Factors for Timely Identification of Possible Occurrence of Delirium in Palliative Care: A Prospective Observational Study

Abstract

Delirium occurs in 50-80% of end-of-life patients but is often misdiagnosed. Identification of clinical factors potentially associated with delirium onset can lead to a correct early diagnosis. To this aim, we conducted a prospective cohort study on patients from an Italian palliative care unit (PCU) admitted in 2018-2019. We evaluated the presence of several clinical factors at patient admission and compared their presence in patients who developed delirium and in those who did not develop it during follow-up. Among 503 enrolled patients, after a median follow-up time of 16 days (interquartile range 6-40 days), 95 (18.9%) developed delirium. Hazard ratios (HR) and corresponding 95% confidence intervals were computed using Cox proportional hazard models. In univariate analyses, factors significantly more frequent in patients with delirium were care in hospice, compromised performance status, kidney disease, fever, renal fail-

Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study

“…First, we observed the importance of the palliative care setting. Our previous publication found that hospice care is associated with a higher risk of developing delirium (HR=2.28, 95% CI 1.45-3.60) as compared to home care [17], while this study, which is not focused on risk factors for delirium but on the role that may have the time to diagnosis on delirium clinical outcomes, highlights a different aspect concerning the setting of care. Among 49 patients with early diagnosis, 46 were managed in hospice and only 3 in a home care program.…”

“…As already described [17], a total of 503 patients aged 18 or more were enrolled between October 2018 and December 2019 and followed till the date of delirium resolution, death, transfer outside the PCU, patient withdrawal, or end of follow-up (October 28, 2020).…”

“…A prospective, single-center, cohort study was conducted in 2018-2019 at the specialist PCU of Giussano, ASST Brianza (MB), Italy. Our first publication on the whole cohort of 503 patients aimed to identify relevant clinical factors that could be related to the risk of delirium onset [17], and we found that the setting of care, presence of breathlessness, and administration of psychoactive drugs, particularly haloperidol, were significantly associated with the risk of developing delirium.…”

A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness

“…Thus, this results in patients being inappropriately treated or untreated (Breitbart & Alici, 2008;Moyer, 2011). It is therefore paramount for clinicians to properly identify the clinical signs of delirium in terminallyill patients and use effective measures of non-pharmacologic and pharmacologic interventions as appropriate to mitigate the distressing problems (Breitbart & Strout, 2000;Corli et al, 2021;Finucane et al, 2020;Hui, 2019). As a dying individual approaches the EOL, treating refractory terminal delirium to mitigate suffering may sometimes require the use of palliative sedation (Arantzamendi et al, 2021;Patel et al, 2019).…”

“…In terminally-ill people, delirium syndrome usually involves multifactorial causes. The most recent evidence from prospective observational studies, systematic reviews and meta-analysis studies report risk factors for terminal delirium to include older age, male sex, organ failure, fluid and electrolyte imbalances, dehydration, suboptimal pain management, hypoxia, breathlessness, poor well-being with declining performance status, and medication adverse effects (Bush et al, 2014; Corli et al, 2021; Ellsworth et al, 2021; Guo et al, 2021). Delirium care poses a significant challenge in EOL care, causing significant distress for the dying person and families, as it is often under-diagnosed or undetected.…”