Delirium, Advanced Cancer, & ED Visits

Delirium, Advanced Cancer, & ED Visits
Author Information (click to view)

Ahmed F. Elsayem, MD, MPH

Associate Professor, Department of Emergency Medicine

Associate Professor, Department of Palliative Care and Rehabilitation Medicine

Division of Cancer Medicine

The University of Texas MD Anderson Cancer Center

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Ahmed F. Elsayem, MD, MPH (click to view)

Ahmed F. Elsayem, MD, MPH

Associate Professor, Department of Emergency Medicine

Associate Professor, Department of Palliative Care and Rehabilitation Medicine

Division of Cancer Medicine

The University of Texas MD Anderson Cancer Center

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Delirium is a serious cognitive disturbance in which patients have impaired thinking and awareness, and some studies suggest that the condition often goes unrecognized in EDs. “Few studies have explored the frequency of delirium among patients with advanced cancer who come to the emergency room for healthcare,” says Ahmed F. Elsayem, MD, MPH. To address this research gap, he and colleagues had a study published in Cancer that sought to determine delirium frequency and recognition by ED physicians among patients with advanced cancer.

For the investigation, researchers looked for delirium in 243 patients with advanced cancer who seen at the ED of the University of Texas MD Anderson Cancer Center. Patients involved in the analysis were between the ages of 19 and 89, and all participants were assessed with the Confusion Assessment Method (CAM) to screen for delirium and with the Memorial Delirium Assessment Scale to measure the severity of delirium. ED physicians were also asked whether or not they believed that their patients were delirious.

A Common Problem

Results of the study showed that about one in 10 patients with advanced cancer who visited the ED tested positively for delirium, based on results from the CAM tool. Of the 22 patients who had delirium, 18 had a mild form of the condition while four had moderate delirium. Patients with delirium had a poorer performance status than patients without it.

Importantly, age did not appear to be a significant factor. About 10% of patients who were 65 or older tested positive for delirium, compared with a rate of approximately 8% that was observed among those younger than 65. The analysis also revealed that ED physicians correctly identified delirium in only about 59% of cases in which patients tested positive for having delirium.

“Our results suggest that delirium is relatively frequent in patients with advanced cancer who are visiting the ED and appears to be underdiagnosed by ED physicians,” says Dr. Elsayem. Considering that the research team only studied patients who were able to provide consent and who were  medically stable enough to enter the investigation, it is likely that a 10% prevalence rate is a low estimate.

Assessing Implications

“It’s important for clinicians to consider the potential effects of medications and other treatments that may contribute to delirium in patients who are being treated for advanced cancer,” Dr. Elsayem says. “ED physicians can play an important role in sharing treatment information and monitoring the quality of care among advanced cancer patients. More research is needed to identify optimal screening tools that are short and sensitive for detecting delirium in ED. In the meantime, emergency physicians should consider all patients with advanced cancer—regardless of their age—at high risk for delirium.”

Ahmed F. Elsayem, MD, MPH, has indicated to Physician’s Weekly that he has no financial disclosures to report.

 

 

 

Readings & Resources (click to view)

Elsayem AF, Bruera E, Valentine AD, et al. Delirium frequency among advanced cancer patients presenting to an emergency department: a prospective, randomized, observational study. Cancer. 2016 Jul 25 [Epub ahead of print]. Available at: http://onlinelibrary.wiley.com/doi/10.1002/cncr.30133/full.

Lawlor PG. Cancer patients with delirium in the emergency department: a frequent and distressing problem that calls for better assessment. Cancer. 2016 Jul 25 [Epub ahead of print].

Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16:193-200.

Barron EA, Holmes J. Delirium within the emergency care setting, occurrence and detection: a systematic review. Emerg Med J. 2013;30:263-268.

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