Delirium is a pathophysiological condition characterized. Delirium Resolution in Hospitalized Older Patients With Cancer

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1 Copyright B 2008 Wolters Kluwer Health Lippicott Williams & Wilkis Stewart M. Bod, PhD, RN, AOCN Virgiia J. Neelo, PhD, RN Delirium Resolutio i Hospitalized Older Patiets With Cacer K E Y W O R D S Agig Cacer Delirium Hospitalized older patiets Delirium is a troublig complicatio i hospitalized older patiets with cacer. Although prevetable ad potetially reversible, delirium may be prologed. Persistet delirium at the time of hospital discharge is commo ad associated with multiple adverse outcomes. We coducted a secodary data aalysis to examie delirium resolutio i 43 hospitalized older patiets with cacer who had prevalet or icidet delirium. We describe trajectories of delirium resolutio ad evaluate differeces i patiets with ad without delirium resolutio. Delirium was assessed usig the NEECHAM cofusio scale. Forty-oe of the 43 patiets had delirium durig hospitalizatio before discharge; 2 had delirium oly at the time of discharge. Although delirium resolved i 13 patiets, a sigificat majority (70%) had delirium at discharge. Patiets with delirium resolutio were less fuctioally impaired before hospitalizatio ad exhibited fewer etiologic risk patters at admissio. Mild delirium was more likely to resolve tha severe delirium. All patiets with chroic cogitive impairmet had persistet delirium. Care for hospitalized older patiets with cacer should icorporate delirium prevetio ad itervetio strategies. Caregiver educatio, commuicatio betwee providers, ad follow-up are critical whe delirium persists. Additioal research focusig o the maagemet ad impact of persistet delirium i hospitalized older patiets with cacer is eeded. Delirium is a pathophysiological coditio characterized by altered cosciousess ad iattetio, cogitive dysfuctio, ad disturbed psychomotor behavior. Delirium is a frequet complicatio amog hospitalized older adults. 1 Util recetly, delirium has bee uderstood as a trasiet, potetially reversible coditio that resolves with treatmet ad correctio of the uderlyig etiology. There is growig evidece, Authors Affiliatios: Vaderbilt Uiversity School of Nursig, Nashville, Teessee (Dr Bod); ad Biobehavioral Laboratory, Uiversity of North Carolia School of Nursig, Chapel Hill (Dr Neelo). This study was supported, i part, by the Joh A. Hartford Foudatio s Buildig Academic Geriatric Nursig Capacity Award Program through the America Academy of Nursig, a doctoral scholarship i cacer ursig (#DSCN SCN) from the America Cacer Society, ad NINR T32 NR07091: Itervetios to Prevet ad Maage Chroic Illess. Correspodig author: Stewart M. Bod, PhD, RN, AOCN, Vaderbilt Uiversity School of Nursig, 505 Godchaux Hall, st Ave South, Nashville, TN (stewart.m.bod@vaderbilt.edu). Accepted for publicatio March 11, Cacer Nursig TM, Vol. 31, No. 6, 2008 Bod ad Neelo

2 however, that delirium is ot trasiet but rather more prologed. A sigificat umber of hospitalized older patiets have icomplete resolutio of delirium at hospital discharge. I samples of hospitalized older medical ad surgical patiets, delirium symptoms persisted at discharge ad for up to 12 moths after discharge. 2Y6 Especially whe it persists, delirium results i loger hospitalizatio, istitutioal placemet, rehospitalizatio, higher costs, impaired recovery, fuctioal ad cogitive declie, shorter life expectacy, ad icreased mortality. 7Y11 I patiets who are hospitalized with cacer, the rate of delirium rages from 14% to 55%. 12Y16 Delirium occurs more frequetly i certai cacer patiet populatios. Almost 75% of patiets meet the criteria for delirium after boe marrow trasplatio, 17 ad up to 90% of patiets with advaced cacer develop delirium durig their last weeks of life. 18Y20 I a sample of 76 hospitalized older patiets with cacer, we foud a 57% cumulative rate of delirium. 