Hostname: page-component-6766d58669-nf276 Total loading time: 0 Render date: 2026-05-19T18:29:33.364Z Has data issue: false hasContentIssue false
  • English
  • Français

Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients

Published online by Cambridge University Press:  15 September 2020

Annina Seiler Open the ORCID record for Annina Seiler [Opens in a new window] ,
David Blum ,
Caroline Hertler ,
Markus Schettle ,
Carl Moritz Zipser ,
Leonie Bode ,
Samuel Gehrke ,
Jutta Ernst ,
Maria Schubert  and
Roland von Känel
...Show all authors
Annina Seiler*
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland 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
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
Carl Moritz Zipser
Affiliation:
Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
Leonie Bode
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
Samuel Gehrke
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
Jutta Ernst
Affiliation:
Center of Clinical Nursing Science, University Hospital Zurich, University of Zurich, Zurich, Switzerland
Maria Schubert
Affiliation:
School of Health Professions, University of Applied Science, Zurich, Switzerland
Roland von Känel
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
Soenke Boettger
Affiliation:
Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
*
Author for correspondence: Annina Seiler, Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Culmannstrasse 8, 8091 Zurich, Switzerland. E-mail: annina.seiler@usz.ch
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives

Patients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.

Methods

In this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.

Results

In 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).

Significance of results

The results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.

Keywords

DeliriumPalliative-care patientsPrecipitating factorsPredisposing factors

Information

Type
Original Article
Information
Palliative & Supportive Care , Volume 19 , Issue 3 , June 2021 , pp. 274 - 282
Check for updates
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

*

The article has been updated since its original publication. See https://doi.org/10.1017/S1478951521000560.

