Delirium as a Risk Factor for Mortality in Critically Ill Patients With Cancer

Abstract

PURPOSE Although delirium is known to negatively affect critically ill patients, little data exist on delirium in critically ill patients with cancer. METHODS We analyzed 915 critically ill patients with cancer between January and December 2018. Delirium screening was performed using the Confusion Assessment Method for the intensive care unit (ICU), performed twice daily. Confusion Assessment Method-ICU incorporates four features of delirium: acute fluctuations in mental status, inattention, disorganized thinking, and altered levels of consciousness. Multivariable analysis controlling for admitting service, pre-ICU hospital length of stay (LOS), metastatic disease, CNS involvement, Mortality Probability Model II score on ICU admission, mechanical ventilation, and others was performed to determine precipitating factors for delirium, ICU, and hospital mortality and LOS. RESULTS Delirium occurred in 40.5% (n = 317) of patients; 43.8% (n = 401) were female; the median age was 64.9 (interquartile range, 54.6-73.2) years; 70.8% (n = 647) were White, 9.3% (n = 85) were Black, and 8.9% (n = 81) were Asian. The most common cancer types were hematologic (25.7%, n = 244) and gastrointestinal (20.9%, n = 191). Delirium was independently associated with age (OR, 1.01; 95% CI, 1.00 to 1.02; P = .038), longer pre-ICU hospital LOS (OR, 1.04; 95% CI, 1.02 to 1.06; P < .001), not resuscitating on admission (OR, 2.18; 95% CI, 1.07 to 4.44; P = .032), CNS involvement (OR, 2.25; 95% CI, 1.20 to 4.20; P = .011), higher Mortality Probability Model II score (OR, 1.02; 95% CI, 1.01 to 1.02; P < .001), mechanical ventilation (OR, 2.67; 95% CI, 1.84 to 3.87; P < .001), and sepsis diagnosis (OR, 0.65; 95% CI, 0.43 to 0.99; P = .046). Delirium was also independently associated with higher ICU mortality (OR, 10.75; 95% CI, 5.91 to 19.55; P < .001), hospital mortality (OR, 5.84; 95% CI, 4.03 to 8.46; P < .001), and ICU LOS (estimate, 1.67; 95% CI, 1.54 to 1.81; P < .001). CONCLUSION Delirium significantly worsens outcome in critically ill patients with cancer. Delirium screening and management should be integrated into the care of this patient subgroup.

Delirium Among Patients With Cancer in the Intensive Care Unit: Prognostic Sign or Opportunity for Intervention

“…Therefore, the authors concluded that systematic delirium screening and management for critically ill patients with cancer should be integrated in the management of these patients to prevent and shorten delirium. 10 Findings from this work highlight several important points to discuss further.…”

“…Tao et al 10 conducted a retrospective analysis on critically ill, nonterminal patients with cancer admitted to a mixed medical-surgical intensive care unit (ICU) to characterize the impact that delirium has on clinical outcomes. Of the 915 patients they evaluated, the median age was 64.9 years with 73.3% having solid tumor, 78% having metastatic disease, and 6% having CNS involvement.…”

“…Tao et al 10 highlighted the seriousness of delirium in the critically ill population with advanced cancer, and they have shed light on areas where additional research is needed. They have clearly shown that in this population, there are identifiable risk factors that should trigger systematic delirium screening and interventions for prevention.…”

“…9 These concepts are also taught to learners, recognizing that delirium is a challenging syndrome with prognostic uncertainty and unpredictability. 1 New research, including the article that accompanies this editorial by Tao et al, 10 offers insights on important clinical outcomes and provides guidance on who to identify for intervention and discussing prognosis.…”

“…16 An important outcome of this article showed that pre-ICU hospital LOS remained an independent risk factor for developing delirium, increasing deliriums incidence by 4% with every day spent in the hospital before ICU transfer. 10 Most ICUs have delirium screening processes in place with nonpharmacologic prevention measures available and, now with the knowledge that these patients are at higher risk than typical ICU patients, emphasizes the need to further develop a direct intervention for enhanced screening and prevention. Without formal screening objective measures in place, delirium has been reported to be missed by physicians up to 60% of the time.…”