21 Amog patiets with cacer, delirium ca be related to direct ad idirect effects of the cacer ad its treatmet, adverse effects of symptom maagemet, or urelated comorbid medical coditios. I most cases, the etiology of delirium is multifactorial. 19,22,23 Primary or metastatic brai disease ofte results i delirium. Other commo causes of delirium i cacer patiets iclude the followig: drugs, ifectio, metabolic alteratios, dehydratio, hypoxia, hypoperfusio, aemia, utritioal impairmet, liver dysfuctio, ad real dysfuctio. 16,19,22Y25 May causes of delirium i patiets with cacer are treatable ad correctable. Studies idicate that delirium i patiets with cacer is potetially reversible, eve i those with advaced disease 14,18Y20,22,25,26 A umber of factors icludig age; overall physical coditio; baselie cogitive fuctio; the appropriateess, effectiveess, ad timeliess of treatmet of the uderlyig cause; ad the maagemet of delirium itself ifluece the reversibility of delirium. 27 Research o delirium i older patiets with cacer is lackig. 28,29 Because older patiets with cacer are particularly vulerable for delirium, more research is eeded to ehace our uderstadig of delirium patters ad resolutio i this group. We eed to idetify factors associated with delirium resolutio ad persistece to develop targeted prevetio ad itervetio strategies. I this article, we report fidigs from a secodary data aalysis i which we examied delirium resolutio i a sample of hospitalized older patiets with cacer. First, we describe trajectories of delirium resolutio i the sample, ad the we evaluate differeces i patiet characteristics, delirium characteristics, ad etiologic patters i patiets with ad without delirium resolutio. idetified patters of delirium developmet i a sample of hospitalized older patiets. Writte iformed coset was obtaied either from the patiet or a primary caregiver if the patiet exhibited cogitive impairmet. The secod study determied the icidece of delirium i hospitalized older patiets, ad the third study tested patter-specific itervetios to prevet ad maage delirium. The last 2 studies were coducted i cojuctio with a program to icorporate regular cogitive ad fuctioal assessmets as part of usual ursig care. Although the purposes of the 3 paret studies differed, they used similar methodologies ad commo variables. All studies icludig this secodary aalysis were reviewed ad approved by the istitutioal review board. Sample The paret studies icluded 627 participats aged 65 years ad older ad admitted to geeral medical uits i a tertiary medical ceter. Patiets admitted for termial care ad those with a primary psychiatric diagosis were ot icluded. Our study 21 examiig delirium i hospitalized older patiets with cacer icluded a subset of 76 patiets who had cacer as a primary or secodary admittig diagosis. The sample for this secodary aalysis was composed of the 43 hospitalized older patiets with cacer who also had prevalet or icidet delirium (Figure 1). Prevalet delirium was defied as the presece of delirium at the admissio assessmet, ad icidet delirium was defied as the developmet of delirium at ay time durig the etire hospital stay i patiets who were free of delirium at the admissio assessmet. Variables ad Istrumets DELIRIUM Delirium was assessed at admissio, daily durig hospitalizatio, ad at discharge usig the NEECHAM cofusio scale. 31 The NEECHAM scale was developed for the rapid Methods Data for this secodary aalysis were collected i 3 studies of acute cofusio i hospitalized older adults. 30 The first study Figure 1 Sample schema. Delirium Resolutio i Hospitalized Older Patiets With Cacer Cacer Nursig TM, Vol. 31, No. 6,

