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Delirium in the Cancer Patient A guide to identification, assessment, and treatment.

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Presentation on theme: "Delirium in the Cancer Patient A guide to identification, assessment, and treatment."— Presentation transcript:

1 Delirium in the Cancer Patient A guide to identification, assessment, and treatment

2 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

4 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

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

6 Delirium Types Hypoactive confusion, somnolence, alertness Hyperactive agitation, hallucinations, aggression Mixed (>60%) features of both

7 Prevalence of Delirium Common in terminally ill Steifel et al: 20% of medical in-pts Massie et al: >75% terminally ill Pereira et al: 44% on admission 62% at death 30% reversible

8 Incidence Gagnon et al, (J Pall Care 1998) 89 consecutive pts, CRS used 20% delirious on admission 30-40% during stay 44% reversed, >50% died in delirium Assd with high opioid dose

9 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

10 Delirium vs Dementia Delirium Impaired memory Impaired judgement Impaired thinking Disorientation Dementia Impaired memory Impaired judgement Impaired abst thinking Impaired cortical fn Disorientation

11 Delirium vs Dementia Delirium Abrupt onset Decreased LOC Sleep/wake cycle Reversible Dementia Insidious, progressive Alert, LOC intact Minimal Irreversible

12 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

13 Causes CNS effects: tumour seizures RT Indirect: Metabolic Ca ++ Na +, Na + K + Mg ++ O 2, CO 2

14 Causes Infection: pneumonia, sepsis Hematologic: Hgb, WBC, protein Metabolic encephalopathy: organ failure, paraneoplastic syndromes

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

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

17 Opioid-Induced Neurotoxicity (OIN) Neuropsychiatric syndrome Cognitive dysfunction Delirium Hallucinations Myoclonus/seizures Hyperalgesia/allodynia

18 OIN: Risk Factors High opioid doses Prolonged opioid treatment Borderline cognition/delirium Dehydration Renal failure Psychoactive drugs Advanced age

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

20 Treatment Opioid rotation Adjunct medications haloperidol (Haldol): mg q2-4 h PO/SC/IV/IM MTMZ (Nozinan): mg q2-4 h PO/SC/IM midazolam (Versed): 1-20 mg q2 h SC/IV or mg/24 h CSCI or CIVI

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

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

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

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