Delirium After Hematopoietic Stem-Cell Transplantation Affects HRQOL

Summary and Comment |
April 13, 2007

Delirium After Hematopoietic Stem-Cell Transplantation Affects HRQOL

  1. Barbara A. Murphy, MD

In a stem-cell transplant population, delirium was associated with adverse effects on neurocognition and with high levels of distress at 80 days post-transplant.

  1. Barbara A. Murphy, MD

Delirium often is perceived as a transient event that resolves without lasting effects; however, a growing body of literature indicates that delirium is associated with poor long-term physical and neuropsychological outcomes. Although delirium is a recognized problem among patients with terminal disease, its incidence and effects are underappreciated in the general oncology population. Using patient-reported outcome measures, investigators conducted a prospective study to assess late effects of delirium on health-related quality of life (HRQOL) in stem-cell transplant patients.

Researchers in Seattle enrolled 90 patients (age range, 22–62 [27% older than 45]; 67% men) who were scheduled for either bone-marrow or stem-cell transplantation (73 allogeneic). All but two patients had hematologic malignancies; 14% had received previous cranial irradiation, 58% had received conditioning with total-body irradiation, and 80% had received treatment with glucocorticoids. Before undergoing stem-cell transplantation, each patient completed self-assessment tools in the following categories:

-- Distress (Symptoms Checklist-90-R, Profile of Mood States, Cancer and Treatment Distress Scale)

-- Neurocognitive functioning (Behavioral Dyscontrol Scale, Trailmaking A & B, Neurobehavioral Rating Scale, Wechsler Adult Intelligence Scale, Hopkins Verbal Learning Test-Revised, Controlled Oral Word Association Test)

-- HRQOL (Medical Outcomes Study Health Survey)

A subset of these questionnaires was repeated at 30 days post-transplant, and the full battery was repeated at 80 days post-transplant. Delirium (evaluated with the Delirium Rating Scale and the Memorial Delirium Assessment Scale), distress, and pain were assessed by study nurses 7 days before treatment and three times weekly through post-transplant day 30. At 30 days, 80 patients were still participating; at 80 days, 59 patients remained in the study.

Fifty percent of patients experienced episodes of delirium (mean duration, 10 days); 86% of delirium episodes were of the hypoactive subtype. At 80 days post-transplant, patients who had suffered at least one episode of delirium experienced worse cognitive impairment, characterized by poorer executive/frontal function, attention, and processing speed, than did patients with no delirium episodes. Patients with delirium also reported higher levels of anxiety, fatigue, and cancer- and treatment-related distress.

Comment

In patients without cancer, delirium is associated with long-term cognitive decline and poor functional recovery. More importantly, randomized trials have indicated that delirium in patients without cancer can be prevented and treated. Now, we have data showing that delirium in a stem-cell transplant population is associated with adverse effects on neurocognition and higher levels of distress at 80 days post-transplant. Similar studies should be conducted to assess the incidence and effect of delirium in other cancer populations. Among elders, who might have baseline neurocognitive deficits and be predisposed to delirium, such studies are particularly important.

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