Delirium in Palliative Outpatients and Associated Caregiver Coping

Background:  Delirium causes suffering and in terminal illness undermines important goals to die at home.  Improved knowledge about delirium among palliative outpatients can lead to improved patient outcomes through early identification and treatment in the home.  Conversely, a missed diagnosis leads to costly hospital admissions, and is the most common reason to seek long-term care placement (Breitbart & Alici, 2008).   Medicare stresses the importance by listing it as a common cause of falls among non-reimbursed hospital events.  Prior evaluation of outpatient delirium rate was 14% among demented community dwelling elders (Steis, Evans, et al., 2012a).  It is hypothesized that frail, palliative care outpatients have high rates of missed delirium, and it is the most common neuropsychiatric disorder that terminally ill patients face, with prevalence as high as 88% (Breitbart & Alici, 2008).

Purpose:  To identify the prevalence rate of delirium among palliative care outpatients and correlate patient factors associated with delirium.  Caregiver coping strategies associated with the episode were also examined.  

Methods:  This study was a descriptive, correlational study conducted over a three-month period in late 2013.  A convenience sample of patient/caregiver dyads were recruited at an urban cancer center.  Patients with a life-limiting illness undergoing non-curative therapy consented to a chart review for demographic risk factors.  Caregivers were asked to complete two survey instruments at the time of their usual visit.  Caregivers were asked to reflect upon the patient’s behavior over the past month using the 12 simple yes/no questions on the Family Administered Confusion Assessment Method (FAM-CAM) (Inouye et al., 2011).  Risk factors such as age, gender, marital status, medications and diagnosis were correlated with delirium.  The Folkman Lazarus Ways of Coping Questionnaire (1988) was also administered to caregivers comparing positive and negative coping techniques.  Data was analyzed with ANOVA correlations.

Results: The rate of delirium among palliative care outpatients in this sample of 52 patient/caregiver dyads was 27%.  The results suggested that opioid use slightly increases the odds for an episode of delirium, and approaches significance (r(50) = .270, p = .052).  The majority of caregiver participants reported positive coping styles, however positive reappraisal and emotion-focused coping mechanism were more common in caregivers with a cognitively intact patient.  When a patient screened positive for delirium, problem-focused coping was more common than emotional methods among caregivers (m = .22, SD = .073).

Implications:  Clinicians caring for frail, vulnerable outpatients must promote increased awareness and screening for delirium. Knowledge and communication about these symptoms in the home can increase quality of care and lower costs by increasing safety, quality of life, and lower hospital readmissions.  This feasibility study suggests that caregivers cope using an analytic approach during an episode of stress and delirium in the home, which may preclude healthy grief and coping mechanisms.  Outpatient delirium screening can improve quality of care and safety by lowering costs and hospital admission rates.