Delirium Resolution in Hospitalized Older Patients With Cancer

Stewart M. Bond, PhD, RN, AOCN; Virginia J. Neelon, PhD, RN

Disclosures

Cancer Nurs. 2008;31(6):444-451. 

In This Article

Abstract and Introduction

Abstract

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.

Introduction

Delirium is a pathophysiological condition characterized by altered consciousness and inattention, cognitive dysfunction, and disturbed psychomotor behavior. Delirium is a frequent complication among hospitalized older adults.[1] Until recently, delirium has been understood as a transient, potentially reversible condition that resolves with treatment and correction of the underlying etiology. There is growing evidence, however, that delirium is not transient but rather more prolonged.

A significant number of hospitalized older patients have incomplete resolution of delirium at hospital discharge. In samples of hospitalized older medical and surgical patients, delirium symptoms persisted at discharge and for up to 12 months after discharge.[2,3,4,5,6] Especially when it persists, delirium results in longer hospitalization, institutional placement, rehospitalization, higher costs, impaired recovery, functional and cognitive decline, shorter life expectancy, and increased mortality.[7,8,9,10,11]

In patients who are hospitalized with cancer, the rate of delirium ranges from 14% to 55%.[12,13,14,15,16] Delirium occurs more frequently in certain cancer patient populations. Almost 75% of patients meet the criteria for delirium after bone marrow transplantion,[17] and up to 90% of patients with advanced cancer develop delirium during their last weeks of life.[18,19,20] In a sample of 76 hospitalized older patients with cancer, we found a 57% cumulative rate of delirium.[21]

Among patients with cancer, delirium can be related to direct and indirect effects of the cancer and its treatment, adverse effects of symptom management, or unrelated comorbid medical conditions. In most cases, the etiology of delirium is multifactorial.[19,22,23] Primary or metastatic brain disease often results in delirium. Other common causes of delirium in cancer patients include the following: drugs, infection, metabolic alterations, dehydration, hypoxia, hypoperfusion, anemia, nutritional impairment, liver dysfunction, and renal dysfunction.[16,19,22,23,24,25]

Many causes of delirium in patients with cancer are treatable and correctable. Studies indicate that delirium in patients with cancer is potentially reversible, even in those with advanced disease[14,18,19,20,22,25,26] A number of factors including age; overall physical condition; baseline cognitive function; the appropriateness, effectiveness, and timeliness of treatment of the underlying cause; and the management of delirium itself influence the reversibility of delirium.[27]

Research on delirium in older patients with cancer is lacking.[28,29] Because older patients with cancer are particularly vulnerable for delirium, more research is needed to enhance our understanding of delirium patterns and resolution in this group. We need to identify factors associated with delirium resolution and persistence to develop targeted prevention and intervention strategies.

In this article, we report findings from a secondary data analysis in which we examined delirium resolution in a sample of hospitalized older patients with cancer. First, we describe trajectories of delirium resolution in the sample, and then we evaluate differences in patient characteristics, delirium characteristics, and etiologic patterns in patients with and without delirium resolution.

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