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

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The diagnosis of cognitive disorders and delirium should be considered in any patient with cancer demonstrating an acute onset of agitation or uncooperative behavior, personality change, impaired cognitive functioning, altered attention span, fluctuating level of consciousness, or uncharacteristic anxiety or depression. The diagnoses of delirium and cognitive impairment are frequently missed and poorly documented, however.[1,2,3,4,5] Medical and nursing staff, as well as family members, may attribute a functional cause to some of the early, prodromal, and more subtle signs of delirium such as increased anxiety, restlessness, and emotional lability.[6] Failure to recognize delirium is particularly likely if the patient is encountered in a transient lucid phase, which can commonly occur as part of the fluctuating nature of delirium.[7] Delirium is most frequently misdiagnosed as depression or dementia.[7,8,9,10] The hypoactive subtype is considered especially likely to be misdiagnosed as depression.[7]

Differentiating delirium from dementia or recognizing delirium superimposed on dementia can be difficult because of some shared clinical features such as disorientation and impairment of memory, thinking, and judgment.[11,12,13] Dementia, however, typically appears in relatively alert individuals; disturbance of consciousness is not a common feature. The temporal onset of symptoms of delirium is acute (hours to days), not insidious (months to years) as in dementia.[14] In elderly patients with cancer, delirium is often superimposed on dementia, giving rise to a particularly difficult diagnostic challenge. In this situation, the diagnosis may become more apparent when delirium fails to reverse or when some features of delirium, especially cognitive impairment, persist. Dementia is often then the most likely explanation for a persistent or residual cognitive deficit.[14]

Vigilance on the part of nursing staff and a systematic approach to recording serial observations assist in the detection of delirium. Regular cognitive screening facilitates the diagnosis of delirium in cancer patients.[15] Instruments such as the Minimental State Examination (MMSE), Blessed Orientation Memory and Concentration Test (BOMC), and Confusion Assessment Method (CAM) have favorable psychometric properties and are brief enough to allow repeated administration in cancer patients.[16,17,18] The BOMC and MMSE screen for cognitive impairment and require active patient participation in assessment. The Bedside Confusion Scale (BCS) also requires active patient participation; however, it is remarkably brief, and its psychometric potential as a screening instrument compares favorably with the CAM.[19] The CAM does not require formal patient participation. The Memorial Delirium Assessment Scale (MDAS) and Delirium Rating Scale-Revised-98 have been validated as having diagnostic and severity rating potential.[20,21] The MDAS allows prorating of scores when a patient cannot actively participate in testing for reasons such as dyspnea or fatigue.

References:

  1. McCartney JR, Palmateer LM: Assessment of cognitive deficit in geriatric patients. A study of physician behavior. J Am Geriatr Soc 33 (7): 467-71, 1985.
  2. Harwood DM, Hope T, Jacoby R: Cognitive impairment in medical inpatients. II: Do physicians miss cognitive impairment? Age Ageing 26 (1): 37-9, 1997.
  3. Hustey FM, Meldon SW: The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39 (3): 248-53, 2002.
  4. Rincon HG, Granados M, Unutzer J, et al.: Prevalence, detection and treatment of anxiety, depression, and delirium in the adult critical care unit. Psychosomatics 42 (5): 391-6, 2001 Sep-Oct.
  5. Inouye SK, Foreman MD, Mion LC, et al.: Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med 161 (20): 2467-73, 2001.
  6. Breitbart W, Chochinov HM, Passik S: Psychiatric aspects of palliative care. In: Doyle D, Hanks GW, MacDonald N, eds.: Oxford Textbook of Palliative Medicine. 2nd ed. New York, NY: Oxford University Press, 1998, pp 933-56.
  7. Inouye SK: The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 97 (3): 278-88, 1994.
  8. Nicholas LM, Lindsey BA: Delirium presenting with symptoms of depression. Psychosomatics 36 (5): 471-9, 1995 Sep-Oct.
  9. Farrell KR, Ganzini L: Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med 155 (22): 2459-64, 1995 Dec 11-25.
  10. Armstrong SC, Cozza KL, Watanabe KS: The misdiagnosis of delirium. Psychosomatics 38 (5): 433-9, 1997 Sep-Oct.
  11. Fick D, Foreman M: Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. J Gerontol Nurs 26 (1): 30-40, 2000.
  12. Johnson J, Sims R, Gottlieb G: Differential diagnosis of dementia, delirium and depression. Implications for drug therapy. Drugs Aging 5 (6): 431-45, 1994.
  13. Cole MG, McCusker J, Dendukuri N, et al.: Symptoms of delirium among elderly medical inpatients with or without dementia. J Neuropsychiatry Clin Neurosci 14 (2): 167-75, 2002 Spring.
  14. Lipowski ZJ: Delirium in the elderly patient. N Engl J Med 320 (9): 578-82, 1989.
  15. 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.
  16. Folstein MF, Folstein SE, McHugh PR: "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12 (3): 189-98, 1975.
  17. Inouye SK, van Dyck CH, Alessi CA, et al.: Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113 (12): 941-8, 1990.
  18. Katzman R, Brown T, Fuld P, et al.: Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry 140 (6): 734-9, 1983.
  19. Stillman MJ, Rybicki LA: The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population. J Palliat Med 3 (4): 449-56, 2000.
  20. Trzepacz PT, Mittal D, Torres R, et al.: Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 13 (2): 229-42, 2001 Spring.
  21. Breitbart W, Rosenfeld B, Roth A, et al.: The Memorial Delirium Assessment Scale. J Pain Symptom Manage 13 (3): 128-37, 1997.

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,
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  • 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.

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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>.

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Last Revised: 2011-02-04

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