Skip Navigation


Japanese Journal of Clinical Oncology Advance Access originally published online on January 31, 2008
Japanese Journal of Clinical Oncology 2008 38(1):56-63; doi:10.1093/jjco/hym155
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
38/1/56    most recent
hym155v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Fang, C.-K.
Right arrow Articles by Lai, Y.-L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fang, C.-K.
Right arrow Articles by Lai, Y.-L.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?


© The Authors (2008). Published by Oxford University Press. All rights reserved

Prevalence, Detection and Treatment of Delirium in Terminal Cancer Inpatients: A Prospective Survey

Chun-Kai Fang1,2, Hong-Wen Chen2,3,4, Shen-Ing Liu1,2,5, Chen-Ju Lin1, Li-Yun Tsai2,6 and Yuen-Liang Lai3,4,7,

1 Department of Psychiatry and Center of Suicide Prevention, Mackay Memorial Hospital, Taipei, Taiwan
2 Department of Nursing, Mackay Medicine, Nursing, and Management College, Taipei, Taiwan
3 Hospice and Palliative Care Center, Mackay Memorial Hospital, Taipei, Taiwan
4 Department of Radiation Oncology, Mackay Memorial Hospital, Taipei, Taiwan
5 Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
6 Department of Nursing, Mackay Memorial Hospital, Taipei, Taiwan
7 Center for General Education, National Yang-Ming University, Taipei, Taiwan

For reprints and all correspondence: Yuen-Liang Lai, Hospice and Palliative Care Center, Mackay Memorial Hospital, 45 Minsheng Road, Damshui 251, Taipei County, Taiwan. E-mail: enochlai49{at}yahoo.com

Received April 2, 2007; accepted October 12, 2007


   Abstract
TOP
 Abstract
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
 DISCUSSION
 Acknowledgement
 References
 
Background: Delirium is a common syndrome in terminal cancer patients. However, its detection and treatment by palliative care teams are not well documented. This survey aimed to determine the prevalence, detection and treatment of delirium in terminal cancer inpatients.

Methods: The survey was conducted in Mackay Hospice and Palliative Care Center, Taiwan, from August 2006 to January 2007. All terminal cancer inpatients were invited to participate. The Delirium Rating Scale-Chinese Version was used by a research assistant as the screening instrument. Patients detected by screening were reviewed by psychiatrists to verify the diagnosis and determine the sub-type of delirium. The palliative care team members were asked to evaluate all the participants weekly. The medications used for delirium were obtained by a medical chart review.

Result: Two hundred and twenty eight participants (49.9%) among 457 inpatients were screened. The prevalence of delirium was 46.9% (n = 107). Of these, the most common subtype was hypoactive (68.2%, 95% confidence interval (CI): 59.4–77.0%). The mortality rate of inpatients with delirium (77.6%, 95% CI: 69.7–85.5%) was higher (P < 0.0001) than those without delirium (50.9%, 95% CI: 44.4–57.4%). The overall detection rate by any member of the palliative team was 44.9% (n = 48) (95% CI: 35.5–54.3%). The detection rate of the hypoactive subtype was only 20.5% (95% CI: 11.2–29.8%), which was significantly lower than that of the hyperactive/mixed subtypes (P < 0.0001). Therapy for delirium was prescribed in 42.1% (n = 45) (95% CI: 32.7–51.5%) with haloperidol being the most common medication.

Conclusion: The prevalence of delirium was high, but the rates of detection and treatment were low. Interventions are recommended to improve the diagnosis and treatment of delirium in palliative care units.

Key Words: delirium • terminal cancer inpatient • prevalence • detection • treatment


   INTRODUCTION
TOP
 Abstract
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
 DISCUSSION
 Acknowledgement
 References
 
Delirium is one of the most difficult syndromes to diagnose and treat in terminal cancer patients, yet it substantially impairs the quality of life for both the patient and their family near the end of life (1). Delirium is defined as an acute confusional state which results from diffuse organic brain dysfunction (2). According to previous surveys, the prevalence of delirium in cancer patients is from 11 to 35% (3–6). In terminal cancer patients, the prevalence of delirium may be as high as 85% (7). Delirium, during hospitalization in a palliative care unit, has been found to vary between 28 and 88% (8,9). The exact prevalence of delirium in terminal cancer patients is unknown (10), but frequent, close assessment results in better detection (11). With appropriate treatment, delirium may be reversed in almost 50% of cases (11,12). In some terminal cancer patients, delirium can be ameliorated by identifying and managing underlying causes and providing concurrent symptomatic treatment such as pharmacotherapy (13). However, some causes of delirium in terminal cancer patients are irreversible. Therefore, it is important to detect delirium in clinical practice to ascertain that the underlying causes are treatable or not.

