Diagnosis and management of delirium in hospital oncology services
Introduction
Delirium is an earnest problem in hospital-care and it is considered a vulnerability marker associated to adverse results in patients who suffer from it, due to decompensation at brain level in response to a pathophysiological stressor [1]. In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), delirium has been included in the category of a neurocognitive and neuropsychiatric syndrome [2].
The definition of delirium has changed over time. One of the diagnostic criteria has been the variability in the conscience. But nevertheless, due to its difficulty to objectify it, the DSM-5 has erased this variable. It recognizes the importance of the attention and behavior changes in the diagnosis of delirium, but in the opinion of the authors, all states of alert alteration (except coma) should be included in the delirium spectrum for scientific, practical and clinical safety reasons.
DSM-5 has determined the following for delirium diagnosis: a) disturbance of attention (a reduced capacity for focusing during daily life), b) development in a short time span (hours or days) with fluctuation in attention and alertness throughout the day, c) cognitive disturbance (memory deficit, disorientation, language, visuospatial ability, or perception). DSM-5 warns about how cognition and attention alterations cannot be due to a pre-existing or developing neurocognitive disorder and cannot happen in a patient in coma [1].
Delirium is one of the most common medical emergencies, its prevalence is even bigger in hospitalized and ICU patients [3] and is common in the elderly population and in people with cancer, especially in its advanced stages and even in the last hours of life [[4], [5], [6]]. The presence of delirium is associated with a higher risk of mortality, increased morbidity, and is a situation that generates distress for the patient, its family, and caregivers; however, there are few studies on the presence of delirium in older patients with cancer, therefore, in some publications these consequences are extrapolated to the older patients with oncological pathology [7]. This is why it is important to recognize and treat it, even if it is difficult to find and eliminate its cause [8].
This article contains an updated review of delirium in patients with cancer, emphasizing its early diagnosis, prevention, and treatment.
Section snippets
Definition and Classification of Delirium
Delirium is a neurocognitive and neuropsychiatric syndrome characterized by a disturbance in attention and reduced orientation to the environment, the disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day and additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception), is not
Epidemiology
The incidence of delirium in patients with advanced cancer is highly variable; in some studies, up to 88% is reported in the last weeks of life, hypoactive delirium being more common [6]. The highest incidence of delirium is found in patients in the intensive care and palliative care units, although these data are very likely underestimated because patients with cognitive impairment or underlying dementia, who are from the most vulnerable groups, are rarely included in studies [9].
Regarding the
Risk Factors for Delirium in Patients with Cancer
Risk factors for delirium in patients with cancer have been classified as direct and indirect (Fig. 1).
Among the direct risk factors are: a) those related to cancer (primary or secondary tumors of the central nervous system, brain or meningeal metastases, paraneoplastic neurological syndromes), b) those related to the toxicity of cancer treatments (brain radiation therapy or chemotherapy with methotrexate, cisplatin, vincristine, asparaginase, 5-fluorouracil, ifosfamide, etoposide). Among the
Clinical Features and Diagnosis of Delirium
Delirium is considered a neurological emergency, it also affects executive functions and predisposes to later cognitive deterioration, increases the risk of mortality and the need for institutionalization [27]; the above demonstrates the priority of making a timely diagnosis. Delirium can be hypoactive; hyperactive or mixed, hypoactive is the most difficult to identify, for both the health personnel and relatives of the patient, due to the lack of symptoms that suggest its presence [1].
The
Delirium in Hospital Oncology Services
In a study by Bond SM et al. (2012), it is noted that there are differences in prevalence in patients with cancer and delirium according to the environment studied, as follows: in outpatients between 33 and 70 years of age it reaches 8.6%, in the 10% emergency service, in general hospitalization wards it reaches 43%, and in palliative care units the prevalence is 42% [29]. The prevalence of delirium in patients with cancer increases with age [9].
Hospitalized patients who develop delirium are at
Management of Delirium in Oncology
In patients with cancer, it has been found that 20 to 50% of the causes of delirium are reversible. It is recommended to make a comprehensive evaluation with an excellent clinical history, complete physical examination, pharmacological treatment and document alterations in the laboratory and images according to the patient's need [6]. Treatment of delirium is addressed from a pharmacological and non-pharmacological approach, as described below.
a. Non-pharmacological treatment
The
Prevention
Considering delirium is a serious and potentially fatal disorder, particularly in hospitalized patients; it is key to remember that it can be prevented in 30 to 40% of the cases, being this the most cost-effective strategy to minimize both its occurrence and its associated negative consequences [2]. Incidence of delirium can be reduced through interventions that decrease the exposure to known risk factors. The incidence of Delirium can be reduced through interventions aimed at decreasing
Suggestions for the Future
It is acknowledged that delirium is very common in hospitalized patients with oncologic pathologies and the appropriate use of diagnostic tools allows for its early identification. For this reason, it is necessary to increase the education, sensitization of staff and implementation of an adequate diagnosis in the oncology departments in order to achieve a positive impact on an opportune and correct treatment of delirium in this group of patients. We must be aware that to successfully treat the
Declaration of Competing Interest
None.
Acknowledgements
Special thanks to Lucas Ruano Ramírez for helping with the translation of the article.
Author Contributions
Contribution Name(s) of author(s)
Study concepts AA-I, FB.
Study design AA-I, FB, MO’R, FK.
Data acquisition AA-I.
Quality control of data and algorithms AA-I, MO’R.
Data analysis and interpretation AA-I, FB, FK, MO’R, HJ, GW.
Statistical analysis AA-I, FB.
Manuscript preparation AA-I, FB, MO’R, FK.
Manuscript editing AA-I, FB, FK, MO’R, GW.
Manuscript review All authors
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