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Delirium in advanced cancer worsens survival, increases hospitalization

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August 1, 2017

Patients with advanced cancer who arrived at the ED with delirium had increased rates of hospitalization and ICU admissions, as well as shorter survival rates, according to a study published in The Oncologist.

Further, many patients with delirium in the ED lacked advance directives. Based on these data, oncologists should regularly assess patients for delirium and discuss goals of care and advance directives, according to the researchers.

“In addition to reversing the cause of delirium and control of symptoms, management of cancer patients with delirium in emergency departments should include addressing goals of care, and resuscitation preferences with the patient’s legally authorized representative and the treating primary oncologist,” Ahmed F. Elsayem, MD, associate professor in the department of emergency medicine at The University of Texas MD Anderson Cancer Center, and colleagues wrote.

Frequently a preterminal event, delirium is the most common and serious neuropsychiatric complication in patients with advanced cancer. Prevalence rates range from 25% to 85% of hospitalized patients with cancer, according to a review by Friedlander and colleagues published in Oncology.

Delirium in patients with advanced cancer often can be resolved by simply stopping or modifying their medication, Elsayem said in a press release.

“Treating the triggers, if known, is the main treatment for an episode of delirium,” he said.

Researchers assessed for delirium and the presence of advance directives in 243 randomly selected patients admitted to an ED.

Patients demonstrated delirium-positive results in both the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS; group A; n = 22), MDAS only (group B; n = 22) or neither (group C; n = 199).

Hospital and ICU admission rates, as well as OS, served as primary outcomes.

Hospitalization occurred for 82% of patients in group A, 77% in group B and 49% in group C (P = .0013). ICU rates were 18% in group A, 14% in group B and 2% in group C (P = .0004).

Median OS was significantly longer in group C (10.45 months) than in group A (1.23 months) and B (4.7 months; P < .0001 for both). The difference in median OS between groups A and B did not reach statistical significance.

Presence of advance directives (group A, 52%; group B, 27%; group C, 43%) carried no association with hospitalization. Of those hospitalized, 53.92% had advance directives and 55.47% did not.

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“Delirium should be regularly assessed in advanced cancer patients in the ED setting so that this life-threatening condition can be diagnosed and managed early,” Elsayem and colleagues wrote. “End-of-life discussions are better done by oncologists in the outpatient setting than in the ED; however, these discussions are usually initiated in the last 33 days of life, in the inpatient hospital setting and by providers other than oncologists.”

Researchers did not adjust for comorbidities and acknowledged the small study size and single institution status as limitations.

“Because of the relatively high prevalence of delirium among advanced cancer patients in the ED, and the high mortality we observed in this study, universal screening for delirium is justified,” Elsayem and colleagues wrote. “Clinicians caring for advanced cancer patients with delirium in EDs should strongly consider focusing on goals of care, resuscitation preferences, and quality of life for patients and their family members.” – by Chuck Gormley

For additional information:

Friedlander MM, et al. Oncology (Williston Park). 2004;18:1541-1550.

Disclosures: The researchers report no relevant financial disclosures.

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