NTERNATIONAL JOURNAL of NURSING PRACTICE

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NTERNATIONAL JOURNAL of

NURSING PRACTICE

E D I T E D B Y L I N P E R R Y

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I NTERNATIONAL JOURNAL of NURSING PRACTICE

EDITOR-IN-CHIEF Prof Lin Perry

Faculty of Health | University of Technology Sydney

EDITOR: NURSING PRACTICE

Dr Kylie Porritt

The Joanna Briggs Institute, School of Translational Health Science, Faculty of Health Sciences, The University of Adelaide, Australia

ASSOCIATE EDITORS

THE INTERNATIONAL JOURNAL OF NURSING PRACTICE IN CORPORATES:

COCHRANE NURSING CARE NETWORK SUMMARIES

EDITORIAL BOARD

EDITORIAL BOARD RECEIVING EDITOR Canada: Dr Doris Grinspun

Registered Nurses’ Association of Ontario (RNAO), Toronto, Canada USA: Dr Daphne Stannard

San Francisco State University, San Francisco, USA

South America: Dr Dina de Almeida Lopes Monteiro da Cruz Escola de Enfermagem da Universidade de São Paulo, Sao Paulo, Brasil Australasia: Professor Patrick Crookes

Faculty of Health and Behavioural Sciences, University of Wollongong, New South Wales, Australia

Asia: Professor Hu Yan

School of Nursing, Fudan University, Shanghai, Peoples Republic of China Dr Ma’en Zaid Abu-Qamar

Faculty of Health, Edith Cowan University, Western Australia

Professor Heather LovedayUniversity of West London, UK Dr Arja HolopainenNursing Research Foundation, Finland Bart GeurdenUniversity of Antwerp, Belgium

Deborah Norton WestwoodSIDRA Medical Centre, Qatar Dr Patricia McInerneyUniversity of the Witwatersrand, South Africa

Professor Lisa Hopp Purdue University, USA

Professor Susan Salmond University of Medicine and Dentistry of New Jersey School of Nursing, USA

Professor Marriane Lamb Queens University, Canada Dr Donal O’Mathuna Dublin City University, Ireland

Professor Tracey Howe Glasgow Caledonian University, Scotland Dr Coral MacRury SNBTS, Scotland

Professor William Lauder University of Stirling, Scotland

Professor Teresa Moreno-Casbas Institute of Health Carlos III Centre for Coordination and Development of Nursing Research Madrid, Spain Alex Mignone

The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Australia

Professor Peifan MuNational Yang Ming University, Taiwan ROC Professor Guifang GuoPeking University, Peoples Republic of China Professor Lisa HoppPurdue University, USA

Dr Susan WeeksTexas Christian University, USA

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L I T E R A T U R E R E V I E W

Mobile applications for managing symptoms of patients with cancer at home: A scoping review

Dian Putranto S.Kep., Ns, Student |

Erna Rochmawati S. Kp, MNSc, M.Med.Ed, PhD, Lecturer

School of Nursing, Master of Nursing Program, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia

Correspondence

Erna Rochmawati, School of Nursing, Master of Nursing Program, Universitas

Muhammadiyah Yogyakarta, Jl Brawijaya, Tamantirto, Kasihan, Bantul, DI Yogyakarta, 55183, Indonesia.

Email: erna.rochmawati@umy.ac.id

Abstract

Background: Education plays an important role in cancer symptom management for

patients and their families. With the advancement of information and communication technology, there may be additional evidence for the use of mobile apps to support patient and family education.

Purpose: The purpose of this review was to explore and synthesize scientific litera-

ture about cancer symptom management mobile apps that can be used by patients and their families.

Methods: This review adopted a scoping review study framework, using

electronic databases including EBSCO, PubMed, ProQuest, Science Direct, and Goo- gle Scholar using search keywords: ‘caregiver family’, ‘mobile application’, ‘symptom management ’ and ‘palliative care’. Of a total of 2633 papers found, 11 papers were selected.

Findings: Assessment tools are a major component of mobile apps in reporting

and assessing symptoms to provide appropriate education. The information in mobile apps is delivered through various mediums that include modules, videos, avatars and cultural integration features.

Conclusion: Mobile apps can improve provision of palliative care in several ways, most

importantly by increasing the knowledge of the patient's family to manage cancer symptoms. Nurses are expected to play an active role in finding and utilizing appropri- ate mobile apps to assist families in managing a patient's symptoms at home.

K E Y W O R D S

cancer, mobile application, nursing, palliative care, scoping review, symptom management

S U M M A R Y S T A T E M E N T

What is already known about this topic?

• Mobile apps are able to meet some healthcare information needs of patients with cancer.

• The use of mobile apps is proven to be a cost-effective way to provide healthcare information to patients after discharge from hospital.

What this paper adds?

• The assessment feature in a mobile app is a major component in reporting and assessing patient symptoms to enable provision of further appropriate education.

• Delivery of education in mobile apps is through various mediums including modules, videos, avatars and cultural integration features, as well as an emergency call function for managing severe symptoms.

Received: 16 June 2019 Revised: 18 March 2020 Accepted: 15 April 2020 DOI: 10.1111/ijn.12842

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The implications of this paper:

• Nurses are expected to play an active role in finding and utilizing appropriate mobile apps to assist families in managing patients with cancer at home.

• The development of mobile apps might be extended to symptom management of other life-limiting illness due to its benefits.

1 | I N T R O D U C T I O N

Cancer is the most common life-threatening disease in the world and caused 9.6 million deaths in 2018 (World Health Organization, 2018).

