Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers

Bruera, Éduardo; Bush, Shirley H.; Willey, Jie; Paraskevopoulos, Timotheos; Li, Zhijun; Palmer, J. Lynn; Cohen, Marlene Z.; Sivesind, Debra; Elsayem, Ahmed

doi:10.1002/cncr.24215

Cited by 243 publications

(235 citation statements)

References 58 publications

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“…6 very distressing to families and challenging for the health care team, and further compounded at the end of life by impeded communication as a result of the delirium (11,12). A recent systematic review of palliative sedation suggests that delirium is one of the most common indications for palliative sedation (13).…”

Section: A C C E P T E D Accepted Manuscriptmentioning

confidence: 99%

“…Patients who have recovered from an episode of delirium report significant distress, for both hyperactive and hypoactive clinical subtypes (11,12). In contrast to aged care and intensive care populations, there is currently insufficient evidence to support non-pharmacological approaches in the management of delirium at the end of life (32,56).…”

Section: Symptomatic Treatment Of Delirium In the Terminal Phasementioning

confidence: 99%

“…Delirium increases distress for family members (11,12), especially at the end of life where communication is impaired (73,74,78). In M A N U S C R I P T…”

Section: Pharmacological Intervention With a More Sedating Approach Omentioning

confidence: 99%

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End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Bush

Leonard

Agar

et al. 2014

Journal of Pain and Symptom Management

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Context. In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.Objectives. To review: delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. Methods.We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO and CINAHL) to inform this narrative review.Results. The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health care staff, clear communication, education and emotional support are vital components to assist with decision making and direct the treatment care plan. Conclusion.Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement are needed in this patient population.

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Section: A C C E P T E D Accepted Manuscriptmentioning

confidence: 99%

Section: Symptomatic Treatment Of Delirium In the Terminal Phasementioning

confidence: 99%

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End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Bush

Leonard

Agar

et al. 2014

Journal of Pain and Symptom Management

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“…Likewise, witnessing agitation, confusion, moaning, and groaning can cause significant distress in families, caregivers, and health care professionals. [47][48][49][50][51] In dying patients with hyperactive delirium, when the goals are to decrease agitation, relieve muscle tension, ensure amnesia, and minimize the risk of seizures, benzodiazepines appear to be ideal medications to manage and prevent these symptoms. 29,60,68,90,[109][110][111][112][113][114][115][116][117]119 Benzodiazepines.…”

Section: Muscle Relaxation Anticonvulsantmentioning

confidence: 99%

“…It has been shown to produce a high level of distress in family and professional caregivers. 49,51 In addition to general distress, caregivers of delirious patients have 12 times the risk for being diagnosed with a generalized anxiety disorder. 133 Supporting caregivers through education about delirium has been shown to help reduce these negative impacts.…”

Section: Family and Caregiver Education And Supportmentioning

confidence: 99%

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Irwin

Pirrello

Hirst

et al. 2013

Journal of Palliative Medicine

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Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.

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Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care

Hui

Frisbee-Hume

Wilson

et al. 2017

JAMA

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IMPORTANCEThe use of benzodiazepines to control agitation in delirium in the last days of life is controversial.OBJECTIVE To compare the effect of lorazepam vs placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium in the setting of advanced cancer. DESIGN, SETTING, AND PARTICIPANTS Single-center, double-blind, parallel-group, randomized clinical trial conducted at an acute palliative care unit at MD Anderson Cancer Center, Texas, enrolling 93 patients with advanced cancer and agitated delirium despite scheduled haloperidol from February 11, 2014, to June 30, 2016, with data collection completed in October 2016.INTERVENTIONS Lorazepam (3 mg) intravenously (n = 47) or placebo (n = 43) in addition to haloperidol (2 mg) intravenously upon the onset of an agitation episode. MAIN OUTCOMES AND MEASURES The primary outcome was change in Richmond Agitation-Sedation Scale (RASS) score (range, −5 [unarousable] to 4 [very agitated or combative]) from baseline to 8 hours after treatment administration. Secondary end points were rescue neuroleptic use, delirium recall, comfort (perceived by caregivers and nurses), communication capacity, delirium severity, adverse effects, discharge outcomes, and overall survival.RESULTS Among 90 randomized patients (mean age, 62 years; women, 42 [47%]), 58 (64%) received the study medication and 52 (90%) completed the trial. Lorazepam + haloperidol resulted in a significantly greater reduction of RASS score at 8 hours (−4.1 points) than placebo + haloperidol (−2.3 points) (mean difference, −1.9 points [95% CI, −2.8 to −0.9]; P < .001). The lorazepam + haloperidol group required less median rescue neuroleptics (2.0 mg) than the placebo + haloperidol group (4.0 mg) (median difference, −1.0 mg [95% CI, −2.0 to 0]; P = .009) and was perceived to be more comfortable by both blinded caregivers and nurses (caregivers: 84% for the lorazepam + haloperidol group vs 37% for the placebo + haloperidol group; mean difference, 47% [95% CI, 14% to 73%], P = .007; nurses: 77% for the lorazepam + haloperidol group vs 30% for the placebo + haloperidol group; mean difference, 47% [95% CI, 17% to 71%], P = .005). No significant between-group differences were found in delirium-related distress and survival. The most common adverse effect was hypokinesia (3 patients in the lorazepam + haloperidol group [19%] and 4 patients in the placebo + haloperidol group [27%]). CONCLUSIONS AND RELEVANCEIn this preliminary trial of hospitalized patients with agitated delirium in the setting of advanced cancer, the addition of lorazepam to haloperidol compared with haloperidol alone resulted in a significantly greater reduction in agitation at 8 hours. Further research is needed to assess generalizability and adverse effects.

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Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers

Cited by 243 publications

References 58 publications

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care

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