Although delirium is a common psychiatric disorder in terminal cancer patients, it is not easy to diagnose by doctors and nurses in oncology and hospice units (14). In previous studies, there were few reports on the detection rate of delirium (15–17). Some instruments were specifically designed for screening delirium, such as the Confusion Assessment Method, Delirium Symptom Interview, Memorial Delirium Assessment Scale and Delirium Rating Scale (DRS) (18–21). However, using a screening instrument to identify delirium is not common practice. In addition, many medical units do not have access to a psychiatric service. Therefore, it is even more important for doctors and nurses to be able to detect and manage delirium. The management of delirium includes the correction of underlying problems and the prescription of suitable medication (2,5,13,22). For terminal cancer patients, it is difficult to improve the underlying problems, but it is possible to decrease symptoms and signs by drug therapy, thereby improving quality of life (1,9). The three purposes of this prospective survey were (i) to determine the prevalence of delirium in terminal cancer inpatients; (ii) to assess the detection of delirium by clinical staff in a hospice unit and (iii) to document the pharmacotherapy for delirium.


   PATIENTS AND METHODS
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 Therapy of Delirium
 DISCUSSION
 Acknowledgement
 References
 
The survey was conducted from August 2006 to January 2007, in Mackay Hospice and Palliative Care Center, a 63 bed unit within the 2060 bed Mackay Memorial Hospital. Mackay Hospice and Palliative Care Center is the largest acute palliative care unit and the main teaching unit to offer the training for palliative care in Taiwan. The survey was approved by the Mackay Memorial Hospital Committee of Human Testing and passed the inspection of the Institutional Review Board to allow clinical research for the project. All hospitalized terminal cancer patients or their caregivers got the informed consents and were invited to participate by a research assistant who was an experienced nurse counsellor. The research assistant read the informed consent and explained the process and purpose of the survey to inpatients or caregivers. Consenting patients were entered into the study. Patients with brain metastasis were not excluded but had been recorded.

The screening instrument was the DRS-Chinese Version (DRS-C) (23), which was translated from the DRS (21). The DRS, developed by Trzepacz, is a useful tool in both clinical practice and research. It is has good validity, reliability, sensitivity and specificity. The DRS consists of 10 items, with a maximum score of 32. The previously validated cut-off point for probable cases of delirium is a score of 10 (sensitivity = 95%, specificity = 61%) in cancer patients (24). It was previously translated into Chinese and has been used by several investigators in Taiwan (23).

The research assistant screened all the participants with the DRS-C every two days. Before the study, the research assistant with the license of nursing had been trained how to identify delirium and how to complete the DRS-C for six months. The research assistant screened not only at admission but also during the hospitalization. When the score of DRS-C was 10 points or more, the psychiatrists performed a clinical assessment to confirm the diagnosis of delirium and determine its subtype. The psychiatrist visited the patient within 24 hours of being informed by the research assistant. The diagnostic criteria of delirium were based on the DSM-IV (25). The hyperactive subtype of delirium was applied to patients conforming to the DSM-IV criteria of delirium with moderate or severe psychomotor hyperactivity within the first 48 hours of delirium. Patients conforming to the DSM-IV criteria of delirium with moderate or severe psychomotor hypoactivity during the first 48 hours were diagnosed as having hypoactive delirium. Patients with delirium who presented with both psychomotor hyperactivity and hypoactivity during the period were allocated to the mixed subtype (9, 28).

