Abstract
Delirium is one of the most frequent neurological complications occurring in patients with cancer, ranking second after pain among the reasons for requesting a neurological consult at a tertiary cancer center (1). Inappropriate behavior, cognitive disturbance, and lack of judgment can be distressing for patients and families and impact upon attempts to deliver optimal medical care. In addition, delirium is usually a sign of the presence of significant medical complications and is associated with increased mortality. The signs and symptoms of this disorder are diverse and maybe mistaken for other psychiatric disorders including mood and anxiety disorders. Different terms have been used to denote delirium over the years, including confusion, acute confusional states, acute brain failure, acute dementia, acute organic syndrome, cerebral insufficiency, metabolic encephalopathy, organic brain syndrome, reversible toxic psychosis, and intensive care unit psychosis (2). This inconsistent terminology has contributed to the insufficient understanding of delirium in clinical and research settings (2). This chapter will describe the terminology used for delirium, the symptoms that characterize the condition and its diagnosis, etiologic factors, treatment, and prognosis.
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References
Clouston PD, DeAngelis L, Posner JB. The spectrum of neurological disease in patients with systemic cancer. Ann Neurol 1992; 31: 268–273.
Lipowski ZJ. Delirium: Acute Confusional States. Oxford University Press, New York, 1990.
Hippocrates with an English translation by WHS Jones. William Heinemann LTD, London, 1931.
Berrios GE. Delirium and confusion in the 19th century. A conceptual history. Br J Psychiatry 1981; 139: 439–449.
Steinberg D. What modern neuroscience can learn from Hughling Jackson. In: A Short History of Neurology. Clifford Rose F, ed. Buttherworth Heinemann, Oxford, 1999, pp. 165–177.
Mesulam M-M. Attention, confusional states, and neglect. In: Principles of Behavioral Neurology. Mesulam MM, ed. F.A. Davis, Philadelphia, 1985, pp. 125–168.
Plum F, Posner JB. The diagnosis of stupor and coma. F.A. Davis, Philadelphia, 1980.
Adams RD, Victor M. Principles of Neurology, 6th ed. McGraw-Hill, New York, 1997.
Engel GL, Romano J. Delirium a syndrome of cerebral insufficiency. J Chronic Dis 1959; 9: 260–277.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Third Edition Revised. American Psychiatry Association, Washington, DC, 1987.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington, DC, 1994.
World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO Publications, Geneva, 1992.
Ross CA. Etiological models and their phenomenological variants. CNS arousal systems: possible role in delirium. Intl Psychogeriatr 1991; 3 (2): 353–371.
Trzepacz PT. Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999; 10: 330–334.
Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroenceph Clin Neurophysiol 1949; 1: 455–473.
Perry E, Walker M, Grace J, Perry R. Acetylcholine in mind: a neurotransmitter correlate of consciousness. Trends Neurosci 1999; 22 (6): 273–280.
Fukutani Y, Katsukawa K, Matsubara R, Kobayashi K, Nakamura I, Yamaguchi N. Delirium associated with Joseph disease. J Neurol Neurosurg Psychiatry 1993; 56 (11): 1207–1212.
Mesulam MM, Waxman SG, Geschwind N, Sabin TD. Acute confusional state with right cerebral artery infarction. J Neurol Neurosurg Psychiatry 1976; 39: 84–89.
Kaufer D, Catt K, Lopez O, De KS. Dementia with Lewy bodies: response of delirium-like features to donepezil. Neurology 1998; 51 (5): 1512.
Blass JP, Gibson GE. Cerebromeabolic aspects of delirium in relationship to dementia. Dement GeriatrCognDisord 1999; 10: 335–338.
Gibson GE, Blass JP, Huang H, Freeman GB. The cellular basis of delirium and its relevance to age-related disorders including Alzheimer disease. Intl Psychogeriatr 1991; 3 (2): 373–395.
