Delirium in Acute Stroke: A Review

Background

Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation.

Summary of review

Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke.

Conclusion

This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.

[Using psychostimulants in end-of-life patients with hypoactive delirium and cognitive disorders: A literature review]

OBJECTIVE

To review the research about psychostimulant effects on cognitive functions in end-of-life patients diagnosed with hypoactive delirium or cognitive disorders.

METHOD

The MEDLINE (1966-March 2008), Embase (1974-March 2008), PsycINFO (1806-March 2008), IPA (1970-March 2008), CINAHL (1982-March 2008), ISI Web of Science (1945-March 2008), Current Contents (March 2007-March 2008), Access Medicine (2001-March 2008), and ProQuest Dissertations & Theses (1980-March 2008) databases were searched with keywords related to delirium, cognition, psychostimulants, and palliative care for French or English articles in a dementia-free and hyperactive delirium-free end-of-life population. Cognitive functions had to be assessed before and after initiation of the psychostimulant treatment. Moreover, treatment had to be initiated after the onset of cognitive impairments.

RESULTS

A total of 173 studies were screened. Five studies on methylphenidate and 1 study on caffeine met inclusion criteria and were included in this review. Two studies were case reports, 2 were open-label trials, and 2 were double-blind, crossover randomized placebo-controlled trials. Three studies were conducted with hypoactive delirium patients and all studies were conducted in an advanced cancer patient population.

CONCLUSIONS

The reviewed studies support the use of methylphenidate to improve end-of-life patient cognitive functions, particularly in the case of hypoactive delirium. Caffeine seems to have beneficial effects on psychomotor activity. Further well-designed studies are needed to consolidate these findings.

Psychostimulants and delirium in patients receiving palliative care

The use of psychostimulants to relieve opioid-induced drowsiness and symptoms of depression in medically ill patients has become increasingly established in North America. The role of psychostimulants in the care of patients receiving palliative care is beginning to be debated in the United Kingdom both in the hospice and hospital setting. Delirium has been well defined and reported as a significant problem in populations of patients receiving palliative care. Two case histories are presented to illustrate the potential benefit of psychostimulants in hypoactive delirium.

Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care

Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.

The delirium subtypes: A review of prevalence, phenomenology, pathophysiology, and treatment response

Delirium is a highly prevalent disease in the elderly and postoperative, cancer, and AIDS patients. However it is often misdiagnosed and mistreated. This may be partly due to the inconsistencies of the diagnosis itself. Delirium is best defined currently by an association of cognitive impairment and arousal disturbance. Three subtypes (hyperactive, hypoactive, mixed) receive a definition in the literature, but those definitions may vary from author to author according to the importance they give either to the motoric presentation of the delirium or to the arousal disturbance. Our aim is to point out the inconsistencies we found in the literature, but also to identify different paths that have been explored to solve them, that is, the suggestion to emphasize the arousal disturbances in defining the subtypes instead of the motoric presentations, which seem to be more fluctuating, and because of the fluctuating course of the disease to extend the observation over a period of time, which may improve the accuracy of the diagnosis. This is not without importance from a clinical standpoint. Subtypes of delirium may be explained by different pathophysiologic mechanisms, which remain partly unexplained, and may respond to specific treatments. There is a trend to isolate core symptoms (disorientation, cognitive deficits, sleep–wake cycle disturbance, disorganized thinking, and language abnormalities) so as to distinguish them from secondary symptoms that may be correlated with the different etiologies. Our contribution is also to challenge, with new data, the accepted belief that psychotic features are quite rare in the hypoactive type of delirium. We demonstrate that delusions and perceptual disturbances, although less frequent, are present in more than half of the patients with hypoactive delirium. The psychotic features are clearly correlated with a highly prevalent rate of patients', spouses', and caregivers' distress. The mixed subtype of delirium seems to have the worst prognosis, the hyperactive showing the best prognosis. The treatment of the agitated delirious patient is also more consensual. Haloperidol remains the gold standard in the treatment of delirium regardless of the clinical presentation, but the literature provides several alternatives that may prove more specific and have less adverse effects (atypical antipsychotics, psychostimulants, anesthetics).

The panorama of opioid-related cognitive dysfunction in patients with cancer: a critical literature appraisal

BACKGROUND

Opioids have an essential role in the management of pain in cancer patients, particularly those with advanced disease. Cognitive dysfunction is a recognized complication of opioid use. However, misconceptions and controversy surround the nature and prevalence of its occurrence. A projected increase in the aging cancer population highlights the need for a better understanding of this phenomenon.

METHODS

A critical appraisal of the literature evidence in relation to the pattern, pathophysiology, assessment, impact, and management of cognitive dysfunction due to opioid use in cancer pain management is given.

RESULTS

Studies in cancer patients with less advanced disease reveal subtle evidence of cognitive impairment, largely related to initial dosing or dose increases. In advanced cancer, opioid-induced cognitive dysfunction usually occurs in the form of delirium, a multifactorial syndrome. The presence of both cognitive impairment and delirium frequently is misdiagnosed or missed. Potential risk factors include neuropathic and incidental pain, opioid tolerance, somatization of psychologic distress, and a history of drug or alcohol abuse. Elevation of opioid metabolites with renal impairment may contribute to cognitive dysfunction. Recognition of opioid-related cognitive dysfunction is improved by objective screening. Successful management requires either dose reduction or a change of opioid, in addition to addressing other reversible precipitants such as dehydration or volume depletion.

CONCLUSIONS

Opioid-related cognitive dysfunction tends to be subtle in the earlier stages of cancer, whereas delirium, a more florid form with behavioral disturbance is likely to be present in the advanced cancer population. In patients with advanced disease, an optimal management approach requires careful clinical assessment, identification of risk factors, objective monitoring of cognition, maintenance of adequate hydration, and either dose reduction or switching to a different opioid.

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.

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).

Common psychiatric disorders in cancer patients. II. Anxiety and acute confusional states

Anxiety is a very prominent symptom of cancer patients and appears most frequently in connection with adjustment disorders. However, it can also be part of a normal adaptation to the disease, related to an anxiety disorder, or can be caused by variety of other reasons, including underlying somatic processes. The clinical presentation, etiology, diagnostic proceedings and the treatment of anxiety in patients with cancer is surveyed. Delirium (acute confusional states) is a neglected psychiatric syndrome in regard to diagnosis, treatment and research efforts. Especially in cancer patients, delirium is frequent and its incidence increases with advanced disease. A brief overview on the current literature of acute confusional states in cancer patients is presented.