Delirium as a contributing factor to "crescendo" pain: three case reports

Treatable complications of cancer patients referred to an in-patient hospice

This paper illustrates the importance of accurate diagnoses and treatments of complications in terminally ill cancer patients. The paper reports on five hospice in-patients who completely recovered from life-threatening complications; three of them had been incorrectly labeled as “imminently dying” by the referring physicians.

The paper concludes that it would be beneficial for patients to receive examinations and a trial of medical treatment in their continuing treatment settings.

A comprehensive review of palliative care in patients with cancer

One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.

Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice

Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.

Pre- and post-transplantation risk factors for delirium onset and severity in patients undergoing hematopoietic stem-cell transplantation

PURPOSE

To determine pre- and post-transplantation risk factors for delirium onset and severity during the acute phase of myeloablative hematopoietic stem-cell transplantation (HSCT).

PATIENTS AND METHODS

Ninety adult patients with malignancies admitted to the Fred Hutchinson Cancer Research Center for their first HSCT were assessed prospectively from 1 week before transplantation to 30 days after transplantation. Delirium was assessed three times per week using the Delirium Rating Scale and the Memorial Delirium Assessment Scale. Potential risk factors were assessed by patient self-report, charts, and computerized records. Multivariable analysis of time to onset of a delirium episode was undertaken using Cox proportional hazards regression with time-varying covariates. Analysis for delirium severity was carried out using a linear mixed effects model. Validation and sensitivity analyses were performed on the final models.

RESULTS

Forty-five patients (50%) experienced a delirium episode. Pretransplantation risk factors for onset and higher severity of delirium were higher mean alkaline phosphatase and blood urea nitrogen (BUN) levels. Poorer pretransplantation executive functioning was also associated with higher delirium severity. Higher doses of opioid medications were the only post-transplantation risk factor for delirium onset (hazard ratio, 1.05; 95% CI, 1.02 to 1.08). Higher opioid doses, current and prior pain, and higher BUN levels were post-transplantation risk factors for greater delirium severity (all P < .01).

CONCLUSION

Pre- and post-transplantation factors can assist in identifying patients who are at risk for delirium during myeloablative HSCT and may enable clinical interventions to prevent delirium onset or decrease delirium symptoms.

Ease of screening for depression and delirium in patients enrolled in inpatient hospice care

BACKGROUND

Major depression and delirium are prevalent, underrecognized, and undertreated in hospice and palliative care settings. Furthermore, they are both associated with significant morbidity and mortality.

OBJECTIVE

A screening study of patients receiving inpatient hospice care was conducted in order to determine the ease of screening for depression and delirium in patients with advanced, life-threatening illnesses by hospice social workers and nurses, respectively.

METHODS

A two-question depression screening tool was administered to 20 consecutive patients on admission to a hospice general inpatient care center by social work staff during their initial assessment. A delirium-screening tool was administered daily to 22 consecutive patients admitted to the ICC daily by nursing staff. Screening results were collected, as were patient and staff feelings about the burden of the screening process.

RESULTS

Of the 20 patients screened on admission for depression by social work, 70% (14/20) screened positive. Of the 22 patients screened daily for delirium by nursing, 64% (14/22) screened positive at least once during their admission. Screening for both conditions was considered relatively easy to accomplish by the hospice staff. There were no significant associations between a positive screen of depression or delirium and patient gender, age, ethnicity, terminal diagnosis, or marital status.

DISCUSSION

These results support the notion that depression and delirium are very common in hospice inpatients, and that screening for both is relatively easy and practical for hospice clinicians to conduct.

Impact of delirium on decision-making capacity after hematopoietic stem-cell transplantation

BACKGROUND

Delirium is a common complication of myeloablative hematopoietic stem-cell transplantation (HSCT), yet no studies have explored the later effects of an episode of delirium in this setting on patients' decision-making capacity after the acute symptoms of delirium have resolved.

OBJECTIVE

The authors assessed the impact of delirium during the acute phase of myeloablative HSCT on later decision-making capacity.

METHOD

Decision-making capacity was assessed with the MacArthur Competence Assessment Tool in 19 patients before they received their first HSCT and at 30 and 80 days post-transplantation. Delirium was assessed 3 times per week with the Delirium Rating Scale and the Memorial Delirium Assessment Scale from 7 days pre-transplantation through 30 days post-transplantation.

RESULTS

Although there was little variance in the pre-treatment scores, with most patients showing very high or perfect scores on decision-making abilities, a multivariate regression model showed that delirium was predictive of a lower reasoning score at Day 30 post-transplantation.