3 ad uobtrusive bedside assessmet of cogitive fuctio ad behavioral performace to detect early sigs of delirium ad moitor its respose to treatmet. The NEECHAM scale is a 9-item scale orgaized ito 3 subscales: processig, behavior, ad physiologic cotrol. Item-specific scores are summed to determie a score for each of the 3 subscales. The subscale scores are the summed to obtai a total NEECHAM score that rages from 0 to 30. Higher scores are associated with more ormal cogitive ad behavioral fuctio. A chage i NEECHAM score of 3 poits or more may be cliically sigificat, requirig further evaluatio. The NEECHAM scale has demostrated excellet psychometric properties i elderly patiets who are hospitalized with acute illesses. 31,32 Scores o the NEECHAM scale idetify 4 levels of cofusio or delirium. 31 A score greater tha 27 idicates ormal fuctio or low risk for cofusio or delirium. There is a icreased risk for cofusio or delirium if the score is betwee 25 ad 26 or greater tha 26 ad with the presece of oe of the followig cliical risk markers: respiratory rate greater tha 23, use of supplemetary oxyge, oxyge saturatio less tha 91%, serum albumi less tha 3.0 g/dl, or report of metal status chage. A score betwee 20 ad 24 idicates mild cofusio or delirium. A NEECHAM score less tha 20 idicates moderate to severe cofusio or delirium. I this study, a NEECHAM score less tha 24 o admissio, durig hospitalizatio, or at discharge idicated the presece of delirium. Patiets with a NEECHAM score of 20 to 24 are labeled as havig mild delirium, ad those with a NEECHAM score less tha 20 are labeled as havig severe delirium. Patiet Characteristics Patiet characteristics determied at the time of admissio icluded age, ethicity, sex, educatio, severity of illess, ad fuctioal status. Severity of illess was measured with the Acute Physiology ad Chroic Health Evaluatio (APACHE II) scale. 33 Scores o the APACHE II rage from 0 to 71. A icreasig score is associated with greater severity of illess. Fuctioal status was measured by the istrumetal activities of daily livig (IADL) subscale of the Older Americas Resources ad Services Scale. 34 Istrumetal activities of daily livig scores rage from 0 to 14. A lower score idicates greater fuctioal impairmet. The items were asked so as to measure performace withi the moth before hospitalizatio to elimiate the impact of the acute episode. Hospital legth of stay was measured i days from admissio to discharge. Etiologic Risk Patters at Admissio Patiets were screeed at admissio for key cliical risk markers to idetify etiologic patters of delirium developmet. Belyea et al 35 idetified 5 etiologic patters usig cluster aalysis ad likelihood ratios of key variables. The 5 etiologic risk patters are metabolic-utritioal, hypoxic, metabolic-toxic, orthostatic-dehydratio, ad chroic cogitive impairmet. Table 1 shows the etiologic risk patters ad cliical markers associated with each. Patiets were classified as havig a patter if they exhibited at least 1 cliical marker for that patter. Aalysis To determie delirium resolutio, the lowest NEECHAM score either at admissio or durig hospitalizatio was compared to the discharge NEECHAM score. Delirium was cosidered resolved if the discharge NEECHAM score was greater tha or equal to 25. I patiets with persistet delirium, sigificat improvemet was defied as a chage i NEECHAM category from severe (NEECHAM G 20) to mild (NEECHAM, 20Y24). Descriptive statistics were used to examie patiet characteristics ad delirium resolutio. Fisher exact, # 2, ad t tests were used to evaluate the differeces i patiet characteristics, etiologic patters, ad factors betwee patiets with ad without delirium resolutio. Etiologic Risk Patter Table 1 & Etiologic Risk Patters ad Cliical Markers a Hypoxic Metabolicutritioal Metabolictoxic Orthostaticdehydratio Chroic cogitive impairmet a Adapted with permissio. 30 Results Patiet Characteristics Cliical Markers Body mass idex G 20 Weight loss 9 5 kg or 10% Albumi G 3.5 g/dl Lymphocyte cout G 1000/2L O oxyge Oxyge saturatio G 91% Hemoglobi G 9.0 g/dl Albumi G 3.0 g/dl Creatiie mg/dl Diagosis of liver or real failure Diagosis of dehydratio Presece of orthostatic symptoms Blood urea itroge/creatiie ratio 9 20 Report of metal status problems ad requires assistace takig medicatios Diagosis of demetia The characteristics of the 43 hospitalized older patiets with cacer who had delirium are preseted i Table 2. The patiets had a mea age of 74.6 years. Patiets were almost evely divided by sex ad ethicity. Multiple hematologic ad solid orga maligacies were represeted i the sample, icludig multiple myeloma ( = 8), leukemia ( = 3), ad lymphoma ( = 1) ad lug ( = 9), breast ( = 8), prostate ( = 4), colo ( = 2), liver ( = 2), ad other ( = 6) maligacies. The mea APACHE II score (16.0) idicated a 446 Cacer Nursig TM, Vol. 31, No. 6, 2008 Bod ad Neelo

