Delirium screening tools validated in the context of palliative care: A systematic review

Abstract

Background: Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. Aim: To systematically review studies that validate delirium screening tools conducted in palliative care settings. Design: Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. Data sources: Five electronic databases were systematically searched (January 1, 1982–May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. Results: Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included ( n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. Conclusions: The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.

The conscious state of the dying patient: An integrative review

“…Despite delirium being an important area of concern at the end of life, only 3 of the 11 studies mentioned delirium (Fainsinger et al, 1991; Turner et al, 1996; White et al, 2019). This is consistent with other recent research, suggesting that delirium is often not recognized or not identified in palliative care patients (Watt et al, 2021), despite the availability of both diagnostic criteria (American Psychiatric Association, 2013) and validated delirium screening tools (Watt et al, 2021). Given that delirium is perceived as a very distressing condition by those who have experienced it and recovered (Kuusisto-Gussmann et al, 2021), it is possible that the dying patient with an altered level of consciousness is equally distressed.…”

“…This review also highlighted a further cohort of patients who may be unable to convey their own care needs: those who develop delirium or become terminally restless or agitated due to the dying process (Lichter and Hunt, 1990;Fainsinger et al, 1991;Turner et al, 1996;Bruera et al, 2003;Barbato et al, 2018;Pereira et al, 2018;White et al, 2019). The incidence of delirium is reported elsewhere, varying from 58% to 88% in dying patients, with the prevalence increasing closer to death (Hosie al., 2013(Hosie al., , 2019Lawlor et al, 2014;Maeda et al, 2020;Watt et al, 2021). Delirium affects perception, attention, and communication, leading to a reduced ability to express symptoms (Hosie et al, 2019;Hui, 2019).…”

The detection of delirium in admitted oncology patients: a scoping review

“…The discussion has aimed to identify recent updates in the area, again these are largely limited to aged care or stand-alone settings, with one systematic review of delirium in palliative care fining an incidence of 9–57% across hospital palliative care consultative services, with a majority of patients having cancer diagnoses [ 20 ]. a further systematic review, again in the palliative care setting, identified 14 delirium detection tools and heterogeneity of methods [ 23 ], Important questions for future work include which tools translate well to inpatient oncology from aged care and stand-alone inpatient palliative care settings, which tools are most suitable for patients, carers and staff, and which reference standards are most appropriate. Requirements for clinical and research uses of detection tools will differ according to purpose, however establishing methodical approaches to the detection of delirium in either setting is a prerequisite to determining the incidence, prevalence and reversibility of delirium for oncology inpatients.…”

“…Although guidelines for the management of delirium in cancer settings exist [ 15 ], fewer studies have primarily focussed on adults (defined as 18yrs or older) in an acute hospital, oncology, inpatient setting [ 16 – 18 ]. More commonly studies including cancer patients have been in “stand-alone” palliative care units [ 19 , 20 ], or subsets of cancer inpatient cohorts on the basis of palliative care [ 21 – 23 ] or psychiatry consultation/liaison services in acute hospitals [ 11 ]. A recent review of delirium in the palliative care setting yielded a point prevalence estimate of 35% [95% confidence interval (CI) = 0.29–0.40] at inpatient admission.…”

The Dilemma of Treating Delirium: the Conundrum of Drug Management

“…It is recommended that routine screening is implemented for high-risk patients [ 11 , 16 ••]. The choice of optimal screening measure should consider the setting, the cancer population, and clinician characteristics including training and skills [ 17 ]. A single question (“Do you feel (…the patient’s name) has been more confused lately?”) offers reasonable specificity (87%, 95% CI 74–96) but lower sensitivity (44%, 95% CI 41–80), and is a simple approach that can be integrated into routine clinical histories, adding to the sources of information that may alert the clinical team to the presence of delirium [ 18 ].…”