To assess the detection rate of delirium, the research assistant prepared the name lists of all participants every week and asked all the treating staff to evaluate whether their patients had delirium in the past one week. In the two hospice wards, there were the team meetings for grand run every week; one was on Monday, the other was on Wednesday. Members who might join the team meetings in the two palliative care teams included three attending physicians, four residents, 54 nurses, three social workers, two senior volunteers and a pastor. The research assistant joined the meetings and promoted all staff to evaluate all inpatients on the lists of the participants for the detection of delirium. Any treatment of delirium, particularly prescription of anti-psychotics, by the medical staff was recorded by the research assistant. The final status of the participants were also recorded, including death during hospitalization, discharge from hospital and transfer to home care or other hospitals.

Statistical analyses were performed using the Statistical Package for the Social Science SPSS, version 14.0, and Statistical Analysis System SAS, version 8.2 (SAS institute). Tests were two-tailed with a significance level of 0.05. In order to determine the prevalence of delirium in terminal cancer inpatients, descriptive statistics and multivariate analysis for identifying the factors related to prevalence and those related to death were used. In addition, there may be less awareness of the hypoactive subtype. Some publications have suggested that early detection of delirium in cancer patients could be promoted by greater awareness by medical staff, and improved knowledge of its delineating characteristics (30, 31). Distributions of continuous variables were tested for normality using the Shapiro–Wilks test. Variables with non-normal distributions were analysed using the Kruskal–Wallis H-test. Categorical variables were described using frequency distributions, {chi}2-test or Fisher's exact test. The mean and median survival time of the subjects to death from the onset of delirium was analysed by using Kaplan–Meier survival analysis using the log-rank test and the Cox proportional hazard model, respectively.


   RESULTS
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
Therapy of Delirium
 DISCUSSION
 Acknowledgement
 References
 
The Characteristics of Terminal Cancer Inpatients
Of a total of 457 terminal cancer patients during the survey period, 228 (49.9%) agreed to participate in the study. The remaining 229 patients included 42 (18.3%) who refused enrolment to be surveyed, 69 (30.1%) who died within 24 hours of hospitalization, 118 (51.5%) who were too ill to sign the informed consent, and others where no family or legal caregivers could be notified to sign the informed consent. The characteristics of participants are shown in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1. The characteristics of all terminal cancer inpatients and terminal cancer inpatients with delirium

 
Terminal Cancer Patients with Delirium
Among 228 terminal cancer patients, the prevalence of delirium was 46.9% (n = 107). There were 109 inpatients whose scores of DRS were 10 points or greater, but 2 of them were excluded by psychiatrists after the clinical assessment. As shown in Table 1, 73 (68.2%, 95% confidence interval (CI): 59.4–77.0%) were of the hypoactive subtype, 23 (21.5%, 95% CI: 13.7–29.3%) were of the hyperactive subtype and 11 (10.3%, 95% CI: 4.5–16.1%) were of the mixed subtype. The scores of DRS-C were 18.53 ± 2.92(95% CI: 16.84–20.22), 19.91 ± 3.66(95% CI: 18.43–21.39) and 17.36 ± 3.80(95% CI: 15.27–19.46) for hypoactive, hyperactive and mixed subtypes, respectively. There was no significant statistical difference (P = 0.128, Kruskal–Wallis H-test) in the DRS-C scores among the three types of delirium. There were 38 patients with brain metastasis among all 228 participants, and only 9 of them had delirium. Brain metastasis was not absolutely related with delirium in the study.

Eighty-three patients with delirium died during hospitalization. The mortality rate of patients with delirium (77.6%, 95% CI: 69.7–85.5%) was higher (P < 0.0001, {chi}2-test) than those without delirium (50.9%, 95% CI: 44.4–57.4%). The outcome of the subtypes of delirium was significantly different (Exact P < 0.0001, Fisher's exact test), as shown in Table 2. The mean and median survival time to death from the onset of delirium was 7.86 ± 1.13(95% CI: 5.65–10.07) days and 4.00 ± 0.38 (95% CI: 3.26–4.74) for the hypoactive subtype, 24.75 ± 7.48(95% CI: 10.10–39.40) days and 9.00 ± 4.89(95% CI: 0.0–18.59) days for the hyperactive subtype and 30.70 ± 5.13 (95% CI: 20.65–40.75) days and 40.00 ± 0.00 for the mixed subtype (P < 0.0001, Fig. 1, Kaplan–Meier survival analysis using the log-rank test). The mortality rate of the hyperactive and hypoactive subtypes combined was over 82%. By using the Cox proportional hazard model, as shown in Table 3, we found that hypoactive had a significant higher risk of mortality than mixed subtype (Relative risk = 5.49, 95% CI: 1.93–15.60, P < 0.001). Patients below 59 years old had a higher risk of mortality than patients over 80 years old (Relative risk = 2.22, 95% CI: 1.17–4.23, P = 0.015).


