How is delirium in cancer patients managed?

Management of Delirium in Cancer Patients

The management of delirium in cancer patients requires first identifying and addressing potentially reversible causes through a comprehensive initial assessment, followed by non-pharmacological interventions, and if needed, appropriate pharmacological treatment with atypical antipsychotics like olanzapine, quetiapine, or aripiprazole rather than haloperidol or risperidone. 1

Diagnosis and Assessment

• Diagnosis should be made by a trained healthcare professional using DSM or ICD criteria 1
• Look for:
  • Acute onset and fluctuating course
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness 2
• While screening tools exist, evidence is insufficient to recommend their routine use in cancer patients 1

Management Algorithm

Step 1: Identify and Address Reversible Causes

• Conduct comprehensive initial assessment to identify predisposing and precipitating factors 1
• Common reversible causes in cancer patients:
  • Medications (particularly opioids)
  • Infections
  • Metabolic disturbances
  • Hypercalcemia
  • Hypomagnesemia
  • SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
  • Cancer treatments (chemotherapy, immunotherapy) 1, 2

Step 2: Implement Specific Interventions for Identified Causes

• Opioid-induced delirium: Rotate opioids to fentanyl or methadone 1
• Hypercalcemia: Administer IV bisphosphonates (pamidronate or zoledronic acid) 1
• SIADH: Discontinue implicated medications, implement fluid restriction, ensure adequate oral salt intake 1
• Hypomagnesemia: Provide magnesium replacement 1
• Infection: Treat if consistent with patient's goals of care and illness trajectory 1
• Medication-induced: Withdraw medications related to anticancer treatments 1

Step 3: Implement Non-Pharmacological Interventions

• Reorientation strategies (orientation boards, visible clocks)
• Environmental stability (minimize transfers, consistent care teams, reduce noise)
• Manage sensory deficits (ensure access to glasses and hearing aids)
• Early mobilization
• Regulate sleep-wake cycles 2

Step 4: Consider Pharmacological Management (if non-pharmacological approaches insufficient)

• First-line options (for symptomatic management):

  • Olanzapine (2.5-5 mg PO or SC) 1, 2, 3
  • Quetiapine (25 mg immediate release) 1, 2
  • Aripiprazole (5 mg PO or IM) 1, 2

• For hypoactive delirium without delusions or perceptual disturbances:

  • Consider methylphenidate 1, 4

• For severe symptomatic distress:

  • Benzodiazepines can provide sedation and anxiolysis 1

• Avoid:

  • Haloperidol and risperidone in mild-to-moderate delirium (shown to worsen symptoms) 1, 2

Special Considerations

Refractory Delirium in Actively Dying Patients

• Delirium is usually refractory in the dying phase
• Focus on symptom management rather than reversibility 1

Education and Support

• Provide relatives with information about delirium pre-emptively, especially if patient's condition is declining 1
• Implement interprofessional delirium education interventions as part of a unit- or hospital-wide strategy 1

Common Pitfalls to Avoid

• Underrecognition of hypoactive delirium (less obvious than hyperactive form)
• Overreliance on medications without addressing underlying causes
• Using haloperidol or risperidone for mild-to-moderate delirium 1, 2
• Failing to consider opioid rotation when opioids are implicated 1
• Neglecting family education and support 1

Prognosis

• Delirium occurs in 26-44% of cancer patients admitted to hospital or hospice
• Over 80% of advanced cancer patients eventually experience delirium in their final days
• Excluding terminal delirium, up to 50% of cases may be reversible in advanced cancer patients 4

By systematically addressing underlying causes, implementing non-pharmacological interventions, and using appropriate pharmacological management when necessary, the impact of delirium on cancer patients' morbidity, mortality, and quality of life can be significantly improved.