Elsevier

The Lancet Oncology

Volume 10, Issue 2, February 2009, Pages 164-172
The Lancet Oncology

Review
Palliating delirium in patients with cancer

https://doi.org/10.1016/S1470-2045(09)70018-XGet rights and content

Summary

Delirium is a frequent complication in oncology. Its definition as a disorder of consciousness, attention, and cognition is useful to elaborate a rational framework of its pathophysiology and to interpret the role of different aetiological factors and therapeutic interventions. Many aetiologies and an interaction between risk and predisposing factors have been shown to contribute to most cases of delirium. A screening of potential aetiologies is always mandatory to benefit reversible cases. The palliative treatment of symptoms of delirium includes non-pharmacological, environmental, and preventive interventions and the use of haloperidol. If haloperidol fails to control delirium, sedation with other drugs can be necessary. Specific attention to the qualitative aspects of care and to the effect of delirium on family members should be given in the overall assessment of the patient in his or her cancer trajectory.

Introduction

Delirium (figure 1) is one of the most common neurological complications seen in hospitalised patients with cancer.1 Its frequency in oncology compared with other medically ill populations is shown in table 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11 which highlights how elderly individuals and patients with advanced or terminal cancer are especially at risk from this complication. The probability of developing delirium is determined by the combined effect of predisposing or vulnerability factors, such as previous cognitive failure or dementia and age,4, 12 incident factors, such as drug toxicity and metabolic abnormalities, and other conditions that are more often associated with the severity of the underlying illness (figure 1). Delirium in cancer can be a challenging diagnosis, because it can be a reversible complication, it can herald the progression of the disease to the brain, and it can be irreversible as part of the terminal evolution of an incurable disease.

The aims of this Review are to clarify the definition of delirium, assess the pathophysiological aspects useful for its understanding and rational therapeutic strategy, and investigate specific aspects of its aetiology and management in patients with cancer. The comprehensive description of specific conditions, such as postoperative delirium and alcohol withdrawal syndrome, is not within the scope of this Review.

Section snippets

Diagnostic definition of delirium

Delirium is a brain syndrome only rarely associated with a specific brain lesion. The Diagnostic and Statistical Manual of Mental Disorders IV—Treatment Revision (panel 1) established the most commonly used diagnostic definition of delirium,12 which highlights a few core concepts—delirium is a disorder of consciousness and attention combined with abnormalities of cognition and perception. Delirium is an acute syndrome as opposed to dementia, and an organic cause affecting the brain is usually

Pathophysiology and aetiology

The pathophysiology of delirium remains to be fully elucidated, but the reticular formation of the brainstem, with its connection with the hypothalamus, thalamus, and diffuse effects on the cortex—regulating normal wakefulness and sleep—is thought to have a significant role. The neurotransmitters and receptors that are important for wakefulness and consciousness functions, and for toxic and pharmacological effects, are listed in panel 3.15, 22, 23, 24 Among the neurotransmitters, a central role

Assessment of cognitive functions

A formal assessment of cognitive function is needed in patients who develop acute mental status changes and would be desirable in routine monitoring of patients who are at an especially high risk of developing delirium. Although there are a plethora of assessment instruments that are potentially useful,24 the most interesting and practically useful are restricted to a few. The Mini-mental State Exam is sensitive to changes in cognition and includes items that explore temporal orientation and

Non-pharmacological interventions

Screening potentially reversible aetiological factors is a mandatory initial step in all cases of delirium. Even in the advanced phase of cancer, 50% of delirium episodes are reversible, especially when associated with drug toxicity.9 It is important to remember that providing safety, companionship, orientation, a quiet environment, emotional support to both the patient and the care-givers, and a caring relationship can avoid pharmacological and eventually physical restraint in many patients

Effect of delirium on family and care-givers

Delirium is regarded by family and care-givers as a difficult experience to witness.71 In one study, high levels of distress were reported by spouses and by the nurses caring for patients with delirium.72 In a multicentre Japanese study, 50% of family members reported being emotionally distressed about the experience of terminal delirium.73, 74 The same researchers also identified some aspects of care that were perceived as important in this situation by family members, including: respect for

Conclusion

Delirium is a demanding clinical condition that complicates the history of patients with cancer. Strategies for early detection, prevention, and management are still insufficient. Careful diagnostic assessment and appropriate care should be combined to meet the needs of patients with different clinical perspectives and disease burden. An interdisciplinary approach to the clinical management and research of delirium would enhance our understanding of a syndrome that covers many disciplines of

Search strategy and selection criteria

Articles for this Review were identified by a search of Medline, Current Content, and Pubmed by use of the search terms “delirium”, “cancer”, and “delirium and neoplasm”, and by a hand search of major textbooks and three monographic books on delirium. References from identified articles were selected for relevance, with priority given to systematic reviews and meta-analyses. Only articles published in English between 1990, and 2008, were included, unless necessary to support specific

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