Trajectories and patterns of delirium and vulnerability in older cancer patients in the hospital and at home near the end of life.

摘要

Patients with advanced cancer often develop delirium (acute confusion), the prevalence rising to 90% in the final weeks of life. Age, illness severity, comorbidity, and preexisting cognitive impairment increase the risk of delirium, but despite its prevalence, little is known about delirium in older cancer patients. This three-phase study addresses the empirical gap in knowledge about delirium in older cancer patients. The first phase, a secondary analysis of data from studies of acute confusion in hospitalized elders, examined delirium and its etiology in 76 hospitalized older cancer patients, 10 of whom were near the end of life. The second phase comprised a pilot study of a home-based protocol to evaluate delirium in older adults with advanced cancer. The third phase was a descriptive, longitudinal, multiple case study of delirium and delirium vulnerability in seven older adults with advanced cancer near the end of life. The findings clarify the role of delirium in older cancer patients. Delirium occurred in all seven with advanced cancer (the three patients who died had reversible and terminal episodes of delirium; the four who lived each had one reversible episode). Delirium also was common in the hospitalized older cancer patients: 43 of 76 (56%) were delirious at some point during hospitalization; 8 of 10 (80%) who were near the end of life became delirious. Delirium resolved in 13 of the 43 (30%) hospitalized patients, but in 30 (70%) delirium symptoms persisted at discharge.;These older cancer patients were at risk for multiple etiologies of delirium: 90%, (including all near the end of life) had metabolic-nutritional risks, and hypoxic, orthostatic-dehydration, and metabolic-toxic risks were common. Five of the hospitalized patients and one of the seven with advanced cancer had chronic cognitive impairment (all became delirious).;Physical, behavioral, and physiological functioning in the older adults with advanced cancer declined before they became delirious. This decline in functioning may indicate diminishing reserve capacity, and suggests that early interventions aimed at specific etiologic risk factors may sustain reserve capacity and minimize delirium, thereby enhancing the quality of living and dying of older cancer patients, and minimizing distress for their caregivers.