4 Table 2 & Characteristics of Hospitalized Older Cacer Patiets With Delirium (N = 43) % Sex Male Female Ethicity White Nowhite Cacer type Hematologic Solid tumor Mea SD Rage Age, y Y96 Educatio, y Y20 APACHE II Y30 IADLs Y14 Legth of stay, d Y43 Etiologic patters Y5 Abbreviatios: APACHE II, Acute Physiology ad Chroic Health Evaluatio II; IADLs, istrumetal activities of daily livig. moderately high level of illess severity. Similarly, the patiets had a moderate level of fuctioal impairmet before hospitalizatio, as idicated by a mea IADL score of 6.8. Patiets exhibited cliical markers for multiple etiologic risk patters; the average umber of etiologic risk patters at admissio was 2.6. The average legth of hospital stay was 11.5 days (media = 8.0 days). Trajectories of Delirium Resolutio Figure 2 displays the trajectories of chage i delirium from hospitalizatio to discharge by level of severity. Forty-oe of the 43 patiets had delirium durig their hospitalizatio before discharge; 2 had delirium oted at the time of discharge oly. Amog those with delirium durig hospitalizatio, 18 (44%) had mild delirium, ad 23 (56%) had severe delirium. At discharge, delirium was preset i 30 (70%) patiets: 18 had mild delirium, ad 12 had severe delirium. Delirium persisted i 28 of the 41 (68%) patiets who had delirium durig hospitalizatio: 16 (57%) had mild delirium, ad 12 (43%) had severe delirium. Two patiets with o delirium durig hospitalizatio had mild delirium (NEECHAM score, 20Y24) at discharge. Oe of the patiets had a 3-poit drop i NEECHAM score from 27 durig hospitalizatio to 24 at discharge. The other had a 2-poit drop i NEECHAM score from 26 to 24. Delirium resolved i 12 of the 18 patiets (67%) with mild delirium durig hospitalizatio. The mea chage i NEECHAM score amog the patiets with mild delirium that resolved was 5.1 poits (SD, 2.47; rage 2Y10). All but oe of the patiets had a cliically sigificat chage of greater tha 3 poits i their NEECHAM scores. Six patiets (33%) had persistet mild delirium. No patiets with mild delirium durig hospitalizatio had more severe delirium at discharge. At discharge, delirium had resolved i oly 1 patiet with severe delirium durig hospitalizatio. This patiet s lowest NEECHAM score durig hospitalizatio was 7, ad at discharge, the NEECHAM score was 27. More tha half ( = 12, 52%) with severe delirium durig hospitalizatio had persistet severe delirium at discharge. Delirium improved from severe to mild i 10 (43%) patiets. The mea chage i NEECHAM score for those who improved was 6.1 poits (SD, 4.38; rage 1Y17). All but oe of the patiets had a chage i NEECHAM score greater tha 3 poits. Characteristics i Patiets With ad Without Delirium Resolutio Table 3 compares the characteristics of patiets with delirium resolutio to those without delirium resolutio. The 2 patiets who exhibited delirium at discharge oly are icluded i the Bo resolutio[ group. Patiets with delirium resolutio were less fuctioally impaired before hospitalizatio (mea IADL score, 10.3 vs 5.3) ad exhibited fewer etiologic risk patters at admissio (mea, 1.9 vs 2.8). Patiets with delirium resolutio also had a shorter legth of hospital stay (mea legth of stay, 7.3 vs 13.3 days). Patiets with mild delirium were more likely to have resolutio tha those with severe delirium (Figure 3). There were o differeces betwee patiets with delirium resolutio ad those without resolutio with regard to sex, ethicity, cacer type, or time of delirium oset at admissio or durig hospitalizatio. Although delirium was more likely to resolve i patiets with fewer etiologic risk patters at admissio, there were o differeces i delirium resolutio with regard to specific etiologic risk patters except i those with chroic cogitive impairmet. Five patiets exhibited markers for chroic cogitive impairmet at admissio. All 5 had severe delirium at some poit durig hospitalizatio. Delirium persisted at Figure 2 Trajectories of chage i delirium from hospitalizatio to discharge by level of severity. Delirium Resolutio i Hospitalized Older Patiets With Cacer Cacer Nursig TM, Vol. 31, No. 6,