Most cancer patients receive palliative care at home, assisted by their family. However, there are obstacles in providing care at home that include lack of preparation and knowledge among family caregivers and limited availability of information sources (Mayahara, Wilbur, O'Mahony, & Breintenstein, 2017). Education for patients with cancer and their families plays an important role in strengthening their capac- ity, particularly for managing symptoms at home. Changes in reforms and healthcare policies in many countries have emphasized the need to support families in taking a more active role in managing care for patients with cancer at home (Capurro, Ganzinger, Perez-Lu, &

Knaup, 2014). Family empowerment can be used to control and support a patient's health status and health behaviour. Providing training and information to patients and families about the patient's disease, treatment, management of side effects and symptoms has several benefits. Such benefits include an improvement in patient quality of life and coping mechanisms, decreased patient and family anxiety and reduced conflict in decision making, and promoting patient's auton- omy. This can help patients in self-monitoring and self-efficacy (Armoiry et al., 2018).

Educational interventions through mobile applications (apps) can be used to promote the exchange of information between patients and healthcare providers. Mobile apps can send decision and information tools to more patients than traditional communication mediums as well as providing social media features for support and facilitating behavioural changes in cancer patients. Another advantage is that patients can use mobile apps to request information or ask questions through a questionnaire to trigger standardized or adapted feedback from the healthcare system (Tanabe et al., 2018).

Mobile apps are known as an effective tool for nurses to use with patients because they offer various advantages over assessment with printed materials. Mobile app interventions have the potential to improve quality of care in cancer management by providing training to families. In addition, the use of mobile apps has been proven to be cost-effective in providing special healthcare services to patients after discharge from hospital (Sturt, Dliwayo, &

Forjaz, 2018).

Several innovations have been created to increase available resources in palliative care to address the needs of patients and family

caregivers in managing symptoms at home. At present, with the advancement of information and communication technology, there may be additional evidence for the effectiveness of mobile apps to facilitate patient and family learning about the management of cancer symptoms. Previous systematic reviews have only discussed mobile apps that facilitate learning for patients (Richards et al., 2018), however there was no investigation into the effectiveness of mobile apps in symptom management at home. Therefore, there is a need to synthesize available evidence on mobile apps in managing cancer symptoms at home.

2 | R E V I E W M E T H O D 2.1 | Aims

This scoping review aimed to explore and synthesize scientific literature on mobile applications that can be used to manage cancer symptoms at home.

2.2 | Design

A scoping review was utilized, incorporating summaries, explana- tions and interpretations from available quantitative and qualitative studies to address the review questions. In contrast to systematic reviews, this type of review requires identification of all relevant literature regardless of research designs. Along with the increasing knowledge of researchers in the literature, a scoping review allows researchers to define search terms and conduct more sensitive literature searches. Researchers do not place strict limits on search terms, identification of relevant studies or study selection at the beginning, for this purpose. The study identification process is iter- ative that requires researchers to engage with each stage reflex- ively and, if necessary, repeat the steps to ensure that the literature is discussed comprehensively (Arskey & O'Malley, 2005).

This method allows a review to extract different data and develop it in a way that is meaningful, transparent and systematic (Grant &

Booth, 2009).

2.3 | Search methods

There are five important steps in conducting a scoping review as suggested by Arskey and O'Malley (2005) including (a) identifying research questions; (b) identifying relevant studies; (c) selecting studies; (d) mapping data; and (e) compiling, summarizing and reporting results.

The inclusion criteria for journal articles in this scoping review were published between 1 January 2014 and 31 January 2019; written in English; available in full text, and provided information about the design, development and evaluation of the use of mobile apps or software. In contrast, exclusion criteria were journal articles that reported information about mobile applications for palliative care in general or not specifically for cancer.

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2.3.1 | Stage 1: Identifying research questions

Levac, Colquhoun, and O'Brien (2010) state that having a well-defined research question that includes the scope of the study will enable researchers to conduct a more practical and effective review. For this review, three research questions were asked:

1 What mobile apps can be accessed by the patient's family to manage cancer symptoms?

2 How do the mobile apps work for patient symptom management?

3 What are the results of using the mobile apps?

2.3.2 | Stage 2: Identifying relevant studies

Before identifying relevant journal articles, the authors determined keywords based on the research question. The search keywords from MeSH were then used together: ‘caregiver family’, ‘mobile application’, ‘symptom management’ and ‘palliative care’. Electronic databases including EBSCO, PubMed, ProQuest, Science Direct, and Google Scholar were used to look for journal articles that met the inclusion criteria. Searching using scan reads was also conducted to find papers manually by searching for specific journals and identified papers or reviews. The publication date was limited to journals published in the last 5 years for validity and up-to-date reasons.

2.3.3 | Stage 3: Selection of studies

From search results, 2633 search articles were found. Retrieved articles were exported to a bibliographic file using the reference management software Endnote 9. Among these numbers, 82 articles were determined from the results of matching titles with manual abstract and title filtering techniques. After removing duplicate articles, each article abstract was evaluated by the first author (D. P.) for relevance according to predetermined inclusion criteria: (a) the study was origi- nal research in mobile apps; (b) contained symptom management; and (c) the paper was published in English. Furthermore, from 17 articles obtained, they were read in full, and the relevant results steps were searched. The two authors (D. P. and E. R.) independently read the full text of the selected studies and selected studies based on the stated inclusion criteria. After the full text has been read and assessed against the review question, 11 articles were considered suitable for inclusion in the final dataset. The selection of relevant articles was based on research questions, not a critical assessment process, although minimum quality standards were included (Arskey &

O'Malley, 2005; Grant & Booth, 2009). Researchers conducted detailed methodological criticism of the included study to appreciate the scope or extent of the available literature on the topic under study (Arskey & O'Malley, 2005). The procedure used to select the included papers is displayed in Figure 1.

F I G U R E 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Arksey & O⁰Malley's (2005) scoping study framework stages

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2.3.4 | Stage 4: Mapping data

Each of the 11 selected full-text papers was read thoroughly, several times by the two authors to capture all relevant information and to ensure that no important information was missed. The dataset of the paper was constructed by extracting findings that were relevant to the questions asked. The dataset was perfected regularly by considering whether the extracted data were consistent with the review questions and research objectives. The extracted datasets were then categorized using the author, research objectives, research design, participants or samples and mobile applications used as well as the results found in the practical table (Table 1). The design of this dataset was discussed among the review authors to ensure all relevant information was entered.

