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Delirium in Cancer
Aka: Delirium in Cancer, Delirium in Terminally Ill Patients, Cancer Related Delirium, Mental Status Changes Near End of Life
- See Also
- Delirium
- Altered Level of Consciousness
- Mood Disorders in Cancer
- Epidemiology
- Incidence in terminally ill patients: 25 to 85%
- Sedation required in 25% of patients
- Reversible in 50% of patients
- Causes
- Hypoxia (e.g. Atelectasis)
- Dehydration (Blood Urea Nitrogen >18 mg/dl)
- Hepatic Encephalopathy
- Brain Metastases
- Uncontrolled pain
- Constipation
- Electrolyte disturbance
- Hypercalcemia
- Hyponatremia
- Infection or fever
- Urinary Tract Infection
- Pneumonia
- Medications
- Opioid Withdrawal
- Benzodiazepine Withdrawal
- Corticosteroids
- Metoclopramide
- Antihistamines (Hydroxyzine, Diphenhydramine, Zantac)
- NSAIDs
- Tricyclic Antidepressants
- Scopolamine
- Risk Factors
- Impaired Vision (Snellen Chart <20/70)
- Severe illness
- Cognitive Impairment (Mini-Mental State Exam <24)
- Major Depression (Mood Disorders in Cancer)
- Emotional stress
- Unfamiliar environment
- Immobilization
- Management
- Consider potentially reversible causes above
- Consider gentle rehydration if Dehydration suspected
- Reduce risk factors above
- Family member or sitter presence may calm patient
- Avoid precipitating events
- Avoid Physical Restraints
- Avoid Malnutrition
- Avoid adding more than three medications per day
- Avoid Bladder Catheterization
- Avoid frequent changes in environment or staff
- Consider medications for Delirium with Agitation refractory to other measures
- Haloperidol 0.5 to 5 mg PO, IV, SC, IM q2 to 12 hours
- Agents with less side effects but long response delay
- Risperidone
- Clozapine
- Olanzapine
- Consider short-acting sedation if refractory to above (risk of paradoxical Agitation)
- Lorazepam
- Midazolam
- Other measures reportedly used include Propofol (caution!!)
- References
- Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
- Casarett (2001) Ann Intern Med 135:32-40 [PubMed]
- Lawlor (2000) JAMA 284:2427-9 [PubMed]
- Ross (2001) Am Fam Physician 64(6):1019-26 [PubMed]