5 Table 3 & Characteristics of Patiets With ad Without Delirium Resolutio (N = 43) Delirium Resolutio ( = 13) No Resolutio ( = 30) Patiet Characteristic Mea SD Mea SD t p Age, y APACHE II a j IADLs b j3.97 G.001 Legth of stay, d No. of etiologic patters Abbreviatios: APACHE II, Acute Physiology ad Chroic Health Evaluatio II; IADLs, istrumetal activities of daily livig. a Higher scores idicate greater severity of illess. b Lower scores idicate greater fuctioal impairmet. discharge i all 5 patiets with chroic cogitive impairmet. It remaied severe i 3 patiets but improved to mild i 2. Discussio Our fidigs highlight importat aspects of delirium resolutio i a sample of hospitalized older patiets with cacer. Thirtee of 43 patiets (30%) had delirium resolutio at discharge. Aother 10 (23%) had sigificat improvemet i their delirium durig hospitalizatio from severe to mild. Nevertheless, delirium persisted at discharge i a sigificat majority of patiets (70%). Previous studies have demostrated the potetial reversibility or improvemet i delirium amog patiets with cacer, eve i those with advaced cacer ear the ed of life. 14,18Y20,22,23,26 I Ljubisavljevic ad Kelly s study, 14 the icidece of delirium was 18% i a sample of 113 relatively youg cacer patiets (mea age = 53 years). Delirium reversed i all cases i patiets who survived. The average duratio of delirium episodes was 2.1 days. The authors suggested that early recogitio ad itervetio may have limited the duratio of delirium episodes ad promoted reversibility. The youger age of patiets i their sample may also have iflueced delirium resolutio. Lawlor ad colleagues 19 foud that delirium reversed i 49% of episodes i 71 patiets with advaced cacer. Reversibility of repeated Figure 3 Resolutio by delirium severity. delirium episodes was sigificatly less tha the reversibility of first episodes. Studies also have show that sigificat symptom improvemet ca occur i patiets with advaced cacer, i some cases eve without specific itervetio. 18,20,26 Bruera ad colleagues 18 foud that delirium improved i 22 (33%) episodesvspotaeously i 10 episodes ad as a result of treatmet i 12 episodes. Similarly, Pereira ad colleagues 26 foud that delirium improved i 29% of patiets with advaced cacer before death or discharge from a palliative care uit. I Gago ad colleagues study, 20 delirium was treated with various itervetios, such as addig a euroleptic drug or opioid reductio or switchig to aother opioid. Half of the patiets with delirium experieced cliically sigificat symptom improvemet. Notably, 6 patiets who improved remaied asymptomatic i the last 24 hours of life. Despite the potetial reversibility of delirium i hospitalized patiets with cacer, our fidigs add to the growig literature, suggestig that delirium is ot a trasiet disorder. A sigificat majority (70%) of the older patiets with cacer who had delirium durig hospitalizatio had persistet delirium at discharge. These fidigs are cosistet with other studies showig that a substatial umber of hospitalized older patiets are discharged with delirium. 2Y5 I a sample of medical ipatiets aged 70 years or older, Adamis ad colleagues 2 foud that oly 14 of 33 patiets (42%) with delirium recovered durig their hospitalizatio. The remaiig 19 (58%) patiets were positive for delirium at their last assessmet before death or discharge. Factors Associated With Delirium Resolutio Idetifyig factors associated with delirium resolutio ad persistece i older patiets with cacer is a importat area of ivestigatio. The idetificatio of these factors will provide targets for prevetio ad itervetio. Research i this area may also ehace our uderstadig of the relatioships betwee delirium ad associated outcomes such as log-term cogitive impairmet, fuctioal declie, ad icreased mortality. Patiets with delirium resolutio were less fuctioally impaired before hospital admissio compared to those without resolutio. Similarly, Iouye ad colleagues 36 foud that 448 Cacer Nursig TM, Vol. 31, No. 6, 2008 Bod ad Neelo