2.3.5 | Stage 5: Compiling, summarizing and reporting the results

Arskey and O'Malley (2005) state that there are various ways to com- pile and summarize including managing data thematically. Thematic analysis helps to identify, analyse and tell the patterns identified in the dataset. The themes reflect the main concepts that occur repeat- edly in the text and answer the questions asked (Braun &

Clarke, 2006).

3 | R E S U L T S

A total of 11 papers were reviewed in the current scoping review. The studies included came from six different countries: Australia, Belgium, Ireland, Kenya, Philippines and the United States. Almost all of the papers were studies that developed and tested a mobile app (Andebe et al., 2017; Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Fortier et al., 2016; Gustafson et al., 2017a; Santin et al., 2019; Slater et al., 2018; Sogono et al., 2018; Wittenberg et al., 2018). After reviewing the literature, three major themes were identified: mobile apps development and how they work; available features;

and benefits of using mobile apps.

3.1 | Mobile apps development and how they work

The development of mobile apps involves stakeholders that include:

clinicians, representatives from health authorities and societies and patient/families and computer programmers. Mobile app development starts with conducting a focus group with targeted stakeholders to find out what patients and families need in palliative care at home.

Furthermore, the concepts of the mobile application are explained, and suggestions from patients are accommodated (Fortier et al., 2016;

Santin et al., 2019; Wittenberg et al., 2018). The nurse's role is to ask information or communication technology experts to design a mobile application that is in accordance with the patient's initial concepts and

desires. Next, a doctor is required to choose the content that is appropriate for the patient and the possible symptoms that will be faced by the patient at home. Once formed, a trial was conducted on patient and family respondents for additional features needed and recommended preferred designs. Collaboration with patients and families is needed in the development of this application (Andebe et al., 2017; Beck et al., 2017; Fishbein et al., 2017; Gustafson et al., 2017b).

After the application can be fully accessed by the patient, a nurse is assigned to observe what the family reports about the patient's condition through symptom assessment. Furthermore, the doctor receives a report from the nurse regarding the development of the patient and is responsible for managing the treatment of the patient.

Doctors and nurses are always prepared to receive an emergency call and direct the family if the patient experiences an emergency related to their illness (Rasschaert et al., 2016; Slater et al., 2018).

Broadly speaking, the main function of the mobile application system is to record an assessment of patient symptoms. Furthermore, the symptoms delivered through the application will be followed up. If the symptoms in the range are tolerable, the family can choose to read how to intervene or choose the skills needed through modules that are available independently. Alternatively, after the family reports symptoms, the nurse will recommend reading an article, module or video from the application used or by e-mail, which contains a way to independently manage patients (Andebe et al., 2017; Chung et al., 2018; Fortier et al., 2016; Santin et al., 2019; Sogono et al., 2018; Wittenberg et al., 2018). In severe conditions, when symptoms cannot be tolerated by the patient, the system will automatically connect the family by telephone to the team of experts who are responsible for providing first aid, and then the system will connect to the emergency call at the nearest hospital (Andebe et al., 2017; Beck et al., 2017; Fishbein et al., 2017; Gustafson et al., 2017b; Rasschaert et al., 2016). The integration of patient self- management, family and professional care through healthcare technology facilitates partnerships with shared responsibility, offers valuable insights that complement self-care by patients and families and accommodates further consultations or referrals (Hochstenbach et al., 2017).

3.2 | Available mobile apps and their features

From the reviewed papers, the available apps include the African Palliative Care Association African Palliative Care Outcome scale (APCA African POS), SymptomCare@Home (SCH), Cancer-Tailored Interventions for Pain and Symptoms (C-TIPS), Chemotherapy therapy Assistant (CORA), Pain Buddy, e-Alert System, RemeCoach, LEDs, web-based resource (PLWR), Health-A Communication Guide for Caregivers©, Internet-based Computerized Patient Assessment System (iComPAsS) and Family App Oncology (Andebe et al., 2017; Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Fortier et al., 2016; Gustafson et al., 2017a;

Rasschaert et al., 2016; Santin et al., 2019; Slater et al., 2018;

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TABLE1Summaryofselectedarticles Author/YearTypeofstudy Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult Andebe,Waiganjo, andWeru(2017)

Participatoryaction research(PAR) designwasutilized inthisstudy.PAR designisdescribed tohavefivephases, namely,diagnosing, actionplanning,and actiontakingdesign intervention,impact evaluation,and learningand creationof actionable knowledgeforthe client.

15patientsand caregiverswere eligible.Patients (n=8) Caregivers(n=7).

APCAAfricanPOSMobileapplicationCollectionofdata, transmissionof data,and visualizationofdata throughaweb interface, generationofalerts informofShort MessageTexts (SMSs).

Kenya,AfricaImprovedsymptom monitoringand strengthened provider-patient communication. Beck,Eaton, Echeverria,and Mooney(2017)

Thisstudyutilized researchand developmentof mobileappsaspart ofabiggerRCT study 358patientsduring theircourseof chemotherapy.

SymptomCare@Home (SCH)

WebbasedDailysymptom monitoring, Self-management coaching,alerting, andnurse practitioner follow-up Utah,United States

Availablemodelof telehealththathas patientassessment, self-management coaching,reminding doctors,and systematic follow-upusing evidence-based guidelinesare importantfeatures ofacomprehensive disease management approach Chungetal.(2018)Themethodinthis articlehastwo stages,namely,

Participantsconsisted of26mothers (87%)andfour fathers(13%)of childrenwithcancer Cancer-Tailored Interventionfor PainandSymptoms (C-TIPS)

WebbasedAtailoringalgorithm, customizationtools, guided diaphragmatic breathingtraining, relaxationpractice, andeducational material(COPE modules).

