Delirium in the Cancer Patient

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Delirium in the Cancer Patient

• A guide to identification, assessment, and
  treatment

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Delirium

• Definition
• Recognition
• Screening/diagnostic tools
• Etiologic factors
• Treatment of underlying cause
• Prevention

3
Definition

• Etiologically non-specific global cerebral
  dysfunction associated with changes in LOC,
  attention, thinking, perception, memory,
  psychomotor behavior, emotion and the sleep/wake
  cycle

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DSM-IV Criteria

• A) Change in consciousness with reduced ability
  to focus, sustain or shift attention
• B) Change in cognition (e.g., memory,
  disorientation, change in language, perceptual
  disturbance) that is not dementia
• C) Abrupt onset (hours to days) with fluctuation
• D) Evidence of medical condition judged to be
  etiologically related to disturbance

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Characteristics

• Abrupt onset
• Disorientation, fluctuation of symptoms
• Hypoactive vs hyperactive vs mixed
• Early signs often mistaken as
• anger, anxiety, depression, psychosis

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Delirium Types

• Hypoactive
• confusion, somnolence, ? alertness
• Hyperactive
• agitation, hallucinations, aggression
• Mixed (gt60)
• features of both

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Prevalence of Delirium

• Common in terminally ill
• Steifel et al 20 of medical in-pts
• Massie et al gt75 terminally ill
• Pereira et al 44 on admission
• 62 at death
• 30 reversible

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Incidence

• Gagnon et al, (J Pall Care 1998)
• 89 consecutive pts, CRS used
• 20 delirious on admission
• 30-40 during stay
• 44 reversed, gt50 died in delirium
• Assd with high opioid dose

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Incidence

• Lawlor et al (J Pall Care 1998)
• 103 pts, MDAS used
• 50 of episodes reversible
• Terminal delirium in 88
• Hyperactive (3) vs hypoactive (47)
• Mixed (48) most common

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Delirium vs Dementia

• Delirium
• Impaired memory
• Impaired judgement
• Impaired thinking
• Disorientation

• Dementia
• Impaired memory
• Impaired judgement
• Impaired abst thinking
• Impaired cortical fn
• Disorientation

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Delirium vs Dementia

• Delirium
• Abrupt onset
• Decreased LOC
• Sleep/wake cycle ?
• Reversible

• Dementia
• Insidious, progressive
• Alert, LOC intact
• Minimal ?
• Irreversible

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Screening Tools

• Delirium Rating Scale
• temporal onset
• perceptual ?
• hallucinations
• psychomotor behavior
• cognitive status
• mood lability
• variability of symptoms

• MMSE
• orientation
• registration
• attention/calculation
• recall
• language

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Causes
CNS effects tumour seizures RT Indirect M
etabolic Ca Na, Na K Mg
O2, CO2
14
Causes

• Infection
• pneumonia, sepsis
• Hematologic
• ? Hgb, ? WBC, ? protein
• Metabolic encephalopathy
• organ failure, paraneoplastic syndromes

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Causes

• Endocrine
• hyper/hypothyroidism, Cushing syndrome
• Drug withdrawal
• alcohol, narcotics, hallucinogens
• Immunologic
• SLE, vasculitis
• Nutritional deficiencies

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Drug Causes

• Chemotherapy
• MTX, 5FU, VCR/VBL, Bleo, Plat, IL-2
• Steroids
• Opioids
• BZD, phenothiazines
• Anti-cholinergics (Gravol, Elavil)
• Anti-virals

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Opioid-Induced Neurotoxicity (OIN)

• Neuropsychiatric syndrome
• Cognitive dysfunction
• Delirium
• Hallucinations
• Myoclonus/seizures
• Hyperalgesia/allodynia

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OIN Risk Factors

• High opioid doses
• Prolonged opioid treatment
• Borderline cognition/delirium
• Dehydration
• Renal failure
• Psychoactive drugs
• Advanced age

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Treatment

• Stop any offending Rx
• Hydration (oral, IV, SC)
• Correct metabolic abnormalities
• Structured setting
• quiet room, low lights, calendar, clock
• Family support

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Treatment

• Opioid rotation
• Adjunct medications
• haloperidol (Haldol) 0.5-5 mg q2-4 h
  PO/SC/IV/IM
• MTMZ (Nozinan) 12.5-50 mg q2-4 h
  PO/SC/IM
• midazolam (Versed) 1-20 mg q2 h SC/IV or
  30-100 mg/24 h CSCI or CIVI

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Sedation in Terminal Delirium
Mild haloperidol 1-2 mg PO/SC q8h plus q1h
prn Moderate haloperidol 2.5 - 5 mg SC
q4h plus q1h prn midazolam 2.5 - 5
mg Severe haloperidol 5 mg SC
q4h plus q1h prn midazolam 5 - 20 mg OR CSCI
or CIVI haloperidol 1.25 mg/hr
midazolam 1.25 - 5 mg/hr
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Prevention

• Staff and family awareness
• Structured settings
• Minimize use of medications
• Opioid rotation
• Hydration

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Algorithm
Agitation ? cognition ? LOC
Confirm with tool MMSE/DRS/CRS
Reversible cause? Investigations
Interventions Medications Prevention