6 fuctioal impairmet before hospitalizatio was a idepedet risk factor for delirium at discharge. Patiets with fuctioal impairmet were 1.7 times (95% cofidece iterval, 1.2Y3.0) more likely to have delirium at discharge tha those without fuctioal impairmet. The severity of delirium iflueced its resolutio. Similar to fidigs from Adamis ad Colleague s study, 2 mild cases of delirium were more likely to resolve tha severe cases. Although patiets with severe delirium were more likely to have persistet delirium at discharge, it is importat to ote that i 10 (23%) patiets, delirium improved from severe durig hospitalizatio to mild at discharge. Others have foud that although delirium may ot resolve completely, sigificat symptom improvemet is possible. 18,20,26 Early recogitio of mild delirium is importat because it may be more ameable to treatmet. Furthermore, the idetificatio ad treatmet of mild delirium may ameliorate the developmet of more severe delirium. I our study, delirium was more likely to resolve i patiets with fewer etiologic risk patters; however, specific risk patters, except for chroic cogitive impairmet, were ot associated with delirium resolutio. The effect of differet combiatios of etiologic patters was ot examied but may have iflueced delirium resolutio. I a recet study, Doriath ad colleagues 22 foud that delirium was reversible i 34% of patiets with cacer, ad delirium was more likely to reverse i patiets with toxic ad metabolic causes compared to those with structural brai lesios. Studies i patiets with advaced cacer 19,25 also have examied the relatioships betwee delirium etiology ad reversibility. I Lawlor ad colleagues study, 19 opioid aalgesics ad other psychoactive medicatios were idepedetly associated with delirium reversal. Dehydratio was also sigificatly associated with delirium reversibility at the uivariate level, but its associatio was ot idepedet i the multivariate aalysis. Hypoxic ecephalopathy resultig from pulmoary cacer or respiratory tract ifectio ad metabolic factors were associated with the oreversibility of delirium i the uivariate aalysis. I the multivariate aalysis, oly hypoxic ecephalopathy was retaied as a factor. I additio, oyrespiratory tract ifectio emerged as a sigificat idepedet factor associated with oreversibility of delirium. Morita ad colleagues 25 foud that recovery ofte occurred i delirium associated with medicatios ad hypercalcemia, ad recovery was ulikely i delirium caused by hepatic failure, dehydratio, hypoxia, ad dissemiated itravascular coagulopathy. Other researchers 37Y39 have foud that delirium resolved i hypoxic patiets who were treated with supplemetal oxyge. Our fidigs highlight the vulerability of patiets with cacer who also have uderlyig cogitive impairmet. All patiets with chroic cogitive impairmet had severe delirium at some poit durig hospitalizatio. Furthermore, all patiets with chroic cogitive impairmet had persistet delirium at discharge. Iouye ad colleagues 36 also foud that cogitive impairmet (ie, demetia) was a sigificat risk factor for delirium at discharge. Similarly, Adamis ad colleagues 2 oted that baselie cogitive fuctio was associated with recovery from delirium. Patiets with better cogitive fuctio at admissio were more likely to recover from delirium durig hospitalizatio. I our study, delirium improved from severe to mild i 2 patiets with chroic cogitive impairmet. Prologed Hospitalizatio Patiets with delirium resolutio had a shorter legth of hospital stay compared to those who had persistet delirium. The impact of prologed hospitalizatio i older cacer patiets with persistet delirium is a importat cosideratio. Older adults ofte experiece a declie i physical fuctio durig hospitalizatio. 