California, UnitedStates

Parent'ssatisfaction Betteroutcomereport intermofreduced stressandincreased relaxationPhaseI—Development ofC-TIPS:Approval fromstakeholders, Content-making procedures, Technicalattributes ofC-TIPS,Sewing algorithms, customizationtools, (Continues)

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TABLE1(Continued) Author/YearTypeofstudy

Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult relaxationtraining andpractice,COPE modules(Painin proceduresand moduletests, treatmentand modulepain, Obstaclespain reportingmodule, symptom managementand modulesupport services, Treatment-specific COPEmodules). PhaseII—Formative evaluationof C-TIPS(selectionof participants),steps ofevaluation (medicalrecord abstractionand demographic sheets,Stressand relaxationratings, Contentand usabilitymeasures, Formative evaluation interviews), Procedures (Deployment, Assessment), Analysis(Current studiesincluded descriptive statistics, correlational analyses,and one-sampletand Wilcoxon signed-ranktests)

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TABLE1(Continued) Author/YearTypeofstudy Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult Fishbein etal.(2017)

PhaseIconsistedof themobileapp development processandinitial resultsof acceptabilitythat werecompletedin 5steps.

4keystakeholder groups:(a) patient/families (n=8);(b)oncology clinicians(n=8);(c) cancerpractice administrators (n=8);and(d) representativesof thehealthsystem, community,and society(n=8).

Chemotherapy Assistant(CORA) Mobile application

medicationreminders, self-reportingof medication adherenceand symptoms,an educationlibrary includingnutritional information,Fitbit integration,social networking resources,and individuallytailored symptom management feedback Massachusetts, UnitedStates

Availablemobileapps thathasfeatures: medication reminder,medical adherence Fortier,Chung, Martinez, Gago-Masague, &Sender,2016

PhaseIdevelopment ofpainbuddy: stakeholders, procedures,base technology.

12childrenbetween theagesof8and 18participatedina pilotstudyofPain Buddy(n=12)

PainbuddyMobileapplicationDailypainand symptomdiaries completedby children,remote monitoringof symptomsby uploadingpatient's datathrough internettoacloud server,cognitive andbehavioural skillstraining, interactive three-dimensional avatarsthatguide childrenthrough theprogram,andan incentivesystemto motivate engagement California, UnitedStates

Improvedpainand symptom management PhaseIIformative evaluationofpain buddy:participants, measures, procedures,analysis (included descriptivestatistics andone-sample Wilcoxonsigned ranktests. One-sample Wilcoxonsigned ranktestswere performedto determinewhether theobserved medianisequalto themiddlevalueof thescaleforeach test) Gustafson etal.(2017a)

Apooledanalysis fromtwo randomizedclinical 235ofpatientswith advancedlung, breast,orprostate e-AlertSystemWebbased(Comprehensive Health Enhancement Wisconsin, UnitedStates EHealthsupporthelps caregiversplaya moreeffectiverole (Continues)

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Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult trials (NCT00214162and NCT00365963) comparedoutcomes at12monthsfor twounblinded groups:acontrol group (Comprehensive Health Enhancement SupportSystem [CHESS]-only)that gavecaregivers accesstoCHESS,an onlinesupport system,andan experimentalgroup (CHESS+CR [ClinicianReport]), whichalsohad CHESSbutwitha CRthat automatically alertedcliniciansif symptoms exceededa predetermined thresholdof severity.

cancerandtheir respectivefamily caregiversfrom5 oncologyclinicsin theUnitedStates..

SupportSystem [CHESS]-only)that gavecaregivers accesstoCHESS,an onlinesupport systemand (CHESS+CR [ClinicianReport]), whichalsohad CHESSbutwitha CRthat automatically alertedcliniciansif symptoms exceededa predetermined thresholdof severity

inthecareoftheir lovedones.In addition,theresults showthateHealth warningsoriginating fromfamily caregiverscan influencedoctor behaviour.eHealth fromcaregiverscan affectcarefor patientswithmany typesofcancer. Rasschaert etal.(2016)

Thepresenttrialwasa preplanned, single-centred, nonrandomized proofofconcept studyinwhichthe useofthe RemeCoachwas evaluated.

11patientswith cancer

RemeCoachWebbasedTreatment compliance, symptom self-reporting,and safetyandadverse events Belgium, Europe

Self-reporttoolis feasible,reliableand acceptableto outpatients Allmeasuresare reportedusing descriptivestatistics (medianandrange).

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Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult Compliancetothe electronicdevice canbesubdivided intotwocategories: patient-centred (e.g.,toxicity scoring)and therapy-centred (e.g.,treatment intake).The compliancewas calculatedasa proportionof registrations performedbythe patientversus registrationsasked bythedevice. Santin,McShane, Hudson,and Prue(2019)

Themethoddescribed inthisarticle discussesthesteps usedinmakingthis application:

9staffand6parents andcaregivers.

Peer-ledweb-based resource(PLWR)

WebbasedVideoedpersonal experiences,full unclippedpeer stories,and diagnosis-specific information, bereavement, cancertreatment, self-care

Ireland,EuropePLWRcontentand designseems acceptableto cancerguards.The co-designmodelis aneffectivewayto developinformation thatisappropriate forserviceusers andcanbeusedas aframeworkforthe developmentof otherinterventions invariousdisease groups.

Appdevelopment, selectionofa vendor,privacy, security,and readiness,testing andpublishing, promotion, evaluation Slater,Fielden,and Bradford(2018)

Theprojectwas conductedintwo phases;(a)a four-stepco-design modeltoinformthe developmentofthe resourceand(b) usertesting evaluatingresource acceptability.

12expertadvisory team

OncologyFamilyAppMobileapplication‘StatewideHospital Contacts’,‘Whento Call’,‘BloodResults Table’,‘Information’ module-linksto recommended websites,healthcare teamcontact details, appointments,and Queensland, Australia

Theappisefficient andconvenientway toprovideneeded information. (Continues)

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Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult Developmentwas guidedbytheMRC frameworkfor developingcomplex interventions.

freetextallowing thestorageof personalnotes. Sogono etal.(2018)

Thisstudyusesa cross-sectional studydesign.

