Are common delirium assessment tools appropriate for evaluating delirium at the end of life in cancer patients?

Abstract

Objectives: The objectives of this study are to investigate how many advanced cancer patients became unconscious or non-communicative after pharmacological treatment for delirium, and to explore whether existing delirium assessment tools can successfully evaluate its severity at the end of life. Methods: This was a secondary analysis of a registry study that examined the efficacy and safety of antipsychotics for advanced cancer patients with delirium. A total of 818 patients were recruited from 39 specialized palliative care services in Japan. The severity of delirium was measured using the Richmond Agitation-Sedation Scale-Palliative care version, the Delirium Rating Scale-Revised-98 (DRS-R-98), and the Nursing Delirium Screening Scale (Nu-DESC) on Day 3. Data from 302 patients with motor anxiety with an Agitation Distress Scale score ≥2 on Day 0 were analyzed for this study. The patients were categorized into four treatment response groups: complete response (CR: no agitation and fully communicative), partial response (PR: no/mild agitation and partially communicative), unconscious/non-communicative (UC), and no change (NC). Results: On Day 3, 29 (10%; 95% confidence intervals [CI], 7-13) and 2 (1%; 95% CI, 0-2) patients became unconscious and non-communicative, respectively. Forty-four patients were categorized as CR, 97 as PR, 31 as UC, and 96 as NC. The scores of the DRS-R-98 and Nu-DESC in the UC group were rated higher than patients in the NC group were. Conclusions: A considerable number of cancer patients with delirium became unconscious or non-communicative. Existing delirium assessment tools may be inappropriate for measuring the severity of delirium in end-of-life.

Palliative sedation – revised recommendations

“…However, these numbers may be overestimated due to the lack of tools to identify delirium at the end of life. The normal dying process may trigger false positives using the available delirium screening tools for hypoactive delirium [39,59]. According to the literature, hyperactive delirium is the main indication for palliative sedation [7].…”

A decision tree prediction model for a short-term outcome of delirium in patients with advanced cancer receiving pharmacological interventions: A secondary analysis of a multicenter and prospective observational study (Phase-R)

“…Because both the original and the Japanese versions of DRS-R98 did not investigate the cutoff score for delirium severity determination (Trzepacz et al, 2001; Kato et al, 2010), this result could be a new finding. However, the DRS-R98 severity scale has been suggested as unsuitable for evaluating end-stage patients’ delirium because of unconsciousness or non-communicativeness (Uchida et al, 2020). This inappropriateness might also affect the association between the baseline severity score and that on day 3.…”

“…The present study is a secondary analysis of Phase-R, a multicenter and prospective observational study (Okuyama et al, 2019;Maeda et al, 2020Maeda et al, , 2021Matsuda et al, 2020;Uchida et al, 2020). Data were collected at 14 palliative care units certified by the Hospice Palliative Care Japan and 9 psycho-oncology settings of tertiary cancer care hospitals or university hospitals across Japan from September 2015 to May 2016.…”