), 1.56 (95% CI 1.34–1.85), 1.57 (95% CI 1.32–1.86) and 1.50 (95% CI 1.25–1.80) after 1–3, 4–6, 7–9, and 10–12 months of follow‐up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79–6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%).
Conclusions
Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects.
See related editorial by Bellelli et al. in this issue.
In patients with cancer pain, identifying a neuropathic pain component (NPC) may inform the selection of subsequent therapeutic interventions.
The objective of this study was to determine the ...prevalence, clinical characteristics, associated psychological distress, pre-referral treatment, and predictors of cancer pain with an NPC in patients referred to a cancer pain clinic.
Participants had standard assessments and documentation: Brief Pain Inventory ratings, presence of an NPC, based on a Douleur Neuropathique 4 (DN4) (neuropathic pain screening scale) score ≥4 combined with a physician's clinical assessment (blinded to DN4 result), the Hospital Anxiety Depression Scale, and Emotion Thermometer scores. Logistic regression analyses were used to determine predictors associated with an NPC.
Of 371 study participants, 120 (32.3%) had a designated NPC. Overall, psychological distress indices were similar in the NPC and nociceptive pain groups, except for a Hospital Anxiety and Depression Scale >7 score that was proportionately higher (74% vs. 63%, P = 0.03) in the nociceptive group. The final multivariable logistic regression model generated the following NPC predictors and their respective odds ratios (95% CIs): recent chemotherapy, 2.93 (1.63–5.26); recent surgery, 3.65 (2.03–6.59); adjuvant analgesic use, 2.93 (1.66–5.17); episodic incident pain, 2.63 (1.44–4.84); episodic breakthrough pain, 3.67 (2.00–6.73); pain duration three or more months, 2.35 (1.36–4.06); higher pain intensity, 1.47 (1.24–1.74); and pelvic or perineal pain location, 2.75 (1.09–6.96).
One in three patients with cancer have an NPC, which is independently associated with recent chemotherapy, surgery, adjuvant analgesic use, episodic incident and breakthrough pain, longer pain duration, higher pain intensity, and pelvic or perineal pain location.
Abstract
Background
The Richmond Agitation-Sedation Scale – Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient’s level of agitation or sedation. The objective of ...this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process.
Methods
Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey.
Results
The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs.
Conclusion
Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.
Background:
Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors ...influencing this among UK and Irish palliative medicine physicians is unknown.
Aim:
To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors.
Design:
Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel MBI-HSS (MP) and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life.
Setting/participants:
Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings.
Results:
There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31–40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002–0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62–0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75–49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p < 0.001).
Conclusions:
Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics.
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