20participantswhich werecomposedof 10patients(n=10) and10physicians (n=10).

iComPAsSMobileapplicationPatientInterface: Profile, Prescriptions,Take ESAS,Listof Doctors,Messages, ChangePassword andHelp PhysicianInterface: Profile,Listof Patients,Messages, ChangePassword, andHelp Manila, Philippines

Theappisusableand acceptable Demographic characteristicsand MARStool responseswere encodedusingMS Excel2013,and analysedusing STATA13. Descriptive statisticslikemean andstandard deviation, frequencyand proportionswere usedtopresent quantitativeand qualitative responses. Wittenberg,Xu, Goldsmith,and Mendoza,(2018)

An8-stepprocesswas conducted:(a) reviewofexisting printresources;(b) selectionof theoretical frameworkfor content development;(c) integrationof stakeholder feedbackand literacyassessment intoanalphaprint model;(d)reviewof existingmhealth Assessmentof caregiver acceptability(n=5); assessmentof qualityand perceivedimpactby cancerproviders (n=26);and acceptabilitytesting withcaregivers (n=6).

ACommunication Guidefor Caregivers©

Mobileapplicationimprovecaregiver communication skillsrelatedto caregiving;facilitate informationand resourcesharing withotherfamily members;provide resourcesfor caregiverself-care; andincrease knowledgeabout thediseaseandits management California, UnitedStates

Itconsistsofseveral tipsandresources forcaregiver communication withpatients, families,distant families,and healthcare providers,aswellas generalinformation sharingfeatures.

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Wittenberg et al., 2018). The features in the mobile apps are assessment and symptom reporting; medical adherence checking;

follow up by healthcare professional; education and skills training;

and available resources.

Several papers mention the symptoms of cancer in mobile applications, namely, pain, loss of appetite, insufficient sleep, fatigue, stress, high fever, feeling nervous/anxious, feeling sad, stressed, and depressed and reduced quality of life (Andebe et al., 2017; Chung et al., 2018; Fortier et al., 2016; Gustafson et al., 2017b; Sogono et al., 2018; Wittenberg et al., 2018). Five papers have features of assessment and symptom reporting (Andebe et al., 2017; Fishbein et al., 2017; Fortier et al., 2016; Slater et al., 2018; Sogono et al., 2018). Some of the reported symptoms due to chemotherapy include nausea, vomiting, mouth pain, dryness, irritation, diarrhoea, constipation, changes in visual acuity, hand–foot syndrome and insta- bility in body temperature, numbness or tingling and difficulty thinking or concentrating (Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Rasschaert et al., 2016; Slater et al., 2018).

The provision of education and skills training is one feature in the mobile apps as reported in four reviewed papers (Chung et al., 2018;

Fortier et al., 2016; Santin et al., 2019; Wittenberg et al., 2018). The way to deliver education is packaged in various types of application systems including modules, videos, avatars and features of cultural integration (Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Slater et al., 2018). Module form is a common way to provide education to patients and families as reported in several articles.

The module topics in some of the articles covered include relaxation training, information and training on symptom management skills, module names and chemotherapy doses. In addition to the available module in the mobile apps, modules are also obtained from links to websites recommended by nurses (Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Slater et al., 2018).

The content of video media used to educate patients and families has been adjusted to the symptoms reported by the patient. Educa- tion with video media will be more acceptable to patients and families.

With videos of patients and families, it can be easier to understand some cancer symptom management skills with instructors demon- strating in the video. Santin et al. (2019) developed an application that provides a forum for families to share private videos that contain symptom management for patients with cancer (Santin et al., 2019;

Sogono et al., 2018). A high level of technology has been developed in the mobile application, namely a three-dimensional (3-D) avatar feature that guides children throughout the programme. Cognitive skills training and behaviours that use avatars are unique. Unique and mov- able shapes are an attraction for them. Avatars are used to provide examples of skills in children such as a movement to manage the symptoms they feel through their reporting that is helped by their parents (Fortier et al., 2016). In addition to these features, the mobile application can be used to help patients and their families regarding their knowledge of cultural relationships with palliative care. Cancer is often associated with a curse in a culture, the application A Communi- cation Guide for Caregivers © can provide knowledge of it. This application has features for integrating culture with symptom TABLE1(Continued) Author/YearTypeofstudy

Samplesizeof participantsNameofapplicationTypeofapplicationFeaturesCountryResult resources;(e) developmentof prototype;(f) assessmentof caregiver acceptability(n=5); (g)assessmentof qualityand perceivedimpactby cancerproviders (n=26);and(h) acceptabilitytesting withcaregivers (n=6).

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management. Nurses provide recommendations and knowledge for appropriate action and are integrated with local culture (Wittenberg et al., 2018). Packaging information in various types of application system forms is an aspect of creativity from the developers.

3.3 | Benefits of using mobile apps for families

Based on the 11 articles reviewed, the main benefits of the mobile apps are increased family knowledge in managing symptoms in patients with cancer and an increase in adherence to medical treatment. Some other benefits include increasing ability to promote behavioural change for patients and families and monitor a number of symptoms and physiological indicators of cancer patient disease. This review also shows that mobile applications are able to increase family readiness in real-time supportive interventions, reducing stress on families, making it easier for families to communicate with nurses (Chung et al., 2018; Gustafson et al., 2017a).

4 | D I S C U S S I O N

This review shows the development of technology-based interventions in the form of mobile applications to help families care for patients with cancer at home. Eleven studies using web-based interventions and smartphone applications were included in the review.

The current scoping review is the first to describe mobile apps in cancer care that include the development of apps, available features and benefits of using the mobile apps.