CONCLUSION

Patients who experienced a delirium episode during the acute phase of HSCT were not likely to develop clinically meaningful impairments in decision-making capacity post-transplantation, although they evidenced minor impairment in their reasoning ability.

Impact of delirium on cognition, distress, and health-related quality of life after hematopoietic stem-cell transplantation

PURPOSE

To determine the impact of delirium during the acute phase of myeloablative hematopoietic stem-cell transplantation (HSCT) on health-related quality of life (HRQOL), distress, and neurocognitive functioning 30 and 80 days after transplantation.

PATIENTS AND METHODS

Ninety patients completed a battery assessing HRQOL, distress, and neuropsychological functioning before receiving their first HSCT. Delirium was assessed three times per week using the Delirium Rating Scale and the Memorial Delirium Assessment Scale from 7 days before transplantation through 30 days after transplantation. At 30 days after transplantation, distress and neurocognitive functioning were assessed. At 80 days after transplantation, HRQOL, distress, and neuropsychological functioning were re-evaluated.

RESULTS

After adjusting for confounding factors, patients who experienced a delirium episode, versus patients who did not, reported significantly worse depression, anxiety, and fatigue symptoms at 30 days (linear regression beta(s) = 0.2, 0.3, and 0.5, respectively; P < .04). At 80 days, patients with a delirium episode had significantly worse executive functioning (beta = -1.1; P < .02), attention and processing speed (beta(s) = -4.7 and -5.4, respectively; P < .03), mental health on the Medical Outcomes Study Health Survey, 12-item short form (beta = -6.5; P < .02), and anxiety, fatigue, and cancer and treatment distress symptoms (beta(s) = 0.4, 0.6, and 0.3, respectively; P < .03).

CONCLUSION

Patients with a malignancy who experience delirium during myeloablative HSCT showed impaired neurocognitive abilities and persistent distress 80 days after transplantation. Effective prevention or treatment of delirium during HSCT may improve both cognitive and psychological outcomes.

Symptom control in palliative care--Part I: oncology as a paradigmatic example

Achieving the best quality of life for patients and their families when a disease becomes progressive and no longer remains responsive to curative therapy is the primary goal of palliative care. A comprehensive care plan focusing on control of physical symptoms as well as psychological, social, and spiritual issues then becomes paramount in that context. Symptom assessment and treatment are a principle part of palliative care. This paper is the first of three in a series addressing non-pain symptoms, which are frequently encountered in the palliative care populations. The most frequent non-pain symptoms are constipation, chronic nausea and vomiting, anorexia, dyspnea, fatigue, and delirium. As symptoms are subjective, their expression varies from patient to patient, depending on the individual patient's perception and on other factors such as psychosocial issues. While symptoms are addressed individually, patients frequently have multiple coexisting symptoms. Generally told, once the intensity of a symptom has been assessed, it is necessary to assess the symptom in the context of other symptoms such as pain, appetite, fatigue, depression, and anxiety. Given that fact, adopting a multidimensional assessment allows for formulation of a more effective therapeutic strategy. More pertinently, this paper highlights the management of non-pain symptoms as an integral part of patient care and reviews the pathophysiologies, causes, assessment, and management of constipation, chronic nausea, and vomiting, each of which is common among the palliative care population.

Psychologic issues in palliative care

As medical science progresses and the life spans of patients with serious illnesses increase, the process that leads to death is becoming more feared than death itself. This fear is particularly intense in technologically advanced cultures with access to advanced medical care. The lives of patients who previously would have died rapidly are now often extended. As a result, images of suffering, such as dying in isolation and experiencing great pain, often are at the forefront of concerns about those struggling with terminal illnesses. This article provides medical practitioners with an overview of the issues and symptoms common in terminal illness, to help them work most effectively with their mental health colleagues.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Delirium in advanced cancer patients