View this table:
[in this window]
[in a new window]

  		Table 2. The outcome of the different types of deliriuma

 

Figure 1
View larger version (24K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1. Kaplan–Meier survival analysis for the different subtypes of delirium.

 

View this table:
[in this window]
[in a new window]

  		Table 3. Multivariate survival analysis for Cox proportional hazard model

 
Detection of Delirium
Among 107 terminal cancer inpatients with delirium, the total detection rate by the palliative care team was 44.9% (n = 48) (95% CI: 35.5–54.3%): 14.0% (95% CI: 7.4–20.6%) detected by doctors alone; 15.0% (95% CI: 8.2–21.8%) detected by nurses alone; 15.0% (95% CI: 8.2–21.8%) detected by both doctors and nurses and 0.9% (95% CI: 0.0–2.7%) detected by a social worker. The detection rate of delirium was not significantly different between doctors and nurses. The detection rates of different subtypes of delirium are showed in Table 4. The detection rate of the hypoactive subtype (20.5%, 95% CI: 11.2–29.8%) was significantly lower than the hyperactive and mixed subtypes (Exact P < 0.0001, Fisher's exact test). The detection of delirium was not associated with mortality ({chi}2 = 0.010, P = 0.920, {chi}2-Test).


View this table:
[in this window]
[in a new window]

  		Table 4. The detection rates of different type of deliriuma

 

   Therapy of Delirium
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
DISCUSSION
 Acknowledgement
 References
 
Among 107 terminal cancer inpatients with delirium, the rate of pharmacotherapy for delirium was 42.1% (n = 45) (95% CI: 32.7–51.5%), including 21.5% (n = 23) (95% CI: 13.7–29.3%) treated with anti-psychotics and 20.6% (n = 22) (95% CI: 12.9–28.3%) with sedatives or opioid. Medications are shown in Table 5. Haloperidol was the most commonly prescribed drug. Some atypical anti-psychotics were also prescribed, such as quetiapine and olanzapine. Pharmacotherapy correlated strongly with detection rate ({chi}2 = 18.547, P < 0.0001, {chi}2-Test).


View this table:
[in this window]
[in a new window]

  		Table 5. The characteristics of the prescription for delirium

 

   DISCUSSION
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
 DISCUSSION
Acknowledgement
 References
 
The results of this prospective survey found a high prevalence and a low rate of detection and management of delirium in terminal cancer inpatients. The low detection and treatment rate indicates deficiencies in the quality of care by palliative care teams. This may be due to inadequate knowledge and skill in palliative care medical professionals. These are common barriers to the quality of care (26).

The prevalence of delirium in our samples was 46.9%, which is comparable to other studies, which report a range from 28 to 88% (8,9). The proportion with hypoactive delirium, almost 70%, was also similar to other surveys. In the UK, 29.4% of 109 inpatients in a hospice ward had delirium, and 78% of these had the hypoactive subtype (27). In contrast to the other studies, in Japan, 17 % of 1721 cancer patients with psychiatric referrals had delirium, and more than 70% were of the hyperactive subtype (5).

Approximately half the patients in this study suffered from delirium, but more than half of these were missed by palliative care staff. Detection rates of delirium by either doctors (30%) or nurses (29%) were low. Only one patient with delirium was found by a social worker. However, the detection rate varied markedly by subtype. The detection of hyperactive and mixed delirium was nearly 100%. This was not related to the severity of delirium because the mean score of the DRS-C was similar for all three subtypes. It is more likely to be because of the obvious symptoms and signs, for example, agitation, aggressiveness and hallucination. By contrast, patients with hypoactive delirium were often sleepy, drowsy and withdrawn, so hypoactive delirium was more difficult to detect (9,29). In addition, there may be less awareness of the hypoactive subtype. Some publications have suggested that early detection of delirium in cancer patients could promote greater awareness in medical staff, and improve knowledge of its delineating characteristics (30,31). Some medical staff might misdiagnose the symptoms and signs of hypoactive delirium as another condition, such as anorexia-cachexia syndrome, because they do not fully understand the diagnostic criteria (32,33,34). Not only in the palliative care team but also in the intensive care unit, hypoactive delirium is frequently missed (17,34).