Based on information obtained from the article, it shows that in the last 5 years mobile apps development has occurred in several countries, namely six articles from the United States, two from Europe (one Belgium and one Ireland), one article from Australia, one article from (Philippines), and one article from Kenya. More papers reporting mobile apps are from developed countries (eight papers). More mobile apps development might be due to higher prevalence of cancer in developed countries in addition to more advanced technology. The highest prevalence of cancer worldwide is in Europe with 23.4% of total global cancer cases and 20.3% of cancer deaths, followed by 21% of cancer cases in America and 14.4% of deaths (Bray et al., 2018). From the data, it can clearly be seen that America has the lowest percentage of total deaths of patients with cancer in the world. If it is synchronized with the management of symptoms in cancer, the percentage is a success of the United States to manage cancer pain. In terms of reducing severity and death in patients with cancer, the United States certainly has developed several innovations. One of them is the development of a mobile application for managing cancer symptoms by reporting symptoms and emergency systems (Beck et al., 2017; Chung et al., 2018; Fishbein et al., 2017; Fortier et al., 2016; Gustafson et al., 2017b). Research conducted by Tanabe et al. (2018) compares the quality of web-based applications between America and Japan; the results show that American scores were

higher and had a large effect on ability, validity and procedures for producing content.

Five of the seven included papers that described the development process state involving the stakeholders (Beck et al., 2017;

Fishbein et al., 2017; Slater et al., 2018; Sogono et al., 2018;

Wittenberg et al., 2018). This shows the importance of involving stakeholders (patients/families, healthcare team and society) to ensure that the developed mobile apps will be suitable for patients/families, healthcare teams and society. The developer's creativity aspects such as simple practice, the accuracy of the content for the target and the attractive appearance of a mobile application feature are determinants of application acceptance by users and the popularity of applications (Hochstenbach et al., 2017;

Wittenberg et al., 2018). Wittenberg et al. (2018) state that accom- modating caregivers' needs shows some benefits that lead to better quality of life for the patient and family.

The assessment and symptom report feature is the most common feature reported in the selected papers. Assessment is fundamental in care provision to enable providing appropriate prescriptions and education and skills training for patients and families.

In all articles, the assessment tool feature is the main component in providing information to provide appropriate education for patients and families. Family education that suits the needs of patients is an important aspect of achieving success in palliative care. In general, in each article that was reviewed, it was stated that pain is a symptom that can be managed using a mobile application. Pain is the most reported symptom among patients with cancer (Jamwal & Kumar, 2016). This review found that the use of mobile apps is associated with reduced pain in cancer patients. This evidence is supported by research conducted by Allsop, Taylor, Mulvey, Bennet, and Bewick (2015) that found ICT is associated to manage pain. Furthermore, pain in patients with cancer is a symptom that most affects the quality of life and pain is a symptom that has the most descriptive types of assessment (Allsop et al., 2015).

Two papers (Chung et al., 2018; Gustafson et al., 2017b) reported that patients have better outcomes after using mobile apps. This supported findings from previous studies. A randomized controlled trial study conducted by Egbring et al. (2016) among patients with breast cancer demonstrates that the use of mobile apps is associated with better patient outcomes especially when used under collaboration with the treating patients. This reinforces the need for future mobile app development to include real time data that connect with the treating healthcare team. In the present review, we found four papers that described mobile apps featuring instructions from healthcare professionals (Andebe et al., 2017; Beck et al., 2017;

Fishbein et al., 2017; Sogono et al., 2018), but these papers did not measure patient outcomes. Such collaboration might influence the outcome due to more precise patients' recorded data, better communication between patient/families in treatment-related symptoms and enable more appropriate management by the healthcare team (Egbring et al., 2016). Royackers, Regan and Donelle (2016) stated that families of patients with cancer who did not use technology-

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based palliative care would experience stress both physically, mentally and financially. The existence of technology allows families to be integrated with healthcare providers who are more flexible and able to handle a variety of patient needs and enables care that is more family-centred and patient-centred. Palliative care using mobile applications can relieve stressors for the patient's family, allowing patients to stay at home.

4.1 | Strengths and limitations

A strength of this literature review is that the search was very comprehensive including the development of mobile apps, available features of mobile apps and benefits of using the mobile apps. Most of the papers describe the development and testing process and available features, which could inform the development of future mobile apps.

In addition, this scoping review was conducted according the standard of methodology. However, there are limitations of the scoping review.

There may be a bias towards the promising mobile apps from the review as only published scientific studies were considered in this review. In addition, date and language limitations that we set may affect the currency of the study and may have excluded some topics.

5 | C O N C L U S I O N

With the current high prevalence of cancer and cancer-related deaths, several technological innovations including mobile apps have been developed in different countries to increase available resources in palliative care. Assessment features in the mobile apps are a major component in reporting and assessing patient symptoms to provide appropriate healthcare education. In order to be more interesting and accessible to patients and families, the delivery of education is packaged in various types of application systems including modules, videos, avatars and cultural integration features, as well as‘emergency call’ functions for severe symptoms. Family education in accordance with the patient's needs is an important aspect of achieving success in palliative care. Some of the benefits of mobile applications for families are increasing knowledge, promoting behaviour change, monitoring physiological symptoms and indicators of disease, increasing family readiness in real-time supportive interventions and reducing stress on families, making it easier for families to communicate with nurses and access to facilities at low cost. With all the conveniences and benefits, nurses can play an active role in searching for and utilizing appropriate mobile apps to support families in the management of patients with cancer at home.

A C K N O W L E D G E M E N T S

The authors would like to thank for Ms. Thea Saliba, MN, for the valuable comments on the manuscript.

C O N F L I C T O F I N T E R E S T

No conflicts of interest have been declared by the authors.

A U T H O R S H I P S T A T E M E N T

DP and ER are responsible for the study design and conception, data collection, data analysis, and manuscript writing and revisions for intellectual content.