Delirium in advanced cancer is often poorly identified and inappropriately managed. It is one of the most common causes for admission to clinical institutions and is the most frequently cited psychiatric disorder in terminal cancer. Diagnosis of delirium is defined as a disturbance of consciousness and attention with a change in cognition and/or perception. In addition, it develops suddenly and follows a fluctuating course and it is related to other causes, such as cancer, metabolic disorders or the effects of drugs. Delirium occurs in 26% to 44% of cancer patients admitted to hospital or hospice. Of all advanced cancer patients, over 80% eventually experience delirium in their final days. In advanced cancer, delirium is a multifactorial syndrome where opioids factor in almost 60% of episodes. Delirium in such patients, excluding terminal delirium, may be reversible in 50% of cases. Providing adequate end-of-life care for a patient with delirium is the main challenge. The family needs advice and it is important to create a relaxing environment for the patient. The primary therapeutic approach is to identify the reversible causes of delirium. Some therapeutic strategies have been shown to be effective: reduction or withdrawal of the psychoactive medication, opioid rotation, and hydration. Haloperidol is the most frequently used drug, and new neuroleptics such as risperidone or olanzapine are being tested with good results. Methylphenidate has been used for hypoactive delirium.

Demographics, assessment and management of pain in the elderly

The prevalence of pain increases with each decade of life. Pain in the elderly is distinctly different from pain experienced by younger individuals. Cancer is a leading cause of pain; however, other conditions that cause pain such as facet joint arthritis (causing low back pain), polymyalgia rheumatica, Paget's disease, neuropathies, peripheral vascular disease and coronary disease most commonly occur in patients over the age of 50 years. Poorly controlled pain in the elderly leads to cognitive failure, depression and mood disturbance and reduces activities of daily living. Barriers to pain management include a sense of fatalism, denial, the desire to be 'the good patient', geographical barriers and financial limitations. Aging causes physiological changes that alter the pharmacokinetics and pharmacodynamics of analgesics, narrowing their therapeutic index and increasing the risk of toxicity and drug-drug interactions. CNS changes lead to an increased risk of delirium. Assessment among the verbal but cognitively impaired elderly is satisfactorily accomplished with the help of unidimensional and multidimensional pain scales. A comprehensive physical examination and pain history is essential, as well as a review of cognitive function and activities of daily living. The goal of pain management among the elderly is improvement in pain and optimisation of activities of daily living, not complete eradication of pain nor the lowest possible drug dosages. Most successful management strategies combine pharmacological and nonpharmacological (home remedies, massage, topical agents, heat and cold packs and informal cognitive strategies) therapies. A basic principle of the pharmacological approach in the elderly is to start analgesics at low dosages and titrate slowly. The WHO's three-step guideline to pain management should guide prescribing. Opioid choices necessitate an understanding of pharmacology to ensure safe administration in end-organ failure and avoidance of drug interactions. Adjuvant analgesics are used to reduce opioid adverse effects or improve poorly controlled pain. Adjuvant analgesics (NSAIDs, tricyclic antidepressants and antiepileptic drugs) are initiated prior to opioids for nociceptive and neuropathic pain. Preferred adjuvants for nociceptive pain are short-acting paracetamol (acetaminophen), NSAIDs, cyclo-oxygenase-2 inhibitors and corticosteroids (short-term). Preferred drugs for neuropathic pain include desipramine, nortriptyline, gabapentin and valproic acid. Drugs to avoid are pentazocine, pethidine (meperidine), dextropropoxyphene and opioids that are both an agonist and antagonist, ketorolac, indomethacin, piroxicam, mefenamic acid, amitriptyline and doxepin. The type of pain, and renal and hepatic function, alter the preferred adjuvant and opioid choices. Selection of the appropriate analgesics is also influenced by versatility, polypharmacy, severity and type of pain, drug availability, associated symptoms and cost.

Delirium in patients with advanced cancer

Managing delirium is of major importance in end-of-life care and frequently gives rise to controversies and to clinical and ethical dilemmas. These problems arise from a number of causes, including the sometimes-poor recognition or misdiagnosis of delirium despite its frequent occurrence. Delirium generates major symptomatic of distress for the patient, consequent stress for the patient's family, the potential to misinterpret delirium symptomatology, and behavioral management challenges for health care professionals. Paradoxically, delirium is potentially reversible in some episodes, but in many patients delirium presents a nonreversible terminal episode. Greater educational efforts are required to improve the recognition of delirium and lead to a better understanding of its impact in end-of-life care. Future research might focus on phenomenology, the development of low-burden instruments for assessment, communication strategies, and the family education regarding the manifestations of delirium. Further research is needed among patients with advanced cancer to establish a predictive model for reversibility that recognizes both baseline vulnerability factors and superimposed precipitating factors. Evidence-based guidelines should be developed to assist physicians in more appropriate use of sedation in the symptomatic management of delirium.

The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses

We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.

