Neuro

Delirium in Cancer

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Delirium in Cancer, Delirium in Terminally Ill Patients, Cancer Related Delirium, Mental Status Changes Near End of Life, Terminal Delirium, Delirium in Palliative Care

  • See Also
  1. Delirium
  2. Altered Level of Consciousness
  3. Mood Disorders in Cancer
  • Epidemiology
  1. Delirium Incidence in terminally ill patients: 25 to 85%
  2. Sedation required in 25% of patients
  3. Reversible in 50% of patients
  • Causes
  1. Hypoxia (e.g. Atelectasis)
  2. Dehydration (Blood Urea Nitrogen >18 mg/dl)
  3. Hepatic Encephalopathy
  4. Brain Metastases
  5. Uncontrolled pain
  6. Constipation
  7. Electrolyte disturbance
    1. Hypercalcemia
    2. Hyponatremia
  8. Infection or fever
    1. Urinary Tract Infection
    2. Pneumonia
  9. Medications
    1. Opioid Withdrawal
    2. Benzodiazepine Withdrawal
    3. Corticosteroids
    4. Metoclopramide
    5. Antihistamines (Hydroxyzine, Diphenhydramine, Zantac)
    6. NSAIDs
    7. Tricyclic Antidepressants
    8. Scopolamine
  • Risk Factors
  1. Impaired Vision (Snellen Chart <20/70)
  2. Severe illness
  3. Cognitive Impairment (Mini-Mental State Exam <24)
  4. Major Depression (Mood Disorders in Cancer)
  5. Emotional stress
  6. Unfamiliar environment
  7. Immobilization
  • Management
  1. See Delirium
  2. Consider potentially reversible causes above
  3. Consider gentle rehydration if Dehydration suspected
  4. Consider circadian rhythm disturbance (day-night confusion with Agitation)
  5. Frequent reorientation
  6. Reduce risk factors above
  7. Family member or sitter presence may calm patient and reorientation
  8. Avoid precipitating events
    1. Avoid Physical Restraints
    2. Avoid Malnutrition
    3. Avoid adding more than three medications per day
    4. Avoid Bladder Catheterization
    5. Avoid frequent changes in environment or staff
  9. Evaluate for Polypharmacy
    1. Discontinue nonessential medications
  10. Consider medications for Delirium with Agitation refractory to other measures
    1. Haloperidol 0.5 to 5 mg PO, IV, SC, IM q2 to 12 hours
    2. Agents with adverse effects but long response delay
      1. Risperidone
      2. Clozapine
      3. Olanzapine
    3. Methadone in place of other Opioids
      1. Moryl (2005) Palliat Support Care 3(4): 311-7 [PubMed]
  11. Consider short-acting sedation if refractory to above (risk of paradoxical Agitation)
    1. Lorazepam
    2. Midazolam
    3. Other measures reportedly used include Propofol (caution!!)
  12. Comorbid condition considerations
    1. Cardiac disease (e.g. CHF, CAD)
      1. Prolonged QTc limits use of Antipsychotic agents (e.g. Agitated Delirium)
      2. Supplemental Oxygen in Hypoxia
    2. Lung Disease (e.g. COPD, ILD)
      1. Consider hypercarbia (CO2 Retention)
      2. Supplemental Oxygen in Hypoxia
    3. Renal disease (e.g. Chronic Kidney Disease, Acute Renal Failure)
      1. Evaluate for Electrolyte disturbance and Uremia
    4. Liver disease (e.g. end-stage Cirrhosis)
      1. Evaluate ammonia level
      2. Consider Lactulose titrated to loose stools (balance with quality of life)
    5. Neurologic disease (e.g. ALS, Dementia, Parkinsonism, stroke)
      1. Evaluate for Seizures
  • References
  1. Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
  2. Casarett (2001) Ann Intern Med 135:32-40 [PubMed]
  3. Lawlor (2000) JAMA 284:2427-9 [PubMed]
  4. McGregor (2025) Am Fam Physician 112(5): 493-503 [PubMed]
  5. Ross (2001) Am Fam Physician 64(6):1019-26 [PubMed]