F U N D I N G I N F O R M A T I O N

This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

O R C I D

Dian Putranto https://orcid.org/0000-0003-2354-3844 Erna Rochmawati https://orcid.org/0000-0003-2193-6812

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How to cite this article: Putranto D, Rochmawati E. Mobile applications for managing symptoms of patients with cancer at home: A scoping review. Int J Nurs Pract. 2020;e12842.

https://doi.org/10.1111/ijn.12842

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O R I G I N A L R E S E A R C H P A P E R

Establishment and validation of a delirium prediction model for neurosurgery patients in intensive care

Jun Wang RN, MM, Professor of Nursing

¹

| Yuanyuan Ji RN, BS, Senior Nurse

¹

| Ning Wang MD, Doctor, Professor of Treatment

¹

| Wenjin Chen MM, Doctor, Doctor-in- Charge

¹

| Yuehong Bao RN, BS, Supervisor Nurse

¹

| Qinpu Qin RN, BS, Senior

Nurse

¹

| Chunmei Ma RN, BS, Senior Nurse

¹

| Qian Xiao MD, Lecturer, Associate Professor

²

| Shulan Li MD, Lecturer

²

1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China

2School of Nursing, Capital Medical University, Beijing, China

Correspondence

Jun Wang, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Email: wangj229@126.com

Funding information

Beijing Education Committee, China, Grant/

Award Number: 16HL05

Abstract

Background: Neurosurgical intensive care unit patients are at high risk for delirium. A risk prediction model could help the staff screen for patients at high risk for delirium.

On the basis of this risk, preventive measures could be taken to reduce the undesired effects of delirium.

Objectives: To establish a delirium prediction model for neurosurgical intensive care unit patients and to verify the sensitivity and specificity of this model.

Design: A prospective, observational, single-centre study.

Methods: Data were collected from a total of 310 patients admitted to the neurosur- gery intensive care unit between January 2017 and February 2018. A risk factor prediction model was then created using multivariate logistic regression. Further data were collected from another 60 patients between March 2018 and June 2018 to val- idate the model.

Results: The model consisted of six predictors, namely, cognitive dysfunction on admission, fever, hypoalbuminaemia, abnormal liver function, sedative use four or more times, and physical restraint. The area under the curve of the model was 0.80, with sensitivity and specificity of 0.68 and 0.83, respectively.

Conclusions: This study established a delirium prediction model for neurosurgical intensive care unit patients, which we believe would help focused prevention of delirium in intensive care unit patients.

K E Y W O R D S

delirium, neurosurgery, nursing, prediction model, risk factors

S U M M A R Y S T A T E M E N T

What is already known about this topic?

• Delirium is an acute medical condition commonly seen in general hospitals.

• There are many reasons underpinning delirium in ICU patients, and early screening and prevention constitute the first steps of delirium management.

• There are a limited number of studies that have addressed delirium in neurosurgical ICU patients.

Received: 21 August 2018 Revised: 28 August 2019 Accepted: 5 January 2020 DOI: 10.1111/ijn.12818

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What this paper adds?

• This study established and validated a delirium prediction model on the basis of the risk factors associated with neurosurgical ICU patients.

The implications of this paper:

• This delirium prediction model for neurosurgical ICU patients allows medical staff to adopt early interventional measures for patients at high risk for developing delirium, thereby preventing and reducing the incidence of this condition.

1 | I N T R O D U C T I O N

Delirium is a brain syndrome characterized by cognitive dysfunction, decreased level of consciousness, inattention, decreased mental activity, and sleep-wake cycle disorders and recurrent fluctuations (Abbas &

Mahin, 2013). Among surgical intensive care unit (ICU) patients, the incidence of delirium has been reported to be between 20% and 73%

(Angles et al., 2008; Pandharipande et al., 2008). Patients with delirium are at high risk of experiencing additional complications, pro- longed hospital stays, increased hospital costs, and in-hospital mortality. Moreover, delirium is associated with negative clinical outcomes and also has long-term effects on patients with decreased cognitive functions including reduced quality of life and even lower survival rates (Wang et al., 2018; Wolters, Van, Cremer, De, & Slooter, 2013). Therefore, accurate diagnosis of delirium can promote effective prevention and early treatment, thereby preventing unfavourable consequences of this condition.

Currently, there is no effective treatment for ICU delirium. Wien, Balsliemke, and Stubhaug (2013) have suggested that early screening and prevention constitute the first steps in promoting favourable delirium prognoses. The authors also emphasized that risk factors for delirium should be identified once the patients enter the ICU. A study by Van den Boogaard, Schoonhoven, van Achterberg, van der Hoeven, and Pickkers (2013) confirmed that interventions in high-risk groups may improve prevention of delirium. Therefore, the establishment of a delirium prediction model that includes high risk factors can effectively support clinical decision making. For example, targeted drug prevention and other nonpharmacological interventions for high- risk patients can reduce the incidence, severity, and duration of delirium (Miller & Barreiro, 2013).

Several ICU prediction models have been developed in countries other than China. For example, Van den Boogaard et al. (2012) established a delirium prediction model for ICU patients, which fea- tured ten risk factors: age, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentra- tion, and urgent admission. This model was then validated by Van den Boogaard et al. (2014) in eight comprehensive ICUs across six

countries, which showed a good prediction ability. Similarly, Wassenaar et al. (2015) have analysed the data including age, history of cognitive impairment, history of alcohol abuse, blood urea nitro- gen, admission category, urgent admission, mean arterial blood pressure, use of corticosteroids, and respiratory failure from 2914 patients in 13 ICUs across seven countries to isolate nine variables capable of developing an early prediction (E-PRE-DELIRIC) model.