Stefano GB, Bilfinger TV, Fricchione GL. The immune neuro-link and the macrophage: postcardiotomy delirium, HIV associate dementia and psychiatry. Prog Neurobiol 1994; 42 (4): 475–488.
Flacker JM, Lipsitz LA. Serum anticholinergic activity changes with acute illness in elderly medical patients. J Gerontol MS 1999; 54A: M 12-M 16.
Barbato M, Rodriguez PJ. Thiamine deficiency in patients admitted to a palliative care unit. Pall Med 1994; 8: 320–324.
O’Keeffe ST, Tormey WP, Glasgow R, Lavan JN. Thiamine deficiency in hospitalized elderly patients. Gerontology 1994; 40 (1): 18–24.
Papersack T, Garbusinski J, Robberecht J, Beyer I, Willems D, Fuss M. Clinical relevance of thiamine status amongst hospitalized elderly patients. Gerontology 1999; 45: 96–101.
Flacker JM, Lipsitz LA. Neural mechanisms of delirium: current hypotheses and evolving concepts. J Gerontol Biol Sci 1999; 54A: B239 - B246.
Trzepacz PT. The neuropathogenesis of delirium. A need to focus our research. Psychosomatics 1994; 35: 374–391.
Erkinjutti T, Wikstrom J, Palo J, Autio K. Dementia among medical inpatients. Evaluation of 2000 consecutive admission. Arch Intern Med 1986; 146: 1923–1926.
Minagawa H, Yosuke U, Yamawaki S, Ishitani K. Psychiatric morbidity in terminally ill cancer patients. Cancer 1996; 78: 1131–1137.
Lawlor PG, Gagnon B, Mancini IL, Pereira JL, Hanson J, SuarezAlmazor ME, Bruera ED. Occurrence, causes and outcome of delirium in patients with advanced cancer. Arch Intern Med 2000; 160: 786–794.
Caraceni A, Nanni O, Maltoni M, Piva L, Indelli M, Arnoldi E, et al. Italian Multicenter Study Group on Palliative Care. The impact of delirium on the short-term prognosis of advanced cancer patients. Cancer 2000; 89: 1145–1149.
Gagnon P, Allard P, Masse B, DeSerres M. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis and continuous monitoring. J Pain Sympt Management 2000: 19 (6): 412–426.
Liptzin B, Levkoff SE, Cleary PD, Pilgrim DM, Reilly CH, Albert M, Wetle TW. An empirical study of diagnostic criteria for delirium. Am J Psychiatry 1991; 148(4): 451 157.
Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med 1995; 13 (2): 142–145.
Wolf HG, Curran D. Nature of delirium and allied states. The disergastic reaction. Arch Neurol Psychiatry 1935; 33: 1175–1215.
Liptzin B, Levkoff SE. An empyrical study of delirium subtypes. Br J Psychiatry 1992; 161: 843–845.
Chedru F, Geschwind N. Writing disturbances in acute confusional state. Neuropsychologia 1972; 10: 343–353.
Macleod AD, Whitehead LE. Dysgraphia in terminal delirium. Palliat Med 1997; 11: 127–132.
Inouye SK. The dilemma of delirium: clinical and research controveries regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97: 278–288.
Smith MJ, Breitbart WS, Platt MM. A critique of instruments and methods to detect, diagnose, and rate delirium. J Pain Sympt Manage 1994; 10: 35–77.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113 (12): 941–948.
Zou Y, Cole M, Primeau F, McCusker J, Bellavance F, Laplante J. Detection and diagnosis of delirium in the elderly: psychiatrist diagnosis, confusion assessment method, or consensus diagnosis? Intl Psychogeriatr 1998; 10 (3): 303–308.
Trzepacz PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988; 23: 89–97.
Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The memorial delirium assessment scale. J Pain Symptom Management 1997; 13: 128–137.
Robertsson B, Karlsson I, Styrud E, Gottfries C. Confusional State Evaluation (CSE): an instrument for measuring severity of delirium in the elderly. Br J Psychiatry 1997; 170: 565–570.