40 I this study, we did ot examie physical fuctioig at discharge, but it is likely that the older patiets with cacer who had persistet delirium were more fuctioally impaired. The combiatio of impaired cogitive ad physical fuctioig i older patiets with cacer adds substatially to a caregiver s burde ad distress. Implicatios for Cliical Practice ad Research The results of this study have sigificat implicatios for cliical practice ad future research. The time surroudig hospital discharge is a importat ad vulerable trasitio period for hospitalized older patiets with cacer ad their caregivers. Patiets with delirium at discharge are a high-risk group. 3,36,41 The persistece of delirium at discharge affects posthospital care ad recovery regardless of the settigvat home or i skilled ursig ad other residetial facilities. Delirium is distressig for patiets ad their family caregivers. 42Y44 Delirium impairs patiet-family commuicatio ad egatively affects treatmet decisio makig ad adherece. Patiets with delirium also may ot be able to report other physical ad psychological symptoms. I additio, caregivers may experiece icreased burde because patiets with delirium require icreased assistace with care ad close moitorig to prevet ijury. Patiets with cogitive impairmet (ie, demetia, delirium, or both) durig hospitalizatio ad their family caregivers ofte have sigificat umet eeds i the weeks after hospital discharge. 45 Additioal research is ecessary to better uderstad the eeds of patiets with persistet delirium ad their family caregivers. Educatioal ad supportive itervetios to address the idetified eeds should be developed. I hospitalized older patiets, delirium at discharge is a poor progostic factor. Patiets with delirium at discharge are at greater risk for ursig home placemet ad death durig a 1-year follow-up period. 41 Persistet delirium at admissio to postyacute care settigs has bee associated with rehospitalizatio, prologed istitutioalizatio, poor fuctioal recovery, ad death. 8,9 Little is kow about outcomes associated with persistet delirium i cacer patiets. Hospitalized older Delirium Resolutio i Hospitalized Older Patiets With Cacer Cacer Nursig TM, Vol. 31, No. 6,

7 patiets with cacer who have delirium at discharge are at risk for adverse outcomes similar to those of hospitalized older patiets with persistet delirium. They may be at eve greater risk because persistet delirium may affect their subsequet cacer treatmet. For example, their cacer treatmet may be delayed or discotiued, or they may eed to receive reduced chemotherapy doses while they are recuperatig. Research is eeded to examie outcomes of delirium, specifically i hospitalized older patiets with cacer. Patiets with persistet delirium require ogoig maagemet, moitorig, ad follow-up after hospital discharge. Patiets with persistet delirium eed to be idetified before discharge. Moreover, persistet delirium eeds to be reported to providers (eg, physicias, urses, ad ursig assistats) i the posthospital care settig. va Zyl ad Davidso 46 foud that eve whe delirium is diagosed ad treated, it is ot cosistetly documeted i hospital discharge summaries, the primary commuicatio lik betwee hospital providers ad providers i other settigs. Therefore, it may ot be commuicated to outside providers. Although patiets with delirium are more likely to be discharged to istitutioal settigs, we do ot kow where ad how to best care for patiets with persistet delirium after discharge. A importat area for future research is to determie the best place to care for patiets with persistet delirium after discharge, as well as to idetify the most appropriate care for these patiets. The goals of care eed to focus o facilitatig improvemet ad prevetig further declie. Educatio focusig o delirium assessmet ad maagemet is eeded for professioal caregivers i postacute care settigs (eg, rehabilitatio, home, log-term care) ad for family