Diagnosis and management of delirium in hospital oncology services

https://doi.org/10.1016/j.jgo.2021.11.016Get rights and content

Abstract

The diagnosis of delirium in oncologic services is a challenge; nowadays, there is very little evidence-based information available to guide the medical personnel in the diagnosis and decision taking regarding delirium in the oncologic patient.

This article provides an updated review of the literature with extensive information on delirium in patients with cancer; the subject includes its definition, clinical features, precipitating and triggering factors, the frequency of delirium in oncological patients, its consequences, its treatment, and prognosis.

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

References (50)

  • T. Yamaguchi et al.

    Effect of parenteral hydration therapy based on the Japanese national clinical guideline on quality of life, discomfort, and symptom intensity in patients with advanced cancer

    J Pain Symptom Manage

    (2012)
  • Y. Lo et al.

    Risk factors of ifosfamide-related encephalopathy in adult patients with cancer: a retrospective analysis

    J Formos Med Assoc

    (2016)
  • W. Breitbart et al.

    An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients

    Psychosomatics.

    (2002)
  • A. Bohórquez Peñaranda et al.

    Tratamiento con antipsicóticos en la fase aguda del paciente adulto con diagnóstico de esquizofrenia

    Rev Colomb Psiquiatr

    (2014)
  • A. Elsayem et al.

    Subcutaneous olanzapine for hyperactive or mixed delirium in patients with advanced cancer: a preliminary study

    J Pain Symptom Manage

    (2010)
  • M.P. Abraham et al.

    Quetiapine for delirium prophylaxis in high-risk critically ill patients

    Surgeon

    (2021)
  • European Delirium Association, American Delirium Society

    The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer

    BMC Med diciembre de

    (2014)
  • Scottish Intercollegiate Guidelines Network et al.

    Risk reduction and management of delirium: a national clinical guideline

    (2019)
  • J.E. Wilson et al.

    Delirium

    Nat Rev Dis Primer diciembre de

    (2020)
  • M.L. Ramírez Echeverría et al.

    En: StatPearls [Internet]

    (2020)
  • S.H. Bush et al.

    Delirium in adult cancer patients: ESMO Clinical Practice Guidelines

    Ann Oncol

    (octubre de 2018)
  • E.M.P. Eeles et al.

    Hospital use, institutionalisation and mortality associated with delirium

    Age Ageing

    (2010)
  • M.G. Grandahl et al.

    Prevalence of delirium among patients at a cancer ward: clinical risk factors and prediction by bedside cognitive tests

    Nord J Psychiatry

    (2016)
  • American Psychiatric Association.

    Guía de consulta de los criterios diagnósticos del DSM-5

    (2014)
  • S.D. Shenkin et al.

    Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

    BMC Med

    (2019)
  • Cited by (2)

    • Risk factors and effect of postoperative delirium on adverse surgical outcomes in older adults after elective abdominal cancer surgery in Taiwan

      2023, Asian Journal of Surgery
      Citation Excerpt :

      Postoperative delirium (POD) is a common surgical complication, with an incidence of 4%–41% in the general population1 and 8%–54% in older patients.2 POD is defined as an acute and fluctuating alteration in mental status.3 It may arise immediately in the recovery room or up to 5 days after surgery.4

    • Preventing and treating delirium in clinical settings for older adults

      2023, Therapeutic Advances in Psychopharmacology
    View full text