The higher mortality of patients with delirium is another important finding of this survey as the previous studies. In cancer care, delirium is associated with a high incidence of mortality, and the incidence is even higher in terminal cancer patients (35,36). The disturbing symptoms of delirium also cause stress and burnout amongst caregivers (37). Palliative care professionals should offer high quality care to both patients and caregivers, whether the delirium is reversible or not. This is especially urgent for the hypoactive subtype, in which the mean survival time is only 7.87 ± 1.13 days. Therefore, detection of delirium gives an opportunity for staff and families to prepare for death, and perhaps allows better quality of life when the delirium is treated (38,39).

In our survey, the detection rate of delirium (44.9%, 95% CI: 35.5–54.3%) was almost identical to the treatment rate (42.1%, 95% CI: 32.7–51.5%) ({chi}2 = 18.547, P < 0.0001, {chi}2 Test). Nearly all the patients with hyperactive delirium were treated with medications by their palliative care team. The medications used for delirium were either anti-psychotics or sedatives. Both drug types are appropriate treatment for terminal cancer patients. In the survey, there were three anti-psychotics used for delirium: haloperidol (n = 23), quetiapine (n = 2) and olanzapine (n = 1). Haloperidol is well recognized for managing the symptoms of hyperactive delirium (40). However, it is associated with extrapyramidal syndrome and anti-cholinergic side effects (41). In the past decade, atypical anti-psychotics, such as risperidone, olanzapine and quetiapine, have been used for delirium in palliative care (41,43). Quetiapine and olanzapine are better tolerated than haloperidol in severely ill patients (44–46). Atypical anti-psychotics might be the most appropriate medication for delirium in terminal cancer patients. Sedation with an opioid or benzodiazepine is the other management of delirium in terminal cancer patients (47–49). In our survey, nearly half the prescriptions for delirium were part of palliative sedation therapy (47,48). In palliative care units in Japan, palliative sedation therapy was performed in accordance with the ethical principles of double effect, proportionality and autonomy (47). The practice in Taiwan is very similar.

Our study has several limitations. First, the response rate was approximately 50%. The survey was a prospective study inviting all hospitalized terminal cancer patients to participate, so it was not easy to have a high response rate. In Asia, terminal cancer inpatients and their families usually wish for a peaceful final phase of life (50). Many families declined to participate because they thought the study would impair such a peaceful passing. Second, the fact that the survey was of short duration, and confined to a single teaching hospital may mean that the results cannot be generalized. (51). Third, there were insufficient numbers of patients to enable a breakdown of the prevalence of delirium by cancer type. This same difficulty has been noted in other studies (8,11,52). Fourth, the sample size was insufficient to compare the efficacy of the different medications, although our results were consistent with the literature (40–49). Fifth, before psychiatric diagnostic interview, screening was conducted by the research assistant, so we could not understand the incidence of the other psychiatric disorders among terminal cancer patients. Sixth, we could not explain the result about patients below 59 years old had a higher risk of mortality than patients over 80 years old. There were not enough data for analysis. The further survey about the phenomenon should be considered.

Despite these limitations, we have two recommendations for improving the detection of delirium and increasing the prescription of atypical anti-psychotics for terminal cancer inpatients with hypoactive delirium or another subtype delirium. The first suggestion is increased education in the field of psycho-oncology for all medical professionals who care for cancer patients (53,54). Specifically, staff need to be taught how to identify and treat delirium, and how to care for and support patients and caregivers (55). How to prescribe haloperidol or any other anti-psychotics for delirium and whether to prescribe or not among different subtype of delirium should be attached importance and be discussed as an ethical issue in further studies. The second suggestion is to reinforce the collaboration between palliative care teams and psychiatrists. Staffing levels in palliative care teams is usually sufficient to take care of patients and caregivers, but they may lack skills in the psychiatric domain. This deficiency can be rectified by close collaboration between a psychiatric service and a palliative care team, as we have developed in the two hospice wards in Mackay Memorial Hospital (56). This concept of a ‘consultation-liaison psychiatry’ service to the oncology units and the palliative care teams is underdeveloped in Taiwan.

