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
ReviewPalliating delirium in patients with cancer
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
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Cited by (71)
Diagnosis and management of delirium in hospital oncology services
2022, Journal of Geriatric OncologyCitation Excerpt :Delirium is a life-threatening condition, but it can often be prevented. Due to the high prevalence of delirium in patients with cancer and its inappropriate outcomes, special attention should be paid to making the diagnosis in order to provide timely management [10]. The presence of delirium in patients with cancer worsens the prognosis and is associated with an increased risk of complications, longer length of hospital stay, and prolonged use of mechanical ventilation [30], thus deteriorating the quality of life of the patient and their family.
Skilled nursing facility placement in hospitalized elderly patients with colon cancer
2016, European Journal of Surgical OncologyCitation Excerpt :Psychoses and delirium are frequent complications of cancer-related hospitalizations, resulting in poor healthcare outcomes including increased mortality.27 Recent evidence suggests the incidence of psychoses and delirium is as high as 30% in geriatric cancer hospitalizations.28 Our data suggests delirium increases hospitalization cost, LOS and odds of SNF placement.
Prevalence of delirium in patients with advanced cancer admitted to a palliative care unit
2016, Medicina PaliativaPalliative Care in the Emergency Department
2015, Critical Care Nursing Clinics of North AmericaAn analytical framework for delirium research in palliative care settings: Integrated epidemiologic, clinician-researcher, and knowledge user perspectives
2014, Journal of Pain and Symptom ManagementCitation Excerpt :This case highlights some of the contextual issues in palliative care relating to assessment, diagnosis, management, impact, and outcome of delirium. The clinical manifestations of delirium in the palliative care population may vary widely and thus present some unique diagnostic and classification challenges.17,21 The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association has been the mainstay in generating diagnostic criteria for delirium, and the 5th edition, DSM-5, has recently been published (Table 2).22
Treating an established episode of delirium in palliative care: Expert opinion and review of the current evidence base with recommendations for future development
2014, Journal of Pain and Symptom ManagementCitation Excerpt :The most common medications used to effect sedation for refractory delirium at the end of life are methotrimeprazine, chlorpromazine, midazolam, and phenobarbital.129 Methotrimeprazine (levomepromazine), a phenothiazine, is often used in agitated delirium at the end of life, in which its sedative properties and subcutaneous route of administration are advantageous.87,130,131 However, it is not available worldwide including in the United States.