Transcript Nowels, Bublitz, Kassner, & Kutner

Cognitive Impairment in
the Terminally Ill
David Nowels, MD, MPH; Caroline
Bublitz, MS; Cordt Kassner, MA; Jean
Kutner, MD, MSPH; and the PoPCRN
Working Group
Background
Confusion is common among the ill
20% or more of hospitalized patients are
acutely confused
Confusion is usually a manifestation of
dementia
delirium (acute confusion syndrome)
depression
Background -
confusion is associated with
fall risk
skin problems
sleep disturbance
incontinence
shortened life-span, even for
those with advanced cancer
behavioral issues for
caregivers
complicated bereavement
Background Confusion is potentially reversible
If a component of a reversible symptom complex
(e.g. delirium)
has been shown in delirious terminally ill cancer
patients
studies in hospitalized patients show potential for
prevention
Background Confusion prevalence in the terminally ill is
unknown
delirium in 15-85% of advanced cancer or AIDS
patients
prevalence unknown for other illness
delirium inversely correlated with functional
status in cancer patients
delirium and confusion often not identified
Study -
confusion prevalence in
hospice patients
Study goals
to describe confusion prevalence among hospice
patients
to describe confusion severity among hospice
patients
to identify associations between confusion and
other variables
to estimate prevalence of delirium
Study -
confusion prevalence in
hospice patients
Study Methods
cross-sectional study in 19 hospices
hospices participants in the Population-based
Palliative Care Research Network (PoPCRN)
one survey of 10 questions per patient
nurses completed questionnaires about their
patients during interdisciplinary team meetings
study conducted over 6 weeks
Study setting The Population-based Palliative Care Research
Network is committed to improving care for
persons at the end of life by conducting rigorous,
high-quality end-of-life research in settings where
palliative care is provided
42 organizations participated in studies
8 studies since inception, 2 formally funded
http://www.uchsc.edu/popcrn
seed funding from UCHSC through Hartford grant
Results -
patient characteristics,
n = 299
Characteristics
N (%)
Gender, female
174 (60%)
Diagnosis, cancer
156 (53%)
Setting, home care
151 (52%)
Median (range)
Days in hospice
30 (1-1035)
Age
78 (30-103)
Confusion - prevalence
Overall 50%
145
148
17% overall were rated as
having severe or disabling
confusion
Confusion associated
with:
advancing age - acts as
confounder
care in nursing home
diagnoses
cancer
ftt
neuro
dementia
41%
77%
78%
97%
Confusion -
frequent manifestations,
n= 145
100
80
60
40
20
0
Disorientation Impaired ST
to time/place
Memory
Drowsiness
Easliy
Distracted
Altered
Misinterpreting
Sleep/Wake
Events
Cycle
Confusion -
a problem for someone,
Confusion causes
problems 79% of the
time.
21%
n=133
Especially if patient
shows:
inappropriate mood
agitation
altered sleep/wake
97%
90%
84%
14%
45%
20%
Demographic and
diagnostic categories are
not significant.
Delirium
Criteria used to identify subset of delirious
confused
impaired attention
altered cognition
rapid onset (hours to days)
Number identified = 21 (7%)
Proposal
Prospective study in hospice population
determine incidence of confusion over time and
functional status
identify associated clinical syndrome
identify symptoms
identify potential etiologies
describe usual management
describe impact on patient well-being
describe impact on grief
Proposal
Following prospective study - develop an
intervention program to reduce impact of
confusion on patient and loved-ones
Association with
Coleman Institute
Contact with others collecting data from
population of impaired individuals
Exposure to innovations aimed at improving
well-being that might be useful to the
terminally ill
example - confused patients fall more commonly
and anecdotally, beds closer to the ground prevent
associated injuries