References

Akechi, T (2020) Optimal goal of management of delirium in end-of-life cancer care. The Lancet Oncology 21(7), 872–873.10.1016/S1470-2045(20)30308-9CrossRefGoogle ScholarPubMed
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Washington, DC: American Psychiatric Association.Google Scholar
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association.Google Scholar
Bellelli, G, Morandi, A, Di Santo, SG, et al. (2016) “Delirium Day”: A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Medicine 14, 106.10.1186/s12916-016-0649-8CrossRefGoogle ScholarPubMed
Boettger, S, Jenewein, J and Breitbart, W (2015) Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences. Palliative & Support Care 13(4), 1087–1092.10.1017/S1478951514001060CrossRefGoogle ScholarPubMed
Breitbart, W and Friedlander, M (2006). Confusion/ delirium. In Bruera, E, Higginson, I, Ripamonti, C and von Gunten, C (eds), Palliative Medicine. London: London Hodder Press, pp. 688–700.Google Scholar
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–iv165.10.1093/annonc/mdy147CrossRefGoogle ScholarPubMed
Casarett, DJ and Inouye, SK (2001) Diagnosis and management of delirium near the end of life. Annals of Internal Medicine 135(1), 32–40.10.7326/0003-4819-135-1-200107030-00011CrossRefGoogle ScholarPubMed
Centers for Disease Control and Prevention (CDC) (2017). Leading Causes of Death. Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm (Last accessed June 23, 2020).Google Scholar
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
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), 415–418.10.1093/gerona/glx214CrossRefGoogle 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), 1425–1431.10.1634/theoncologist.2015-0115CrossRefGoogle Scholar
de Stoutz, ND, Bruera, E and Suarez-Almazor, M (1995) Opioid rotation for toxicity reduction in terminal cancer patients. Journal of Pain and Symptom Management 10(5), 378–384.10.1016/0885-3924(95)90924-CCrossRefGoogle ScholarPubMed
European Delirium Association & American Delirium Society (2014) The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer. BMC Medicine 12, 141–141.CrossRefGoogle Scholar
Fong, TG, Tulebaev, SR and Inouye, SK (2009) Delirium in elderly adults: Diagnosis, prevention and treatment. Nature Reviews Neurology 5(4), 210–220.10.1038/nrneurol.2009.24CrossRefGoogle Scholar
Fong, TG, Inouye, SK and Jones, RN (2017) Delirium, dementia, and decline. JAMA Psychiatry 74(3), 212–213.CrossRefGoogle ScholarPubMed
Friedlander, MM, Brayman, Y and Breitbart, WS (2004) Delirium in palliative care. Oncology (Williston Park) 18(12), 1541–1550; discussion 1551–1543.Google ScholarPubMed
González, M, Martínez, G, Calderón, J, et al. (2009) Impact of delirium on short-term mortality in elderly inpatients: A prospective cohort study. Psychosomatics 50(3), 234–238.10.1176/appi.psy.50.3.234CrossRefGoogle ScholarPubMed
Hamo, CE and Bloom, MW (2017) Cancer and heart failure: Understanding the intersection. Cardiac Failure Review 3(1), 66–70.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
Hosker, CMG and Bennett, MI (2016) Delirium and agitation at the end of life. BMJ 353, i3085.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), 77–89.10.1016/j.jpainsymman.2013.02.021CrossRefGoogle ScholarPubMed
Hunstein, D, Sippel, B, Rode, D, et al. (2012) ePAAC© : Ergebnisorientiertes PflegeAssessment AcuteCare (Version 2.0). Wiesbaden, 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 (1998) Delirium in hospitalized older patients: Recognition and risk factors. Journal of Geriatric Psychiatry and Neurology 11(3), 118–125; discussion 157–118.CrossRefGoogle ScholarPubMed
Inouye, SK and Charpentier, PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 275(11), 852–857.10.1001/jama.1996.03530350034031CrossRefGoogle ScholarPubMed
Inouye, SK, Westendorp, RGJ and Saczynski, JS (2014) Delirium in elderly people. Lancet (London, England) 383(9920), 911–922.10.1016/S0140-6736(13)60688-1CrossRefGoogle ScholarPubMed
Kang, JH, Shin, SH and Bruera, E (2013) Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treatment Reviews 39(1), 105–112.10.1016/j.ctrv.2012.08.001CrossRefGoogle ScholarPubMed
Korevaar, JC, van Munster, BC and de Rooij, SE (2005) Risk factors for delirium in acutely admitted elderly patients: A prospective cohort study. BMC Geriatrics 5(1), 6.10.1186/1471-2318-5-6CrossRefGoogle ScholarPubMed
Kostis, WJ, Sargsyan, D, Mekkaoui, C, et al. (2019) Association of orthostatic hypertension with mortality in the Systolic Hypertension in the Elderly Program. Journal of Human Hypertension 33(10), 735–740.10.1038/s41371-019-0180-4CrossRefGoogle 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), 249–254.10.1016/j.jpsychores.2008.05.026CrossRefGoogle Scholar
Lawlor, PG and Bush, SH (2014) Delirium diagnosis, screening and management. Current Opinion in Supportive and Palliative Care 8(3), 286–295.10.1097/SPC.0000000000000062CrossRefGoogle Scholar
Lawlor, PG, Fainsinger, RL and Bruera, ED (2000a) Delirium at the end of life: Critical issues in clinical practice and research. JAMA 284(19), 2427–2429.CrossRefGoogle Scholar
Lawlor, PG, Gagnon, B, Mancini, IL, et al. (2000b) Occurrence, causes, and outcome of delirium in patients with advanced cancer: A prospective study. JAMA Internal Medicine 160(6), 786–794.Google Scholar