McCusker J, Cole M, Bellavance F, Primeau F. Reliability and validity of a new measure of severity of delirium. Intl Psychogeriatr 1998; 10 (4): 421–433.
Pompei P, Foreman M, Cassel C, Alessi C, Cox D. Detecting delirium among hospitalized older patients. Arch Intern Med 1995; 155: 301–307.
Rockwood K, Gocedman J, Flynn M, Stolee P. Cross-validation of the delirium rating scale in older patients. J Am Geriatr Soc 1996; 44: 839–842.
Grassi L, Caraceni A, Beltrami E, Zamorani M, Maltoni M, Monti M, et al. Assessing delirium in cancer patients the Italian versions of the Delirium Rating Scale and the Memorial Delirium Assessment Scale. J Pain Sympt Management 2001; 21 (1): 59–68.
Trzepacz PT, Brenner RP, Coffman GC, van Thiel DH. Delirium in liver transplantation candidates: discriminant analysis of multiple test variables. Biol Psychiatry 1988; 24: 3–15.
Jacobson SA, Leuchter AF, Walter DO. Conventional and quantitative EEG in the diagnosis of delirium among the elderly. J Neurol Neurosurg Psychiatry 1993; 56: 153–158.
Young GB, Leung LS, Campbell V, DeMelo J, Schieven J, Tilsworth R. The electroencephalogram in metabolic/toxic coma. Am J EEG Technol 1992; 32: 243–259.
Wengs WJ, Talwar D, Bernard J. Ifosfamide-induced nonconvulsive status epilepticus. Arch Neurol 1993; 50: 1104–1105.
Schmidley JW, Messing RO. Agitated confusional states in patients with right hemispere infarctions. Stroke 1984; 5: 883–885.
Mori E, Yamadori A. Acute confusional state and acute agitated delirium. Occurrence after infarction in the right middle cerebral artery territory. Arch Neurol 1987; 44: 1139–1143.
Henon H, Lebert F, Durieu I, Godefroy O, Lucas C, Pasquier F, Leys D. Confusional state in stroke. Relation to preexisting dementia, patient characteristics and outcome. Stroke 1999; 30: 773–779.
Wasserstrom WR, Glass JP, Posner JB. Diagnosis and treatment of leptomeningeal metastasis from solid tumors: experience with 90 patients. Cancer 1982; 49: 759–772.
Posner JB. Neurologic Complications of Cancer. F.A. Davis, Philadelphia, 1995.
Formaglio F, Caraceni A. Meningeal metastases clinical aspects and diagnosis. Ital J Neurol Sci 1998; 19: 133–149.
Weitzener MA, Olofson SM, Forman AD. Patients with malignant meningitis presenting with neuropsychiatric manifestations. Cancer 1995; 76: 1804–1808.
Grossman SA, Trump DL, Chen DCP, Thomson G, Camargo EE. Cerebrospinal fluid abnormalities in patients with neoplastic meningitis. Am J Med 1982; 73: 641–647.
Trzepacz P, Ho V, Mallavarapu H. Cholinergic delirium and neurotoxicity associated with tacrine for Alzheimer’ s dementia. Psychosomatics 1996; 37 (3): 299–301.
Bruera E, Macmillan K, Hanson J, MacDonald RN. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain 1989; 39 (1): 13–16.
Zacny JP. A review of the effects of opioids on psychomotor and cognitive functioning in humans. Exp Clin Psychopharmacol 1995; 3 (4): 432–466.
Sjogren P, Olsen AK, Thomsen AB, Dalberg J. Neuropsychological performance in cancer patients: the role of oral opioids, pain and performance status. Pain 2000; 86 (3): 237–245.
JellemaJG. Hallucinations during sustained-release morphine and methadone administration. Lancet 1987; i: 392.
Caraceni A, Martini C, De Conno F, Ventafridda V. Organic brain syndromes and opioid administration for cancer pain. J Pain Sympt Management 1994; 9 (8): 527–533.