An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients

We conducted an open, prospective trial of olanzapine for the treatment of delirium in a sample of 79 hospitalized cancer patients. Patients all met DSM-IV criteria for a diagnosis of delirium and were rated systematically with the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity, phenomenology, and resolution, over the course of a 7-day treatment period. Sociodemographic and medical variables and measures of physical performance status and drug-related side effects were collected. Fifty-seven patients (76%) had complete resolution of their delirium on olanzapine therapy. No patients experienced extrapyramidal side effects; however, 30% experienced sedation (usually not severe enough to interrupt treatment). Several factors were found to be significantly associated with poorer response to olanzapine treatment for delirium, including age >70 years, history of dementia, central nervous system spread of cancer and hypoxia as delirium etiologies, "hypoactive" delirium, and delirium of "severe" intensity (i.e., MDAS >23). A logistic-regression model suggests that age >70 years is the most powerful predictor of poorer response to olanzapine treatment for delirium (odds ratio, 171.5). Olanzapine appears to be a clinically efficacious and safe drug for the treatment of the symptoms of delirium in the hospitalized medically ill.

Olanzapine in the management of cancer pain

In cancer patients, cognitive impairment, psychological distress, and anxiety may accompany and aggravate pain. Neuroleptics are frequently used to control these symptoms and may be used to treat pain that has been unresponsive to more conventional approaches. Because of prominent side effects of traditional neuroleptics and conflicting data regarding their analgesic efficacy, their use in the treatment of pain remains controversial. Olanzapine, an atypical neuroleptic, might offer advantages because of its safer side effect profile. It has also been shown to have an independent antinociceptive activity in animals. The use of olanzapine in the management of cancer pain has not been previously described. We prospectively collected the data on 8 cancer patients with severe pain, uncontrolled in spite of aggressive opioid titration, who received olanzapine to treat severe anxiety and mild cognitive impairment. Patients did not meet criteria for delirium and their cognitive impairment was defined as cognitive disorder not otherwise specified (NOS) according to DSM-IV. Patients received 2.5 to 7.5 mg of olanzapine daily. In all patients, opioid requirements had escalated rapidly prior to starting olanzapine. Levels of pain, sedation, and opioid use were measured 2 days before and 2 days after olanzapine was started. Cognitive state was assessed daily. All 8 patients had marked reduction of the daily pain scores. The average daily opioid use decreased significantly in all patients. Cognitive impairment and anxiety resolved within 24 hours of initiating olanzapine. In these 8 patients, decreased pain scores and opioid requirements may have resulted from improvement in cognitive function and the known anxiolytic effect of olanzapine. Other mechanisms may include independent or adjuvant analgesic effects of olanzapine. We conclude that olanzapine may be useful in the treatment of patients with uncontrolled cancer pain associated with cognitive impairment or anxiety. Further studies to evaluate possible analgesic effect of olanzapine are needed.

The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients

Most cancer patients will experience pain requiring opioid therapy during their illness. Standard opioid therapy includes fixed scheduled doses and so-called "rescue" doses for breakthrough pain. Circadian rhythms seem to influence the expression of pain and the responsiveness to analgesic medication. Delirium is a common complication in advanced cancer patients and it also may modify the expression of pain and the use of analgesic medication. We reviewed the circadian distribution of breakthrough analgesia (BTA) doses in 104 advanced cancer patients who were part of a prospective study of the occurrence of delirium. We found that the circadian distribution of BTA is significantly different from a random distribution in the case of patients with and without delirium. Patients without delirium tended to use more BTA (P < 0.001) in the morning, whereas patients with delirium tended to use more BTA in the evening and at night (P = 0.02). We conclude that delirium is associated with changes in the circadian distribution of BTA, which is possibly related to reversal of the normal circadian rhythm.

Pain assessment and management

Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.

Donepezil in the treatment of opioid-induced sedation: report of six cases

Donepezil, an oral acetylcholinesterase inhibitor approved for the treatment of Alzheimer's disease, was given to 6 cancer pain patients having sedation related to the analgesic use of opioids. Each patient was taking more than 200 mg of oral morphine equivalents per day, and several were receiving complex analgesic regimens consisting of multiple adjuvant medications. Sedation improved at least moderately in 5 of the patients and mildly in 1 after they began taking donepezil. Patients reported a decrease in episodes of spontaneous sleeping during the day, fewer myoclonic twitches, improved daily function and greater social interaction. Several also reported improved sleep at night. Analgesia was not compromised by the use of donepezil, and in some cases it appeared improved. Donepezil may be a valuable alternative to psychostimulants in the treatment of opioid-induced sedation. A prospective controlled trial comparing the treatment effects of psychostimulants and donepezil on patients having opioid-induced sedation is underway.

