Neuroleptics in the management of delirium in patients with advanced cancer

Abstract

Purpose of review: Delirium is the most common and distressing neuropsychiatric syndrome in cancer patients. Few evidence-based treatment options are available due to the paucity of high quality of studies. In this review, we shall examine the literature on the use of neuroleptics to treat delirium in patients with advanced cancer. Specifically, we will discuss the randomized controlled trials that examined neuroleptics in the front line setting, and studies that explore second-line options for patients with persistent agitation.

Recent findings: Contemporary management of delirium includes identification and management of any potentially reversible causes, coupled with nonpharmacological approaches. For patients who do not respond adequately to these measures, pharmacologic measures may be required. Haloperidol is often recommended as the first-line treatment option, and other neuroleptics such as olanzapine, risperidone, and quetiapine represent potential alternatives. For patients with persistent delirium despite first-line neuroleptics, the treatment strategies include escalating the dose of the same neuroleptic, rotation to another neuroleptic, or combination therapy (i.e., the addition of a second neuroleptic or other agent). We will discuss the advantages and disadvantages of each approach, and the available evidence to support each strategy.

Summary: Adequately powered, randomized trials involving proper control interventions are urgently needed to define the optimal treatment strategies for delirium in the oncology setting.

Figures

Figure 1. Prognosis-Based Decision Making

The prevalence, etiology, treatment and outcomes associated with delirium may differ substantially depending on where the patient is along the disease trajectory. For instance, patients with years of survival often have reversible types of delirium (e.g. post-operative delirium) and may be preventable, patients with months of survival may be more likely to develop delirium as a result of medical illnesses, and patients with weeks to days of survival often have terminal delirium that is not reversible.