In conclusion, delirium is a common and important problem in terminal cancer inpatients, causing increased morbidity and mortality. This survey found that it was significantly underdiagnosed and undertreated. Better detection and treatment should be a priority. The pharmacotherapy of delirium with different kinds of anti-psychotics should be broadly recognized by staff in palliative care unite. Staff education and the creation of a psycho-oncology liaison service are recommended.


   Acknowledgement
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
 DISCUSSION
 Acknowledgement
References
 
We thank Miss Chun-Yu Lin, the research assistant, for her contribution in the survey and Miss Fang-Ju Sun for guiding the statistics. We especially thank Dr Doug Bridge, the senior lecturer at the Department of Palliative Care, University of Western Australia, who did English language correction for the article. The survey was supported by Mackay Memorial Hospital.

Conflict of interest statement None declared.


   References
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 Therapy of Delirium
 DISCUSSION
 Acknowledgement
 References
 
1 Centeno C, Sanz A, Bruera E. Delirium in advanced cancer patients. Palliat Med (2004) 18:184–94.[Abstract/Free Full Text]

2 Casarett DJ, Inouye SK. Diagnosis and management of delirium near the end of life. Ann Intern Med (2001) 135:32–40.[Abstract/Free Full Text]

3 Grassi L, Gritti P, Rigatelli M, Gala C. Psychosocial problems secondary to cancer: an Italian multicentre survey of consultation-liaison psychiatry in oncology. Eur J Cancer (2000) 36:579–85.[CrossRef][ISI][Medline]

4 Massie MJ, Holland JC. Consultation and liaison issues in cancer care. Psychiatr Med (1987) 5:343–59.[Medline]

5 Akechi T, Nakano T, Okamura H, Ueda S, Akizuki N, Nakanishi T, et al. Psychiatric disorders in cancer patients: descriptive analysis of 1721 psychiatric referrals at two Japanese cancer center hospitals. Jpn J Clin Oncol (2001) 31:188–194.[Abstract/Free Full Text]

6 Trzepacz PT, Breitbart W. Practice guideline for the treatment of patients with delirium. Am J Psychiatry (1999) 156(Suppl 5):1–20.[Free Full Text]

7 Massie MJ, Holland J, Glass E. Delirium in terminally cancer patients. Am J Psychiatry (1983) 140:1048–50.[Abstract/Free Full Text]

8 Minagawa H, Uchitomi Y, Yamawaki S, Ishitani K. Psychiatric morbidity in terminally ill cancer patients. A prospective study. Cancer (1996) 78:1131–7.[CrossRef][ISI][Medline]

9 Michaud L, Burnand B, Stiefel F. Taking care of the terminally ill cancer patient: delirium as a symptom of terminal disease. Ann Oncol (2004) 15(Suppl 4):iv199–203.[CrossRef][Medline]

10 Loge JH, Hjermstad MJ, Kaasa S. Delirium in palliative care. (in Norwegian). Tidsskr Nor Laegeforen (2006) 126:616–9.[Medline]

11 Lawlor PG, Gagnon P, Mancini IL, Pereira JL, Hanson J, Suarez-Almazor ME, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer – a prospective study. Arch Intern Med (2000) 160:786–94.[Abstract/Free Full Text]

12 Gagnon P, Allard P, Masse B, DeSerres M. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous monitoring. J Pain Symptom Manage (2000) 19:412–26.[CrossRef][ISI][Medline]

13 Akechi T, Nakano T, Uchitomi Y. Scientific background of psycho-oncology (in Japanese). Seishin Shinkeigaku Zasshi (2004) 106:764–71.[Medline]

14 Voyer P, McCusker J, Cole MG, Khomenko L. Influence of prior cognitive impairment on severity of delirium symptoms among old patients. J Neurosci Nurs (2006) 38:90–101.[Medline]