Sjogren P, Jonsson T, Jensen NH, Drenck NE, Jensen TS. Hyperalgesia and myoclonus in terminal cancer patients treated with continuous intravenous morphine. Pain 1993; 55 (1): 93–97.
Hagen N, Swanson R. Strychnine-like multifocal myoclonus and seizures in extremely high-dose opioid administration: treatment strategies. J Pain Sympt Management 1997; 14: 51–58.
Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990; 263: 1097–1101.
Schor JD, Levkoff SE, Lipsitz LA, Reilly CH, Cleary PD, Rowe JW, Evans DA. Risk factors for delirium in hospitalized elderly. JAMA 1992; 267 (6): 827–831.
Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119 (6): 474–481.
Ferguson JA, Suelzer CJ, Eckert GJ, Zhou XH, Dittus RS. Risk factors for delirium tremens development. J Gen Intern Med 1996; 11 (7): 410–414.
Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275 (11): 852–857.
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Coeney LM. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340 (9): 669–676.
Tuma R, DeAngelis LM. Altered mental status in patients with cancer. Arch Neurol 2000; 57 (12): 1727–1731.
Turner RK, Lichstein PR, Peden JG, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation and treatment. J Gen Intern Med 1989; 4: 432–443.
Seibert CP. Recognition, management and prevention of neuropsychological dysfunction after operation. Int Anesth Clinic 1986; 24: 39–58.
Smith LW, Dinsdale JE. Postcardiotomy delirium: conclusions after 25 years. Am J Psychiatry 1989; 146 (4): 452–458.
Berggren D, Gustafson Y, Erikson B, Bucht G, Hansson L, Reiz S, Winblad B. Postoperative confusion in elderly patients with femoral neck fractures. Anesth Analg 1987; 66: 497–504.
O’Keeffe ST, Chonchubhair A. Postoperative delirium in the elderly. Br J Anaesth 1995; 73 (5): 673–687.
Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994; 271 (2): 134–139.
Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, et al. The relationship of postoperative delirium with psychoactive medication. JAMA 1994; 272: 1518–1522.
Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med 1998; 105 (11): 380–384.
O’Keeffe ST. Clinical subtypes of delirium in the elderly. Dement Geriatr Cogn Disord 1999; 10: 380–385.
Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992; 40: 601–606.
Carlson LA, Gottfries CG, Winbland B, Robertson B, eds. Delirium in the elderly. Epidemiological, pathogenetic and treatment aspects. Dement Geriatr Cog Disord 1999; 10(5): 306–429.
Farrell KR, Ganzini L Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med 1995; 155: 2459–2464.
Morita T, Tsunoda J, Inoue S, Chihara S. The palliative prognostic index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 1999; 7 (3): 128–133.
Ripamonti C, Bruera E. CNS adverse effects of opioids in cancer patients. Guidelines for treatment. CNS Drugs 1997; 8 (1): 21–37.
Bruera E, Fainsinger RL, Miller MJ, Kuehn N. The assessment of pain intensity in patients with cognitive failure: a preliminary report. J Pain Sympt Management 1992; 7 (5): 267–270.
Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliative Care 1994; 10 (2): 57–70.
American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999; 156 (5 Suppl): 1–20. http://www.psych.org
Liptzin B. Delirium. In: Comprehensive Review of Geriatric Psychiatry, 2nd ed. Sadavoy J, Lazarus L, Jarvik L, Grossberg G, eds. American Psychiatric Press, Washington, DC, 1996, pp. 479–495.
Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, et al. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Society of Critical Care Medicine [see comments]. Crit Care Med 1995; 23 (9): 1596–1600.
Levenson JL. High-dose intravenous haloperidol for agitated delirium following lung transplantation. Psychosomatics 1995; 36 (1): 66–68.
Tesar GE, Murray GB, Cassem NH. Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. J Clin Psychopharmacol 1985; 5 (6): 344–347.
Riker RR, Fraser GL, Cox PM. Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med 1994; 22: 433–440.