However, very few studies have yet attempted to develop a delirium prediction model for ICU patients in China. Differences between countries in terms of ethnic culture as well as treatment modalities raise the question whether the predictors identified in delirium prediction models from different cultures might not be applicable to Chinese ICU patients. On the basis of an ICU cohort in Lanzhou, Chen, Du, Wei, Chang, and Dong (2017) established a delirium prediction model using 11 related factors: age, APACHE-II score, coma, emergency surgery, mechanical ventilation, multiple trauma, metabolic acidosis, history of hypertension, history of delirium and dementia, and the use of dexmedetomidine. However, the application of such risk prediction models is mostly limited to internal medicine, emergency-surgery, and general-surgery patients (Chen et al., 2017; Van den Boogaard et al., 2012; Van den Boogaard et al., 2014; Wassenaar et al., 2015), and they are not necessarily applicable to neurosurgery ICU patients. It is well known that delirium is mainly characterized by mental symptoms, and its occurrence and progression are the result of systemic diseases and brain function (Tang, 2019). Neurosurgical ICU patients who have substantial brain damage have differing characteristics to other diagnostic groups of patients. Neurosurgical ICU patients' symptoms may overlap with delirium, making the recognition of delirium in these groups of patients with neurological diseases even more difficult. Moreover, there are differences in the treatment strategies between neurosurgical ICU patients and those in other departments as well, since neurosurgical ICUs specifically host patients with acute and critical conditions who have undergone neurosurgical interventions under general anaesthesia (Piagnerelli & Legros, 2010). The clinical status of such patients changes rapidly, and the treatment strategies commonly involve surgical approaches, control of intracranial pressure, and the protection of neurological functions, which generally require sedative analgesia and mechanical ventilation. Therefore, in order to establish a delirium prediction model for neurosurgical ICU patients, important variables related to neurosurgical diseases and treatments could be included in combination with relevant research results regarding the status of the patient at both home and abroad. Thus, the established risk prediction model can be applied to clinical practice, allowing the development of systematic prevention as well as management strategies by assessing the risks.

On the basis of the above-mentioned evidence, this study set to establish a delirium prediction model on the basis of the risk factors associated with neurosurgical ICU patients and also to verify its sensitivity and specificity. We believe such a model would help doctors and nurses adopt early interventional measures for patients at high risk for developing delirium, thereby preventing the occurrence or reducing the incidence of this condition.

2 of 8 WANGET AL.

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2 | M E T H O D S

2.1 | Design and participants

A prospective, observational, single-centre study was designed to select ICU patients in the Department of Neurosurgery, Capital Medi- cal University, Beijing, China, between January 2017 and February 2018. Inclusion criteria were as follows: (a) patients in the neurosurgery ICU who were operated on electively and admitted to the ICU after their scheduled surgery as well as those with acute brain disorders and those with nonsurgical brain conditions; (b) patients who received a diagnosis of cerebrovascular diseases or neurosurgical diseases such as brain tumours; (c) patients who were admitted to the ICU within the last 24 hours; (d) patients whose estimated ICU length of stay was longer than 24 hours; and (d) patients older than the age of 18 years. Exclusion criteria were as follows: (a) patients with seri- ous visual or auditory disorders who could not communicate with visi- tors; (b) patients with cognitive function score (Mini-Mental State Examination [MMSE]) less than 10 points at the time of admission to the ICU; (c) patients with severe dementia, mental illness, or neurological diseases such as cerebral haemorrhage, cerebral infarction, or pulmonary encephalopathy (a clinical syndrome consisting of various neuropsychiatric symptoms due to chronic pulmonary chest diseases and accompanying respiratory failure, hypoxemia, and hypercapnia prior to their admission); and (d) patients in persistent comatose stage during their stay in the ICU.

2.2 | Sample size calculation

The present study included 28 independent variables. According to the multivariate logistic regression method, each independent variable required 10 to 15 samples; thus, the required sample size was determined as 280 to 420 cases. Considering a potential loss of 10% of cases, the required sample size was 308 to 462 cases. The actual sample size of the final study was 310, which satisfied the predefined sample size requirement.

2.3 | Procedure

The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), which shows good sensitivity and specificity against delirium, was performed for delirium assessment as recommended by the guideline released in 2013 (Barr et al., 2013). Six researchers who were trained and skilled in the CAM-ICU assessment method were on duty to evaluate delirium. Each day, patients were selected according to the inclusion and exclusion criteria. General data and condition monitoring indicators were collected, including the MMSE score to assess cognitive status upon admission (Albert, 2014). The Glasgow Coma Scale was used to evaluate the state of consciousness, and the APACHE II score was used to evaluate the severity of the illness (Knaus, Draper, Wagner, & Zimmerman, 1985). All information was

obtained via medical records, nursing records, or clinical enquiries.

Researchers routinely used the CAM-ICU to assess patient delirium statements twice a day, at 08:00 to 09:00 and 20:00 to 21:00, or whenever patients were suspected of delirium. If a patient was diag- nosed with delirium, the doctor was informed immediately for appropriate treatment. The patient was then closely observed, and clinical data were recorded on a daily basis until the patient was discharged from the ICU or deceased. To investigate short-term outcomes, the patient was also followed up on a daily basis, in both the ICU and general ward, until the patient was discharged from the hospital or deceased.

2.4 | Statistical analysis

Data analysis was performed using IBM SPSS, version 22.0 (Statisti- cal Package for the Social Sciences, Armonk, New York, USA). Uni- variate analysis was used to determine initial variables with an alpha level of .05. Logistic stepwise regression was used to determine the predictors of ICU delirium with entry level of .05 and removal level of .1. The independent predicting ability of predictors was expressed by the odds ratio (OR) value and the 95% confi- dence interval (95% CI). The receiver operating characteristic (ROC) curve and area under the curve (AUC) were subsequently used to evaluate risk factors for predicting the likelihood of ICU patients to develop delirium. P < .05 was considered to be statistically significant.

2.5 | Ethical considerations

This study was approved by the Xuanwu Hospital Ethics Review Com- mittee (Clinical Research Council [2017]008). Written informed consent was obtained from all patients participating in the study or from their families according to the Declaration of Helsinki.

3 | R E S U L T S

3.1 | Participant characteristics

Between January 2017 and February 2018, 522 patients were admitted to the neurosurgery ICU. Two hundred twelve patients were excluded as 42 patients had an MMSE score less than 10 points upon admission, 138 patients were in a persistent comatose state, 20 patients were deceased before experiencing delirium, and 12 patients refused to participate in the study. A total of 310 cases, 140 male and 170 female patients, were eventually included in the study. The mean (SD) patient ages were 51.3 (14.01) years (range 19 to 87 years). Delirium was observed in 118 of the cases (42.2%).

Of those, 49 cases (41.5%) had hyperactive delirium, while 31 cases (26.3%) had hypoactive delirium and 38 cases (32.2%) had mixed delirium.

WANGET AL. 3 of 8