Opioid poorly-responsive cancer pain. Part 1: clinical considerations

Pain that is poorly responsive to opioid analgesics is challenging for physicians who deal with cancer patients. Numerous factors may influence analgesic response during the course of the illness. These include changing nociception associated with disease progression, the appearance of intractable side effects, the development of tolerance, the presence of neuropathic pain, the temporal pattern, the effects produced by the production of opioid metabolites, and many others. These factors influence the delicate balance between pain relief and opioid toxicity that must be achieved in cancer patients with pain.

Symptom control in hospice--state of the art

There are a myriad of physical symptoms which can complicate the care of patients with advanced disease. Without knowledge of and attention to these distressing symptoms, the rest of the work of the interdisciplinary hospice team is greatly hampered. In this article, we review the management of ten prevalent symptoms in hospice care and to identify areas of clinical investigation underway and point of future areas ripe for investigation.

Delirium in patients with cancer at the end of life

PURPOSE

Delirium is a common and distressing syndrome seen in patients with advanced cancer. Behavioral manifestations of delirium, such as agitation, may result in medical intervention, stress to family caregivers, and inpatient hospice admission. The purpose of this study was to examine the frequency, characteristics, and presumed causes of delirium in patients with advanced cancer.

DESCRIPTION OF STUDY

Records of all patients with cancer who were admitted to an inpatient hospice facility in 1995 were reviewed retrospectively (N = 210). Patients were classified as delirious based on the clinical judgment of the admitting physician.

RESULTS

Delirium was the third most common reason for admission (20%). Male gender (P = .04) and the presence of a primary or metastatic brain tumor (P = .03) were significant risk factors for delirium, while advanced age and primary or metastatic liver, lung, or bone cancer were not. Resolution of the agitation, the most disruptive symptom of delirium, occurred in 69% of patients before death or discharge.

CLINICAL IMPLICATIONS

Delirium is common in hospice patients with cancer and is an important cause of family distress and increased cost of care. The recognition of early clinical signs and predisposing factors should facilitate prompt diagnosis. Appropriate intervention is usually successful in alleviating the most distressing symptoms of delirium.

Delirium in the terminally ill

Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.

Advances in pain management for older adult patients

Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.

Sedation for uncontrolled symptoms in a South African hospice

The need to sedate terminally ill patients for uncontrolled symptoms has been previously documented in a few reports. A retrospective consecutive chart review was undertaken at a hospice in Cape Town, South Africa, to develop an understanding of the local experience and assess the potential for improved patient management. Twenty-three of seventy-six (30%) patients received sedating therapies: twenty patients for delirium, two patients for delirium and dyspnea, and one patient for dyspnea alone. Fourteen patients were sedated with a continuous subcutaneous infusion of midazolam, seven patients with intermittent doses of benzodiazepines, and two patients with chlorpromazine and lorazepam. The mean midazolam dose was 29 mg per day (median 30 mg; range 15-60 mg per day). Patients were sedated on average 2.5 days before death (median 1 day; range 4 hours-12 days). The mean equivalent daily dose of parenteral morphine in the last week of life showed a significantly higher mean for the sedated group, as compared to the nonsedated group. There was minimal investigation of reversible causes for delirium, none of the patients underwent an opioid rotation, and the opioid dose was seldom decreased. None of the patients received parenteral hydration. The prevalence for the use of sedating treatment is consistent with the range of other literature reports. Nevertheless, the wide disparity in the reported prevalence of these problems, and the ethical concerns raised by the relative frequency of this sedative approach, cannot be ignored.

Predictive factors and opioid responsiveness in cancer pain

The management of cancer pain not readily responsive to morphine is often problematic. Several factors can interfere with an appropriate analgesic opioid response in the course of the illness, including the progression of the disease and tolerance, the appearance of intractable side-effects, type and temporal pattern of pain, morphine metabolites, pharmacokinetic and pharmacodynamic factors, as well as individual factors. Different methodologies capable of accurately predicting or monitoring opioid response have been proposed in an attempt to allow researchers to 'speak a common language'. Tolerance is a component of the concept of opioid responsiveness. However, the assessment of analgesic tolerance in cancer patients is constrained by numerous difficulties because of the changes in the noxious stimuli with increasing activity in nociceptive pathways.