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), 159–175.10.1016/j.jpainsymman.2013.12.245CrossRefGoogle ScholarPubMed
LeGrand, SB (2012) Delirium in palliative medicine: A review. Journal of Pain and Symptom Management 44(4), 583–594.10.1016/j.jpainsymman.2011.10.013CrossRefGoogle ScholarPubMed
Ljubisavljevic, V and Kelly, B (2003) Risk factors for development of delirium among oncology patients. General Hospital Psychiatry 25(5), 345–352.10.1016/S0163-8343(03)00070-7CrossRefGoogle ScholarPubMed
Maddocks, I, Somogyi, A, Abbott, F, et al. (1996) Attenuation of morphine-induced delirium in palliative care by substitution with infusion of oxycodone. Journal of Pain and Symptom Management 12(3), 182–189.10.1016/0885-3924(96)00050-4CrossRefGoogle ScholarPubMed
Maldonado, JR (2017) Acute brain failure: Pathophysiology, diagnosis, management, and sequelae of delirium. Critical Care Clinics 33(3), 461–519.10.1016/j.ccc.2017.03.013CrossRefGoogle ScholarPubMed
McCoy, TH Jr, Hart, KL and Perlis, RH (2017) Characterizing and predicting rates of delirium across general hospital settings. General Hospital Psychiatry 46, 1–6.CrossRefGoogle ScholarPubMed
Mehta, S, Cook, D, Devlin, JW, et al. (2015) Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults. Critical Care Medicine 43(3), 557–566.10.1097/CCM.0000000000000727CrossRefGoogle 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), 1303–1308.10.1080/03007995.2017.1315332CrossRefGoogle Scholar
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
National Cancer Institute, N. (2019) NCI Dictionary of Cancer Terms. Bethesda, MD: National Cancer Institute at the National Institutes of Health.Google Scholar
Nehring, SM, Tadi, P and Tenny, S (2020) Cerebral Edema. In Hauber, S (ed), StatPearls, Treasure Island. FL: StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537272/.Google Scholar
Oh, ES, Sieber, FE, Leoutsakos, JM, et al. (2016) Sex differences in hip fracture surgery: Preoperative risk factors for delirium and postoperative outcomes. Journal of the American Geriatrics Society 64(8), 1616–1621.10.1111/jgs.14243CrossRefGoogle ScholarPubMed
Pisani, MA, Murphy, TE, Van Ness, PH, et al. (2007) Characteristics associated with delirium in older patients in a medical intensive care unit. JAMA Internal Medicine 167(15), 1629–1634.Google Scholar
Pisani, MA, Murphy, TE, Araujo, KLB, et al. (2009) Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Critical Care Medicine 37(1), 177–183.CrossRefGoogle Scholar
Rigaud, A-S and Forette, B (2001) Hypertension in older adults. The Journals of Gerontology: Series A 56(4), M217–M225.CrossRefGoogle ScholarPubMed
Ryan, DJ, O'Regan, NA, Caoimh, RO, et al. (2013) Delirium in an adult acute hospital population: Predictors, prevalence and detection. BMJ Open 3(1), 1–9.10.1136/bmjopen-2012-001772CrossRefGoogle Scholar
Sampson, EL, West, E and Fischer, T (2020) Pain and delirium: Mechanisms, assessment, and management. European Geriatric Medicine 11(1), 45–52.10.1007/s41999-019-00281-2CrossRefGoogle ScholarPubMed
Schubert, M (2013–2015) Delir-Path: Impact of a Multiprofessional, Multicomponent Delirium Management Protocol on the Incidence of Hospital Acquired Delirium and Associated Costs in Surgical Intensive Care Patients. Zurich: Forschungsdatenbank, Universität Zürich.Google Scholar
Schubert, CR, Fischer, ME, Pinto, AA, et al. (2016) Sensory impairments and risk of mortality in older adults. The Journals of Gerontology: Series A 72(5), 710–715.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), 31–50.10.1891/rtnp.17.1.31.53169CrossRefGoogle ScholarPubMed
Seiler, A, Schubert, M, Hertler, C, et al. (2019) Predisposing and precipitating risk factors for delirium in palliative care patients. Palliative & Support Care 2019, 1–10. doi:10.1017/S1478951519000919.Google Scholar
Stiefel, F and Holland, J (1991) Delirium in cancer patients. International Psychogeriatrics 3(2), 333–336.10.1017/S1041610291000789CrossRefGoogle ScholarPubMed
Strobe, S (2009) Strengthening the Reporting of Observational Studies in Epidemiology. Bern: Institute of Social and Preventive Medicine (ISPM).Google Scholar
Thakur, R, Banerjee, A and Nikumb, V (2013) Health problems among the elderly: A cross-sectional study. Annals of Medical and Health Sciences Research 3(1), 19–25.Google ScholarPubMed
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
Wass, S, Webster, PJ and Nair, BR (2008) Delirium in the elderly: A review. Oman Medical Journal 23(3), 150–157.Google ScholarPubMed
Williams, GR, Mackenzie, A, Magnuson, A, et al. (2016) Comorbidity in older adults with cancer. Journal of Geriatric Oncology 7(4), 249–257.10.1016/j.jgo.2015.12.002CrossRefGoogle ScholarPubMed
Witlox, J, Eurelings, LS, de Jonghe, JF, et al. (2010) Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA 304(4), 443–451.CrossRefGoogle ScholarPubMed
Zimmerman, K, Rudolph, J, Salow, M, et al. (2011) Delirium in palliative care patients: Focus on pharmacotherapy. American Journal of Hospice and Palliative Medicine® 28(7), 501–510.CrossRefGoogle ScholarPubMed
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 161(7), 1307–1315.10.1007/s00701-019-03927-zCrossRefGoogle ScholarPubMed