Cognitive Disorders and Delirium (PDQ®): Supportive care - Health Professional Information [NCI]

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Cognitive disorders and delirium are neuropsychiatric syndromes that occur frequently in patients with cancer, particularly in those with advanced disease. Occurrence rates range from 28% to 48% in patients with advanced cancer on admission to hospital or hospice,[1,2,3] and approximately 90% of these patients will experience delirium in the hours to days before death.[3,4,5] The term acute confusional state has also been used to describe this syndrome; in the last days of life, the condition sometimes referred to as terminal restlessness probably represents a terminal delirium.[6] Although delirium clearly has a recognized association with the dying phase, many episodes of delirium are reversible; therapeutic intervention can result in delirium reversal, or at least improvement, in 30% to 75% of episodes.[3,5,7,8,9,10] Variability in reported occurrence rates and clinical outcomes most likely reflects sampling from different clinical settings or different stages in the clinical trajectory of cancer, in addition to inconsistency in diagnostic terminology.[11] The prevention of delirium in the patient with cancer has not been systematically examined, but studies in elderly medical patients suggest that early identification of risk factors reduces the occurrence rate of delirium and the duration of episodes.[12]

Delirium has been defined as a disorder of global cerebral dysfunction characterized by disordered awareness, attention, and cognition.[13] In addition, delirium is associated with behavioral manifestations. The fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) cites the core clinical criteria for diagnosis as follows:[14]

  • A disturbance of consciousness with reduced clarity of awareness and attention deficit.
  • Other cognitive or perceptual disturbances.
  • Acuity of onset (hours to days) and fluctuation over the course of the day.
  • The presence of an underlying cause such as a general medical condition (e.g., hypoxia or electrolyte disturbance), medication, a combination of etiologies, or indeterminate etiology.

Other associated noncore clinical criteria features include sleep-wake cycle disturbance, delusions, emotional lability, and disturbance of psychomotor activity. The latter forms the basis of classifying delirium into three different subtypes:[15,16]

  1. Hypoactive.
  2. Hyperactive.
  3. Mixed, with both hypoactive and hyperactive features.

References:

  1. Minagawa H, Uchitomi Y, Yamawaki S, et al.: Psychiatric morbidity in terminally ill cancer patients. A prospective study. Cancer 78 (5): 1131-7, 1996.
  2. Pereira J, Hanson J, Bruera E: The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 79 (4): 835-42, 1997.
  3. Lawlor PG, Gagnon B, Mancini IL, et al.: Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 160 (6): 786-94, 2000.
  4. Massie MJ, Holland J, Glass E: Delirium in terminally ill cancer patients. Am J Psychiatry 140 (8): 1048-50, 1983.
  5. Bruera E, Miller L, McCallion J, et al.: Cognitive failure in patients with terminal cancer: a prospective study. J Pain Symptom Manage 7 (4): 192-5, 1992.
  6. Travis SS, Conway J, Daly M, et al.: Terminal restlessness in the nursing facility: assessment, palliation, and symptom management. Geriatr Nurs 22 (6): 308-12, 2001 Nov-Dec.
  7. Gagnon P, Allard P, Mâsse B, et al.: Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous monitoring. J Pain Symptom Manage 19 (6): 412-26, 2000.
  8. Maddocks I, Somogyi A, Abbott F, et al.: Attenuation of morphine-induced delirium in palliative care by substitution with infusion of oxycodone. J Pain Symptom Manage 12 (3): 182-9, 1996.
  9. Tuma R, DeAngelis LM: Altered mental status in patients with cancer. Arch Neurol 57 (12): 1727-31, 2000.
  10. Breitbart W, Gibson C, Tremblay A: The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 43 (3): 183-94, 2002 May-Jun.
  11. Lawlor PG: The panorama of opioid-related cognitive dysfunction in patients with cancer: a critical literature appraisal. Cancer 94 (6): 1836-53, 2002.
  12. Inouye SK, Bogardus ST Jr, Charpentier PA, et al.: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340 (9): 669-76, 1999.
  13. Lipowski ZJ: Delirium in the elderly patient. N Engl J Med 320 (9): 578-82, 1989.
  14. Delirium, dementia, and amnestic and other cognitive disorders. In: American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994, pp 123-33.
  15. Clinical features, course, and outcome. In: Lipowski ZJ: Delirium: Acute Confusional States. New York, NY: Oxford University Press, 1990, pp 54-70.
  16. Camus V, Burtin B, Simeone I, et al.: Factor analysis supports the evidence of existing hyperactive and hypoactive subtypes of delirium. Int J Geriatr Psychiatry 15 (4): 313-6, 2000.

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of cognitive disorders and delirium. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board. Board members review recently published articles each month to determine whether an article should:

  • be discussed at a meeting,
  • be cited with text, or
  • replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."

The preferred citation for this PDQ summary is:

National Cancer Institute: PDQ® Cognitive Disorders and Delirium. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/supportivecare/delirium/HealthProfessional. Accessed <MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page page.

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More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.

Last Revised: 2011-02-04

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