15 Anthony JC, LeResche LA, Von Korff MR, Niaz U, Folstein MF. Screening for delirium on a general medical ward: the tachistoscope and a global accessibility rating. Gen Hosp Psychiatry (1985) 7:36–42.[CrossRef][ISI][Medline]

16 McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK. Detection of delirium in the intensive care unit: comparison of confusion assessment method for intensive care unit with confusion assessment method rating. J Am Geriatr Soc (2005) 53:495–500.[CrossRef][ISI][Medline]

17 Pisani MA, Araujo KL, Van Ness PH, Zhang Y, Ely EW, Inouye SK. A research algorithm to improve detection of delirium in the intensive care unit. Crit Care (2006) 10:R121.[CrossRef][Medline]

18 Inouye SK, van Dyke CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. Ann Intern Med (1990) 113:941–8.[ISI][Medline]

19 Albert MS, Levkoff SE, Reilly C, Liptzin B, Pilgrim D, Cleary PD, et al. The Delirium Symptom Interview: an interview for the detection of delirium symptoms in hospitalized patients. J Geriatr Psychiatry Neurol (1992) 5:14–21.[Medline]

20 Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The memorial delirium assessment scale. J Pain Symptom Manage (1997) 13:128–37.[CrossRef][ISI][Medline]

21 Trzepacz PT. The delirium rating scale. Its use in consultation-liaison research. Psychosomatics (1999) 40:193–204.[Abstract/Free Full Text]

22 Someya T, Endo T, Hara T, Yagi G, Suzuki J. A survey on the drug therapy for delirium. Psychiatry Clin Neurosci (2001) 55:397–401.[Medline]

23 Chuang YM, Liu CY, Lee SH, Huang YC, Yeh EK, Yang YY. Establishment and inter-rater operation reliability study of Chinese version of Delirium Rating Scale. (1998) Annual meeting of the Society of Psychiatrics: Taiwan.

24 Grassi L, Caraceni A, Beltrami E, Borreani C, Zamorani M, Maltoni M, et al. Assessing delirium in cancer patients: the Italian versions of the Delirium Rating Scale and the Memorial Delirium Assessment Scale. J Pain Symptom Manage (2001) 21:59–68.[CrossRef][ISI][Medline]

25 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (1994) 4th edn. Washington, DC: American Psychiatric Association.

26 Morita T, Fujimoto K, Imura C, Nanba M, Fukumoto N, Itoh T. Self-reported practice, confidence, and knowledge about palliative care of nurses in a Japanese regional cancer center: Longitudinal study after 1-year activity of palliative care team. Am J Hosp Palliat Care (2006) 23:385–91.[Abstract/Free Full Text]

27 Spiller JA, Keen JC. Hypoactive delirium: assessing the extent of problem for inpatient specialist palliative care. Palliat Med (2006) 20:17–23.[Abstract/Free Full Text]

28 O'Keeffe ST, Lavan JN. Clinical significance of delirium subtypes in older people. Age Ageing (1999) 28:115–9.[Abstract/Free Full Text]

29 Marcantonio E, Ta T, Duthie E, Resnick NM. Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. J Am Geriatr Soc (2002) 50:850–7.[CrossRef][ISI][Medline]

30 Boyle DA. Delirium in older adults with cancer: implications for practice and research. Oncol Nurs Forum (2006) 33:61–78.[CrossRef][ISI][Medline]

31 Morrison C. Identification and management of delirium in the critically ill patient with cancer. AACN Clin Issues (2003) 14:92–111.[Medline]

32 Lagman RL, Davis MP, LeGrand SB, Walsh D. Common symptoms in advanced cancer. Surg Clin North Am (2005) 85:237–55.[CrossRef][ISI][Medline]

33 Tsai JS, Wu CH, Chiu TY, Hu WY, Chen CY. Symptom patterns of advanced cancer patients in a palliative care unit. Palliat Med (2006) 20:617–22.[Abstract/Free Full Text]

34 Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: a case study. Heart Lung (1996) 25:388–400.[CrossRef][ISI][Medline]

35 Fann JR, Sullivan AK. Delirium in the course of cancer treatment. Semin Clin Neuropsychiatry (2003) 8:217–28.[Medline]

