Meera Agar

Background: Many adults develop delirium in the community, prior to hospital admission. Yet the pathways leading to delirium in this setting and strategies for its prevention remain poorly understood. This scoping review aims to map existing literature on delirium prevention for adults in community settings, identifying who is considered at risk and how preventive strategies have been developed and implemented outside of acute care settings. Methods: Six online scientific databases were searched for original research written in English with no limits on date, with an objective to prevent delirium in adults (⩾18 years) in the community. Narrative synthesis was used to summarise study characteristics and outcomes. Delirium prevention components were analysed according to the “PINCHES ME Kindly” framework. Results: Of 7,845 records, four articles met the inclusion criteria describing three interventions and populations. All studies targeted older people following hospitalisation and offered a hospital-based multicomponent delirium prevention intervention post-discharge, delivered by multidisciplinary teams daily or an outreach nurse over structured sessions. The interventions comprised four to nine components, tailored to participants’ physical and medical needs. Conclusions: Evidence for delirium prevention in community settings remains limited and fragmented, with existing interventions appearing to be extensions of hospital based models without considering specific post-discharge or pre-admission risks. This may limit the potential for delirium prevention across the continuum of care.

Research into unmet needs in older populations with cancer is crucial, as existing studies often overlook these groups and fail to capture their unique experiences. Addressing these gaps is essential to improve quality of life and reduce psychological distress, particularly in those diagnosed with lung cancer, who face a higher burden of unmet needs than other cancer diagnoses. Aim: To explore the needs of older people with lung cancer and their perceptions and experiences of healthcare, social support and daily living in one of Australia’s most culturally diverse communities. Methods: A descriptive qualitative study was conducted from January 2023 to May 2024. Eligible participants were aged 70+ with lung cancer. Data collection occurred through face-to-face interviews, which were audio recorded and transcribed. Recruitment concluded after no new themes were identified. Data were analysed thematically and reported using the COREQ checklist. Results: Seventeen participants (mean age, 80.4), including 10 from culturally and linguistically diverse backgrounds, were interviewed. Four themes, including seven subthemes, were identified. Main themes included: (i) the complexity of ageing, frailty and chronicity in cancer care; (ii) navigating uncertainty: emotional response and adaptive coping; (iii) family as a pillar of functional and emotional support in cancer care and (iv) how health literacy needs shape decision-making and engagement with health services. Conclusion: Older people with lung cancer face multiple unmet needs shaped by ageing, multimorbidity, poor health literacy and psychological distress. While geriatric screening and assessment can identify unmet needs, addressing these requires personalised supportive care interventions.

Introduction: Oral health problems are prevalent among people receiving palliative care, affecting their quality of life. However, little is known about dental practitioners’ perspectives in this setting. Thus, this study aimed to explore the perceptions of public dental practitioners regarding the provision of dental care for people who receive palliative care. Methods: An exploratory focus group with 21 public dental practitioners, with a mean of 8.24 years of experience, was conducted in a public oral health service in Sydney, Australia. The focus group was transcribed and analysed using thematic analysis. Results: Three themes were identified: (1) enhancing quality of life in palliative care through improved oral health; (2) navigating the systemic and practical challenges of palliative dental care; (3) competent, collaborative, and optimised: a palliative oral care model. Participants highlighted the importance of oral health to quality of life while receiving palliative care. Nevertheless, there were several systematic and practical challenges to delivering appropriate dental care, which included competing priorities among clients, disconnects and gaps in care coordination with palliative care providers, limited training, and adapting treatment planning during appointments. Participants highlighted the need for a new model of care in the future that improved dental practitioners’ competence through comprehensive palliative dental training, included protocols to facilitate interdisciplinary collaboration, and optimised dental treatment planning and appointment scheduling. Conclusions: Public dental practitioners in this study demonstrated positive attitudes, but systemic barriers and limited training restrict their care provision. A palliative oral health care model for this setting should include palliative dental training, foster interdisciplinary collaboration, and optimise dental treatment planning.

Objectives: Carers are critical to support discharge home from hospital at end of life yet remain under-represented in health service initiatives to assist this transition. A carer-focused intervention embedded into practice may facilitate hospital discharge. This open-labeled, single-arm phase 2 study aimed to determine the feasibility of (1) delivering a multi-staged intervention (CARENET) to carers of advanced cancer patients in a hospital setting and (2) the study design to inform a phase 3 trial. Methods: CARENET, delivered before and after discharge to address carer support needs, was tested in an Australian specialist cancer hospital. Eligible participants included carers of advanced cancer inpatients with planned discharge home. The primary outcome was intervention and trial feasibility (recruitment and adherence). Secondary outcomes were eligibility and effects of intervention on outcomes including carer preparedness. Results: Of the 382 potential patient–carer dyads, 25 were recruited within required time frames. The intervention adherence outcome feasibility threshold of 80% of carer participants completing all 3 core components of CARENET was not achieved (60% completion). Trends in improvement in overall carer levels of preparedness were observed from baseline to discharge home (n = 12; mean [95% CI]) 0.5 [−0.0007, 1.007]). However, a downward trend in preparedness to provide emotional care after discharge was observed (n = 12; mean [95% CI] 0.25 [−0.30, 0.80]). Significance of results: Delivering all elements of the CARENET intervention to address carers’ needs in the discharge planning context was not feasible. However, some elements were feasible, including identifying and responding to carer need, whilst completing elements after discharge were less feasible. Findings can be explained by problems with adherence, eligibility, and clinician barriers to fitting a multi-staged carer intervention into an acute healthcare setting. Future research should test a more adaptable intervention and delivery model that is accessible to all carers across and compatible with acute care settings.

