Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention

INTRODUCTION

Delirium is a term derived from Latin word ‘delirare’ meaning to ‘go out of furrow’. It is a common complex neuropsychiatric syndrome occurring in terminally ill-debilitated patients and those at end of life care. It also occurs with other conditions such as metabolic disturbances, dehydration, infection and head injuries. It is characterised by acute onset of disturbance in level of alertness, attention, perception, thinking, cognition, psychomotor behaviour, mood and sleep cycle. In terminal cancer patients, delirium prevalence can be as high as 85%.^[1] Although reversibility can occur in one-third of cases with appropriate management, the survival among patients who develop delirium after admission is around 50%.^[2] Occurrence of delirium is associated with significant morbidity, mortality, prolonged hospitalisation, high cost and long-term consequence such as cognitive decline, impaired function and decrease quality of life.^[3]

Three clinical subtypes of delirium have been described based on psychomotor features and arousal level is hyperactive, hypoactive and mixed type.^[4] High level of psychological distress has been reported by family caregivers and health-care provider due to potential irreversibility of condition and difficulty in assessing and managing patient needs.^[5] Multiple risk factors for precipitating delirium include old age, terminal illness, acute illness, electrolyte disturbance, dehydration, drugs, metabolic disorder and therapeutic intervention like mechanical ventilation.^[2] Although some cause of delirium in terminal cancer may be irreversible, yet, it is important in clinical practise to detect delirium and identify the reversible cause of delirium. Unfortunately, delirium is often missed and undertreated. Patients with delirium tend to present with symptoms exaggeration or less relief in comparison with the patient without delirium.^[6] Hence, delirium screening is of most important in those patients who keep on experiencing worsening symptoms despite medical treatment. Delirium diagnosis was missed in more than 60% of patients by the primary referring team as revealed by palliative care consultation team.^[7] Although health professionals acknowledge the importance for delirium screening in palliative care setting, actual implementation is not feasible due to lack of knowledge and confidence, unfamiliarity in using screening tool and unavailability of psychiatric services.^[8] Various tools and criteria are available to help the clinician in diagnosing delirium including Delirium Rating scale,^[9] Delirium Symptoms Interview,^[10] Memorial Delirium Assessment Scale (MDAS),^[11] and Diagnostic and Statistical Manual (DSM-IV)^[12]. Standard management necessitates an examination of aetiology, treatment of contributing elements and symptomatic and steady treatments, involving various pharmacologic and non-pharmacological strategies for management of delirium assume a key part and ought to be upgraded through the aggregate endeavours of the entire inter professional group. Refractory agitated delirium somewhat in the last stage might need the utilisation of pharmacological sedation to alleviate patient’s suffering.^[13] Further, assessments of multi component strategies for prevention and treatment of delirium in palliative care patient populace are direly required. While data about prevalence of delirium are available in hospital, intensive care unit and acute palliative care set up, information regarding hospice are lacking. Hence, we did this study to find out prevalence of delirium in advanced cancer patients admitted at hospice and outcome after palliative intervention.

MATERIAL AND METHODS

This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019–July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion and exclusion criteria.

RESULTS

One hundred and fifty patients admitted to hospice centre were screened in the time period taken into consideration. Three patients were not included in the study due to inability to communicate verbally due to disease associated loss of voice. Of 147 patients, 46 (31.29%) had delirium during their admission to hospice centre and 27 (18.367%) out of 147 had delirium at the time of admission. The median age was 50 year (20–95 years), as shown in Figure 1.

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Figure 1:

Distribution of patients admitted to the hospice centre with reference to the diagnosis of delirium.

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Figure 2 contains the list of primary cancer diagnosis. In our study population, head and neck cancer (57.8%) were the most common primary malignancy encountered, followed by breast cancer (10.2%) and lung cancer (7.5%).

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Figure 2:

Primary diagnosis.

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Table 1 shows the ESAS value at the time of admission to hospice and the number of patients with ESAS score ≥7 signifying severe symptom. Pain (39.4%) was the most common severe symptom reported followed by decreased well-being (21%), sleep disturbance (19%) and fatigue (19%). Figure 3 shows current drug medication at the time of admission. Most common drugs were acetaminophen along with other NSAIDs (95.2%), followed by opioids (93.8%) commonly tramadol and morphine and H2 blocker-Ranitidine (72.2%).

