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  • Review Article
  • Published:

Delirium in patients with cancer: assessment, impact, mechanisms and management

Key Points

  • Delirium occurs often in patients with cancer, especially in advanced-stage disease, owing to acute precipitating factors such as infection or medication effects

  • These precipitating factors are superimposed on predisposing factors, such as advanced-stage cancer, old age or pre-existing or evolving dementia

  • Impeded communication due to delirium generates distress for patients and their families, and challenges for health-care personnel; tools exist to assist practitioners in screening, diagnosing and monitoring delirium in cancer care

  • Delirium might be partly or completely reversible, depending on how modifiable its precipitating factors are, and whether investigation and treatment of these factors is consistent with the goals of care

  • Decisions regarding the level of intervention in a delirium episode are influenced by the practitioner's estimate of prognosis and the agreed goals of care

  • Mechanisms underlying delirium are complex, but the approach to symptom control is based on the use of antidopaminergic and antipsychotic agents; patients with nonreversible delirium can require continuous sedation with agents such as midazolam

Abstract

Delirium is a frequent neurocognitive complication in patients with cancer, particularly in patients with advanced-stage disease (in whom a combination of factors might trigger an episode) and in patients with a high degree of predisposing vulnerability, such as the elderly or patients with dementia. The communicative impediments associated with delirium generate distress for the patient and their family, and substantive challenges for health-care practitioners, who might have to contend with agitation, and difficulty in assessing pain and other symptoms. Validated assessment tools exist for screening, diagnosing and monitoring the severity of delirium in cancer care. The level of investigative and therapeutic intervention in a delirium episode is determined by the patient's estimated prognosis and the agreed goals of care. Although delirium is ominously associated with the terminal phase of life, part or complete reversal can be possible depending on the nature of the precipitating factors, and on whether investigation and treatment of these factors is consistent with the established goals of care. Pharmacological treatment for symptom control is indicated for most patients with delirium, and antipsychotics are the drugs of choice, but some patients with refractory and nonreversible delirium can require continuous deep sedation with agents such as midazolam.

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Figure 1: Strategic interventions in the clinical pathway of delirium in a patient with cancer.

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Jo Ellen Wilson, Matthew F. Mart, … E. Wesley Ely

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Acknowledgements

P.G.L. and S.H.B. receive research awards from the Department of Medicine, University of Ottawa. P.G.L. also receives research support from the Gillin Family and the Bruyère Foundation. Both authors receive administrative research support through the Bruyère Research Institute.

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Lawlor, P., Bush, S. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 12, 77–92 (2015). https://doi.org/10.1038/nrclinonc.2014.147

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