caregivers. Stregths ad Limitatios To our kowledge, this study is oe of the first to examie delirium resolutio ad associated factors i a sample of hospitalized older patiets with cacer. A stregth of the study was the daily assessmet of delirium usig a istrumet that measures delirium severity ad allows moitorig of chages i delirium over time. The study also has several limitatios. A primary limitatio is the small, heterogeeous sample of older patiets with cacer. The patiets had a variety of cacer diagoses, their cacers were at differet stages, ad they were receivig differet cacer treatmets. The reaso for hospital admissio also varied. Some patiets were admitted to the hospital for cacer treatmet, others were admitted for complicatios associated with their cacer or cacer treatmet, ad others were admitted for acute medical coditios urelated to their cacer. The sample icluded prevalet ad icidet cases of delirium. I our study, the time of oset for delirium did ot affect delirium resolutio. Gago ad colleagues 20 foud that symptom improvemet occurred less ofte i patiets who were delirious at admissio compared to those who developed delirium after admissio. Delirium etiology ad progosis may differ betwee prevalet ad icidet cases. 41 I this study, we used a coservative defiitio for delirium improvemetva chage i NEECHAM category from severe to mild. It is likely that some patiets had a cliically sigificat chage i NEECHAM score withi a severity category, but we did ot examie chages withi categories. Fially, we did ot examie specific strategies to treat ad maage delirium durig hospitalizatio. For example, it was ot kow whether patiets received psychotropic medicatios or other supportive itervetios. Coclusio The maagemet of delirium i hospitalized older patiets with cacer eeds to focus o prevetio ad early recogitio of symptoms ad their reversibility. Early recogitio ad itesive treatmet are paramout. Itervetios targeted at commo delirium risk factors i cacer patietsv malutritio, dehydratio, aemia, electrolyte imbalace, pai, ucotrolled physical ad psychological symptoms, ad polypharmacy icludig opioids ad other psychoactive medicatiosvmay prevet the developmet of delirium. If delirium develops, iitial treatmet should aim to idetify ad correct treatable causes. Supportive itervetios are eeded to mitigate further complicatios. The idetificatio of patiets at risk, the recogitio of early maifestatios, ad itervetios targeted at multiple risk factors ad etiologies may prevet delirium or result i its improvemet ad resolutio. Additioal studies are eeded to develop ad test itervetios to prevet ad better maage delirium i hospitalized older patiets with cacer. Although delirium i hospitalized older patiets with cacer is potetially reversible, we foud that a sigificat umber of hospitalized older patiets with cacer had delirium at the time of hospital discharge. As hospital legth of stay decreases, it is likely that eve more patiets will be discharged before delirium resolves. Therefore, the cliical maagemet of delirium ad delirium research ca o loger be cofied solely to the hospital settig. Hospitalized older patiets with cacer who have delirium at discharge represet a high-risk group. Patiets with uresolved delirium eed to be idetified before discharge because they require moitorig ad close follow-up. Strategies to improve discharge plaig ad care coordiatio for patiets with persistet delirium are eeded. Efforts should be made to promote cotiuity of care ad ehace commuicatio betwee healthcare providers i the hospital ad postdischarge care settigs. Family members carig for patiets with persistet delirium eed educatio ad support. Patiets with persistet delirium require cotiued supportive care to promote delirium resolutio ad prevet worseig of delirium or other complicatios. ACKNOWLEDGMENTS The authors thak Dr Lorraie Mio ad Dr Larry Lacaster for reviewig ad editig the mauscript. 450 Cacer Nursig TM, Vol. 31, No. 6, 2008 Bod ad Neelo

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