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Figure 3:

Patients taking drugs at time of admission.

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Table 2 summarises the patient characteristics into two groups; those with delirium and those without delirium throughout the admission. Patients with poor ECOG performance status and poor prognostic PaP score were more likely to have diagnosis with delirium. No statistical significant difference in the two groups was found with regard with age, gender, palliative CT/RT taken in the past 3 month, or associated comorbidities. Statistically significant association was found with probable risk factors such as brain metastasis, dehydration, cachexia, dyselectrolytemia, myiasis and h/o substance abuse.

A summary of the delirium characteristics of patients with delirium are summarised in Table 3. Most frequent subtype is mixed and hypoactive followed by hyperactive. Haloperidol was the most commonly used single agent medication to treat delirium followed by combination of haloperidol with midazolam. Other single interventions include hydration, antibiotics and opioids rotation. Counselling of patients and caregivers was performed in all delirium cases. Most of the delirium management included a combination of various treatment strategies including both pharmacological and non-pharmacological measures.

Table 4 summarise outcomes of different types of delirium. In our study, most common type of delirium is hypoactive and mixed subtype followed by hyperactive delirium. Resolution of delirium was higher among hyperactive delirium (78.57%), followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%), followed by mixed (43.75%) and hyperactive delirium (14.28%).

DISCUSSIONS

The objective of palliative care is to relieve suffering and give the most ideal personal satisfaction for patients and their families. Indications might incorporate agony, depression, shortness of breath, difficulty sleeping and anxiety which are very much related to delirium. Delirium is a profoundly predominant complexity in patients in palliative care settings, particularly towards the end phase of life.^[17,18]

Delirium diagnosis was based on diagnostic criterion of DSM-IV and MDAS. Out of 147 patients, 46 (31.29%) had delirium during their admission to hospice centre. Out of them, 27 (18.367%) had delirium at the time of admission. This finding is comparable with study results by Hosie et al.^[19] 2013 in delirium prevalence at hospice ranging from 13.3% to 42.3%. Palliative intervention encompasses total care to patients and caregivers involving multi-disciplinary team. In our study, mortality was higher among patient who had delirium (47.8%, n-46) as compared to those without delirium (9.9%, n-101). Mortality was higher with hypoactive subtype (81.25%) as compared to mixed (43.75%) and hyperactive delirium (14.28%). Recovery rate of delirium was higher with hyperactive subtype followed by mixed and hypoactive delirium. Similar results were obtained in study done by Fang et al.^[20] 2008 with higher mortality rate in patients with delirium and higher risk with hypoactive delirium.

By consensus, haloperidol remains the standard pharmacological drug for symptomatic control.^[21,22] Dosing plans are derived from well-qualified assessment and different clinical practice rules as evidence-based information are limited from palliative care. The commonly utilised pharmacologic intervention for delirium in this populace warrant assessment in clinical preliminaries to inspect dosing and titration regimens, various routes of administration and safety and efficacy compared with placebo. Delirium management is multidimensional and incorporates the distinguishing proof of aggravating and precipitating factors. Haloperidol remains the standard practice for symptoms management. Further, great collective exploration researching the suitable treatment of this perplexing syndrome is required.

Delirium can often be traced to one or more contributing factors and the main four risk factors statistically significant found in this research are brain metastasis, dehydration, cachexia, dyselectrolytemia and myiasis. Other studies done by Lawlor et al. in 2000 and Casarett et al. in 2001 have reported similar risk factors of delirium such as brain metastasis, dehydration and metabolic factors (hyponatremia, hypercalcemia, etc.).^[23,24] Other risk factors such as age, gender, associated comorbidities; h/o palliative RT and CT in the past 3 months were found statistically insignificant in our study.

CONCLUSION

• An identification and assessment of delirium are vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalisation, expanded time on a ventilator and by and large more prominent medical services costs

• Clinicians should utilise one of a few approved delirium assessment tools to help evaluate and archive cognitive function

• Prevention and recognising the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium

• As the outcomes demonstrate that multicomponent delirium management or projects are generally proficient to lessen the rates of delirium and negative outcomes of delirium

• It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.