Frye MA, Coudreaut MF, Hakeman SM, Shah BG, Strouse TB, Skotzko CE. Continuous droperidol infusion for management of agitated delirium in an intensive care unit. Psychosomatics 1995; 36 (3): 301–305.
Hunt N, Stern TA. The association between intravenous haloperidol and torsades de pointes. Psychosomatics 1995; 36 (6): 541–549.
DiS alvo TG, O’Gara PT. Torsade de pointes caused by high dose intravenous haloperidol in cardiac patients. Clin Cardiol 1995; 18: 285–290.
Wilt JL, Minnema AM, Johnson RF, Rosenblum AM. Torsade de pointes associated with the use of intravenous haloperidol. Ann Intern Med 1993; 119 (5): 391–394.
Jackson T, Ditmanson L, Phibbs B. Torsade de pointes and low-dose oral haloperidol. Arch Intern Med 1997; 157 (17): 2013–2015.
Sharma ND, Rosman HS, Padhi ID, Tisdale JE. Torsades de pointes associated with intravenous haloperidol in critically ill patients. Am J Cardiol 1998; 81 (2): 238–240.
Thomas H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 1992; 21: 407–413.
Passik SD, Cooper M. Complicated delirium in a cancer patient successfully treated with olanzapine. J Pain Sympt Management 1999; 17 (3): 219–223.
Newman JP, Terris DJ, Moore M. Trends in the management of alcohol withdrawal syndrome. Laryngoscope 1995; 105 (1): 1–7.
Fernandez F, Holmes VF, Adams F, Kavanaugh JJ. Treatment of severe refractory agitation with haloperidol drip. J Clin Psychiatry 1988; 49: 239–241.
Fernandez F, Levy JK, Mansell PW. Management of delirium in terminally ill AIDS patients. Int J Psychiatry Med 1989; 19(2): 165172.
Stiefel F, Fainsinger R, Bruera E. Acute confusional states in patients with advanced cancer. J Pain Sympt Management 1992; 7(2): 94–98.
Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C. A double-blind trial of haloperidol, chlorpromazine and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153: 231–237.
Bottomley D, Hanks G. Subcutaneous midazolam infusion in palliative care. J Pain Sympt Management 1990; 5 (4): 259–261.
Burke AL, Diamond PL, Hulbert J, Yeatman J, Farr EA. Terminal restlessness-its management and the role of midazolam. Med J Aust 1991; 155 (7): 485–487.
Burke AL. Palliative care: an update on “terminal restlessness. Med J Aust 1997; 166: 39–42.
Burns MJ, Linden CH, Graudins A, Brown RM, Fletcher KE. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med 2000; 35 (4): 374–381.
Slatkin NE, Rhiner M, Bolton TM. Donezepil in the treatment of opiate induced sedation. J Pain Sympt Management 2001; 21: 425–438.
Morita T, Otani H, Tsunoda J, Inoue S, Chihara S. Succesful palliation of hypoactive delirium due to multiorgan failure by oral methylphenidate. Supp Care Cancer 2000; 8 (2): 134–137.
Levenson JA. Should psychostimulants be used to treat delirious patients with depressed mood. J Clin Psychiatry 1992; 53 (2): 69.
Koponen HJ, Riekkinen PJ. A prospective study of delirium in elderly patients admitted to a psychiatric hospital. Psychol Med 1993; 23: 103–109.
Levkoff SE, Evans DA, Lipzin B, Cleary PD, Lipsitz LA, Wetle TT, et al. Delirium. The occurence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992; 152: 334–340.
van Hemert AM, van der Mast RC, Hengeveld MW, Vorstenbosch M. Excess mortality in general hospital patients with delirium: a 5-year follow-up of 519 patients seen in psychiatric consultation. J Psychosomatic Res 1994; 38 (4): 339–346.
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Caraceni, A., Bosisio, M., Ingham, J.M. (2003). Confusion and Delirium. In: Schiff, D., Wen, P.Y. (eds) Cancer Neurology in Clinical Practice. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-317-0_5
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