Background: Delirium affects up to 25% of hospitalised older patients; however, there are no effective pharmacological treatments. Accumulating evidence of brain insulin resistance and altered cerebral glucose metabolism during delirium present a promising therapeutic target. Objective: To assess the safety and efficacy of intranasal insulin in the treatment of delirium. Design: Single-centre, randomised, double-blind, placebo-controlled trial. Setting: Two geriatric medicine wards in a tertiary hospital. Participants: 100 patients aged over 64 years presenting to hospital and admitted under geriatric medicine with delirium. Interventions: Participants were randomised in a 1:1 ratio to receive 20 IU of long-acting insulin or placebo intranasally twice daily until delirium resolution, hospital discharge or intervention futility defined by prespecified criteria. Main outcome: The primary outcome was delirium duration, assessed daily using the Confusion Assessment Method. Secondary outcomes included acute length of stay (LOS), delirium severity, antipsychotic use, hospital complications and mortality. Results: The intention-to-treat analysis included 97 participants [intranasal insulin n = 48, control n = 49; mean (SD) age, 87.6 (7.0) years; 63% female]. Baseline characteristics were similar between groups. Median delirium duration [days (IQR)] was 4.8 [2.9, 9.2] for intranasal insulin and 6.8 [4.0, 9.8] for the control (HR 0.7, 95% CI 0.43–1.15; P = .16). Median acute LOS (days) was 7.9 [4.6, 14.5] for intranasal insulin and 12.9 [6.9, 16.8] for the control (HR 0.56, 0.35–0.89; P = .014). No significant differences were observed in other secondary outcomes. Intranasal insulin demonstrated favourable tolerability. Overall, 86% of the participants were compliant with the intervention (≥80% of doses). Prespecified subgroup analysis revealed an age-related response, with participants aged ≤88 years showing shorter delirium duration with intranasal insulin [n = 46; intranasal insulin: median 3.9 (IQR 2.9, 6.9) days vs control: 7.0 (4.7, 9.7); HR 0.34, 0.16–0.74; P = .006], whereas no difference was observed in participants aged >88 years [n = 51; intranasal insulin 5.4 (2.9, 11.1) vs control 4.9 (2.6, 12.9); HR 0.87, 0.39–1.94; P = .73]. Conclusion and relevance: This is the first study of intranasal insulin for delirium treatment. The reduced LOS combined with the observed age-related effects warrants further investigation into the clinical potential of intranasal insulin in managing delirium in older patients. Trial registration: ACTRN 12618000318280.

Background: Integration of palliative and supportive care in cancer treatment pathways is becoming standardised. While there has been significant qualitative research in oncology on palliative and supportive care integration into clinical care, there is little evidence that focusses on clinicians who manage hepatocellular carcinoma (HCC) and their perceptions on palliative and supportive care. Aim: To investigate the attitudes and perceptions regarding palliative and supportive care of healthcare professionals managing patients with HCC. Design: Qualitative study involving semi-structured individual interviews transcribed verbatim and analysed thematically. Setting/participants. A total of 25 healthcare professionals including hepatologists, gastroenterology trainees, hepatology clinical nurse consultants, social workers, and palliative care specialists providing care to patients with HCC recruited at 4 tertiary hospitals via purposive sampling. Results: The following themes emerged: (1) availability of palliative care services, (2) need for clear referral pathways and processes, (3) patients’ limited understanding of palliative care, (4) recognition of benefits of palliative care, and (5) the lack of training in hepatology services for palliative care provision. Conclusion: Health professionals’ perceptions of integration of palliative and supportive care in liver cancer care are hampered by multiple barriers. Opportunities to establish a more cohesive approach to care integration for patients with liver cancer have been identified. Trial Registration: ACTRN12623000010695 (date of registration 9/01/2023). What is already known about the topic? • Integration of palliative and supportive care for cancer can have profound benefits for patients’ symptom burden and quality of life. • There is a lack of empirical studies examining the perspectives of health professionals who manage liver cancer on the integration of palliative and supportive care into the treatment pathways for patients. What this paper adds • This study identifies a number of barriers to the implementation of palliative and supportive care into liver cancer treatment algorithms. • The absence of sufficient evidence in clinical guidelines impairs the capacity of health professionals to improve the integration of palliative and supportive care for liver cancer patients. Implications for practice, theory, or policy. • As liver cancer prevalence increases, further effort is required to develop appropriate evidence-based clinical guidelines and referral pathways to support the integration of palliative and supportive care within existing liver cancer services.

People with advanced heart failure experience significant biopsychosocial needs and have a poor prognosis. International guidelines have called for integrating palliative care in heart failure management. This review explores the elements of effective palliative care interventions in advanced heart failure. PubMed, Embase, CINAHL and Cochrane Reviews were searched following an a priori review protocol for clinical trials of advanced heart failure and palliative care. The risk of bias was assessed using Risk of Bias 2 (RoB2). A qualitative, emergent approach was used to synthesize context + mechanism = outcome. Twenty-one papers from 18 studies were the data source. The efficacy of palliative care in advanced heart failure was mixed. Five studies reported significant improvement in health outcomes compared with the usual care control group. Timing may be necessary in accounting for improvement in quality of life (occurring on or about 3 months) and functional and symptomatic improvements (occurring on or about 6 months or longer). Effective models of secondary palliative care in advanced heart failure include interdisciplinary teams comprising primary care, cardiology and palliative care, routine check-ins, personalized care plans that explore goals, evidence-based symptom management and counselling. Integrating palliative care with heart failure management could improve patient outcomes. Future research and policy development may wish to consider when, how and what palliative care modalities are to be incorporated into the care of patients with advanced heart failure.