Evidence-based treatment of delirium in patients with cancer

Abstract

Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

Conflict of interest statement

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Figures

Fig 1.

Clinical features of delirium in patients with cancer. Adapted from Breitbart and Alici.

Fig 2.

Recommendations on monitoring patients with cancer who have delirium for antipsychotic adverse effects. Recommendations are based on the Consensus Development Conference on antipsychotic drugs and obesity and diabetes. (*) The risk of QT prolongation is directly correlated with higher antipsychotic doses, with parenteral formulations (eg, intravenous haloperidol) of antipsychotics, and with certain medications (eg, ziprasidone, thioridazine). In individual patients, an absolute QTc interval of 500 ms or an increase of 60 ms (or more than 20%) from baseline is regarded as indicating an increased risk of torsades des pointes. Discontinuation of the antipsychotic and a consultation with a cardiologist should be considered, especially if there is continued need for the use of antipsychotics.

Fig 3.

Summary of nonpharmacologic interventions used in the prevention and treatment of delirium.–,,– (*) Physical restraints should be avoided both in patients who are at risk for developing delirium and in those who have delirium. The use of physical restraints has been identified as an independent risk factor for delirium persistence at the time of hospital discharge (Inouye, et al: Arch Intern Med 167:1406-1413, 2007). Restraint-free care should be the standard of care for prevention and treatment of delirium among cancer patients.

Fig 4.

Evidence-based management recommendations for patients with cancer with delirium.