36 Toscani P, Brunelli C, Miccinesi G, Costantini M, Gallucci M, Tamburini M, et al. Predicting survival in terminal cancer patients: clinical observation or quality-of-life evaluation? Palliat Med (2005) 19:220–7.[Abstract/Free Full Text]

37 Breitbart W, Gibson C, Tremblay A. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics (2002) 43:183–94.[Abstract/Free Full Text]

38 McNamara B. Good enough death: autonomy and choice in Australian palliative care. Soc Sci Med (2004) 58:929–38.[CrossRef][ISI][Medline]

39 Hirai K, Miyashita M, Morita T, Sanjo M, Uchitomi Y. Good death in Japanese cancer care: a qualitative study. J Pain Symptom Manage (2006) 31:140–7.[CrossRef][ISI][Medline]

40 Bruera E, Neumann CM. Management of specific symptom complexes in patients receiving palliative care. CMAJ (1998) 158:1717–26.[Abstract]

41 Tune L. The role of antipsychotics in treating delirium. Curr Psychiatry Rep (2002) 4:209–12.[Medline]

42 Volavka J, Czobor P, Sheitman B, Lindenmayer JP, Citrome L, McEvoy JP, et al. Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder. Am J Psychiatry (2002) 159:255–62.[Abstract/Free Full Text]

43 Boettger S, Breitbart W. Atypical antipsychotics in the management of delirium: a review of the empirical literature. Palliat Support Care (2005) 3:227–37.[Medline]

44 Schwartz TL, Masand PS. Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry (2000) 2:10–2.[Medline]

45 Sasaki Y, Matsuyama T, Inoue S, Sunami T, Inoue T, Denda K, et al. A prospective, open-label, flexible-dose study of quetiapine in the treatment of delirium. J Clin Psychiatry (2003) 11:1316–21.

46 Breitbart W, Tremblay A, Gibson C. An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics (2002) 43:175–82.[Abstract/Free Full Text]

47 Morita T, Chinone Y, Ikenaga M, Miyoshi M, Nakaho T, Nishitateno K, et al. Ethical validity of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan. J Pain Symptom Manage (2005) 30:308–19.[CrossRef][ISI][Medline]

48 Morita T, Chinone Y, Ikenaga M, Miyoshi M, Nakaho T, Nishitateno K, et al. Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan. J Pain Symptom Manage (2005) 30:320–8.[CrossRef][ISI][Medline]

49 Moryl N, Kogan M, Comfort C, Obbens E. Methadone in the treatment of pain and terminal delirum in advanced cancer patients. Palliat Support Care (2005) 3:311–7.[Medline]

50 Ling J, Rees E, Hardy J. What influences participation in clinical trials in palliative care centre? Eur J Cancer (2000) 36:621–6.[CrossRef][ISI][Medline]

51 Hudson P, Aranda S, McMurray N. Randomized controlled trials in palliative care: overcoming the obstacles. Int J Palliat Nurs (2001) 7:427–34.[Medline]

52 Fainsinger R, Miller MJ, Bruera E, Hanson J, Maceachern T. Symptom control during the last week of life on a palliative care unit. J Palliat Care (1991) 7:5–11.[Medline]

53 Uchitomi Y. Management of psychiatric symptoms in cancer patients (in Japanese). Gan To Kagaku Ryoho (2002) 29:1306–10.[Medline]

54 Brajtman S, Hiquchi K, McPherson C. Caring for patients with terminal delirium: palliative care unit and home care nurses' experiences. Int J Palliat Nurs (2005) 12:150–6.

55 Meijler WJ, Van Heest F, Otter R, Sleijifer DT. Educational needs of general practitioners in palliative care: outcome of a focus group study. J Cancer Educ (2005) 20:28–33.[Medline]

56 Kissane DW, Smith GC. Consultation-liaison psychiatry in an Australian oncology unit. Aust N Z J Psychiatry (1996) 30:397–404.[CrossRef][ISI][Medline]


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
38/1/56    most recent
hym155v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Fang, C.-K.
Right arrow Articles by Lai, Y.-L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fang, C.-K.
Right arrow Articles by Lai, Y.-L.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?