Intravenous phenytoin in the management of crescendo pelvic cancer-related pain

Rapidly progressive pain, or "crescendo" pain, can be a difficult management problem. A cancer patient is presented who experienced crescendo neuropathic pain due to progressive pelvic disease. This patient reported significant pain relief with the administration of intravenous phenytoin. The case illustrates the type of therapeutic approach that may be considered for crescendo pain and highlights a potential role for intravenous phenytoin in the management of patients with crescendo cancer-related neuropathic pain.

A retrospective study of the psychiatric management and outcome of delirium in the cancer patient

This report describes the evaluation and treatment of delirium in the cancer patient in a major comprehensive cancer center. Ninety consecutive cases of delirium seen by the inpatient psychiatry consultation/liaison service were analyzed in a retrospective fashion to evaluate demographic information, alcohol use, central nervous system disease, coexisting medical disease, and past psychiatric history. Delirium cases were divided into hyperalert, hypoalert, and mixed subtypes. For these three subtypes, medication profiles including dose of medication, duration of delirium, outcome, and the venue where the delirium began were also evaluated. The hyperalert subtype of delirium was the commonest type observed (71%) and had the shortest duration (P < 0.0001) and best outcome (P < 0.001). The patients with a hyperalert delirium subtype were treated with the least amount of haloperidol (P < 0.0001). Patients were delirious for longer when the delirium began in the intensive-care units (P < 0.04). In general, patients who received no haloperidol experienced delirium of longer duration (P < 0.02) than those receiving haloperidol. Since the data represent patients who were referred for psychiatric treatment, this may explain the increased number of hyperalert deliriums and, therefore, the generalizability of the results is limited. Delirium in the cancer patient is particularly problematic given the coexisting medical problems these patients experience. Because the outcome of delirium is better when the duration is shorter, it is important for clinicians to be sensitive to early symptoms so that treatment can be implemented faster, leading to less morbidity and mortality.

Opioid therapy for chronic nonmalignant pain: a review of the critical issues

The controversy surrounding the long-term use of opioid drugs in patients with nonmalignant pain has intensified in recent years. This debate is driven by a new willingness to consider the potential benefits of an approach that has been traditionally rejected as invariably ineffective and unsafe. The published literature continues to be very limited, but a growing clinical experience, combined with a critical reevaluation of issues related to efficacy, safety, and addiction or abuse, suggests that there is a subpopulation of patients with chronic pain that can achieve sustained partial analgesia from opioid therapy without the occurrence of intolerable side effects or the development of aberrant drug-related behaviors. Future research must confirm this impression through controlled clinical trials and clarify those factors that may predict therapeutic success or failure. For the present, the clinician who contemplates this approach must have a clear grasp of the relevant issues and an understanding of the guidelines for treatment and monitoring that have proved useful in practice.

Invasive techniques in the management of cancer pain

Familiarity with potentially useful anesthetic and neurosurgical techniques is important in the management of patients who are unable to achieve a satisfactory balance between analgesia and side effects from systemic analgesic therapies. The ability to make specific recommendations is limited by the paucity of controlled data, incorporating details of pain syndromes, prior therapies, validated pain assessment, meticulous reporting of adverse effects, and longitudinal follow-up.

Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer

This article represents the contributions of the panel on "Neuropsychiatric Syndromes and Psychological Symptoms" of the National Cancer Institute of Canada Workshop on Symptom Control and Supportive Care in Patients with Advanced Cancer. The panel's presentations focused on mood disorders and cognitive disorders, and described the current state of knowledge regarding prevalence, assessment, and intervention. Recommendations for future research are presented based on a consensus of the panel as to the need to fill glaring gaps in our current state of knowledge, and a desire to improve the quality of research in this area of palliative medicine. Recommendations for future research on neuropsychiatric symptoms and syndromes in palliative care include (1) adoption of uniform terminology (taxonomy of disorders) and diagnostic classification systems, (2) utilization of existing validated tools and measures in prevalence and intervention research, (3) development of new tools and measures that are more applicable and relevant to the palliative care setting, (4) encouragement for studies of the prevalence of neuropsychiatric symptoms and syndromes, (5) promotion of intervention studies utilizing pharmacologic and nonpharmacologic treatments for depressive disorders and cognitive disorders in advanced cancer patients, and (6) expansion of the focus of such research to other neuropsychiatric disorders (for example, anxiety disorders, posttraumatic stress disorders, and sleep disorders), symptoms (fatigue and tension) and related issues (suicidal ideation and desire for hastened death).