Cognitive Impairment in the Terminally Ill

1. 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

2. 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

3. 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 associated with

4. 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

5. 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

6. 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

7. 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

8. 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

9. Results -patient characteristics, n = 299

10. Confusion - prevalence Confusion associated with: • advancing age - acts as confounder • care in nursing home • diagnoses • cancer 41% • ftt 77% • neuro 78% • dementia 97% Overall 50% 17% overall were rated as having severe or disabling confusion

11. Confusion -frequent manifestations, n= 145

12. Confusion - a problem for someone, n=133 Especially if patient shows: • inappropriate mood 97% • agitation 90% • altered sleep/wake 84% Demographic and diagnostic categories are not significant. Confusion causes problems 79% of the time.

13. Delirium • Criteria used to identify subset of delirious • confused • impaired attention • altered cognition • rapid onset (hours to days) • Number identified = 21 (7%)

14. 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

15. Proposal • Following prospective study - develop an intervention program to reduce impact of confusion on patient and loved-ones

16. 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