Overview
Causes of Cognitive Disorders and Delirium
Effects of Cognitive Disorders and Delirium on the Patient, Family, and Healthcare Providers
Diagnosis of Cognitive Disorders and Delirium
Treatment of Delirium

Treatment of the Symptoms of Delirium by Changing the Patient's Surroundings Treatment of the Causes of Delirium Treatment of the Symptoms of Delirium with Medication Delirium and Sedation

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Changes to This Summary (9/22/2008)
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Overview

Cognitive disorders and delirium are conditions in which the patient experiences a confused mental state and changes in behavior.

People who have cognitive disorders or delirium may fall in and out of consciousness and may have problems with the following:

• Attention.
• Thinking.
• Awareness.
• Emotion.
• Memory.
• Muscle control.
• Sleeping and waking.

Delirium occurs frequently in patients with cancer, especially in patients with advanced cancer.

Delirium usually occurs suddenly and the patient's symptoms may come and go during the day. This condition can be treated and is often temporary, even in people with advanced illness. In the last 24 to 48 hours of life, however, delirium may be permanent due to problems such as organ failure.

Causes of Cognitive Disorders and Delirium

Cognitive disorders and delirium may be complications of cancer and cancer treatment, especially in people with advanced cancer.

In patients with cancer, cognitive disorders and delirium may be due to the direct effects that cancer has on the brain, such as the pressure of a growing tumor. Cognitive disorders and delirium may also be caused by indirect effects of cancer or its treatment, including the following:

• Organ failure.



• Electrolyte imbalances: Electrolytes are important minerals (including salt, potassium, calcium, and phosphorous) that are needed to keep the heart, kidneys, nerves, and muscles working correctly.



• Infection.



• Symptoms caused by the cancer but that occur apart from the local or distant spread of the tumor (paraneoplastic syndromes), such as inflammation of the brain.



• Medication side effects: Patients with cancer usually take many medications. Some drugs have side effects that include delirium and confusion. The effects of these drugs usually go away after the drug is stopped.



• Withdrawal from drugs that depress (slow down) the central nervous system (brain and spinal cord).

Risk factors for delirium include having a serious disease and having more than one disease.

Other conditions besides having cancer may place a patient at risk for developing delirium. Risk factors include the following:

• Advanced cancer or other serious illness.
• Having more than one disease.
• Older age.
• Previous mental disorder, such as dementia.
• Low levels of albumin (protein) in the blood.
• Infection.
• Taking medications that affect the mind or behavior.
• Taking high doses of pain medication.

Early identification of risk factors may help prevent the onset of delirium or may reduce the length of time it takes to correct it.

Effects of Cognitive Disorders and Delirium on the Patient, Family, and Healthcare Providers

Cognitive disorders and delirium can be upsetting to the patient's family and caregivers.

Cognitive disorders and delirium can be upsetting to the family and caregivers, and may be dangerous to the patient if judgment is affected. These conditions can cause the patient to act unpredictably and sometimes violently. Even a quiet or calm patient can suddenly experience a change in mood or become agitated, requiring increased care. The safety of the patient, family, and caregivers is most important.

Cognitive disorders and delirium may affect physical health and communication.

Patients with cognitive disorders or delirium are more likely to fall, be incontinent (unable to control bladder and/or bowels), and become dehydrated (drink too little water to maintain health). They often require a longer hospital stay than patients without cognitive disorders or delirium.

The confused mental state of these patients may hinder their communication with family members and the healthcare providers. Assessment of the patient's symptoms becomes difficult and the patient may be unable to make decisions regarding care. Agitation in these patients may be mistaken as an expression of pain. Conflict can arise among the patient, family, and staff concerning the level of pain medication needed.

Diagnosis of Cognitive Disorders and Delirium

Possible signs of cognitive disorders and delirium include sudden personality changes, impaired thinking, or unusual anxiety or depression.

A patient who suddenly becomes agitated or uncooperative, experiences personality or behavior changes, has impaired thinking, decreased attention span, or intense, unusual anxiety or depression, may be experiencing cognitive disorders or delirium. Patients who develop these symptoms need to be assessed completely.

The symptoms of delirium are similar to symptoms of depression and dementia.

Early symptoms of delirium are similar to symptoms of anxiety, anger, depression, and dementia. Delirium that causes the patient to be very inactive may appear to be depression. Delirium and dementia are difficult to tell apart, since both may cause disorientation and impair memory, thinking, and judgment. Dementia may be caused by a number of medical conditions, including Alzheimer disease. Some differences in the symptoms of delirium and dementia include the following:

• Patients with delirium often go in and out of consciousness. Patients who have dementia usually remain alert.



• Delirium may occur suddenly. Dementia appears gradually and gets worse over time.



• Sleeping and waking problems are more common with delirium than with dementia.

In elderly patients who have cancer, dementia is often present along with delirium, making diagnosis difficult. The diagnosis is more likely dementia if symptoms continue after treatment for delirium is given.

In patients aged 65 or older who have survived cancer for more than 5 years, the risk for cognitive disorders and dementia is increased, apart from the risk for delirium.

Regular screening of the patient and monitoring of the patient's symptoms can help in the diagnosis of delirium.

Treatment of Delirium

Patient and family concerns are addressed when deciding the treatment of delirium. Deciding if, when, and how to treat a person with delirium depends on the setting, how advanced the cancer is, the wishes of the patient and family, and how the delirium symptoms are affecting the patient.

Monitoring alone may be all that is necessary for patients who are not dangerous to themselves. In other cases, symptoms may be treated or causes of the delirium may be identified and treated.

Controlling the patient's surroundings may help reduce mild symptoms of delirium. The following changes may be effective:

• Putting the patient in a quiet, well-lit room with familiar objects.
• Placing a clock or calendar where the patient can see it.
• Reducing noise.
• Having family present.
• Limiting changes in caregivers.

To prevent a patient from harming himself or herself or others, physical restraints also may be necessary.

The standard approach to managing delirium is to find and treat the causes. Symptoms may be treated at the same time. Identifying the causes of delirium will include a physical examination to check general signs of health, including checking for signs of disease. A medical history of the patient’s past illnesses and treatments will also be taken. In a terminally ill delirious patient being cared for at home, the doctor may do a limited assessment to determine the cause or may treat just the symptoms.

Treatment may include the following:

• Stopping or reducing medications that cause delirium.



• Giving fluids into the bloodstream to correct dehydration.



• Giving drugs to correct hypercalcemia (too much calcium in the blood).



• Giving antibiotics for infections.

Drugs called antipsychotics may be used to treat the symptoms of delirium. Drugs that sedate (calm) the patient may also be used, especially if the patient is near death. All of these drugs have side effects and the patient will be monitored closely by a doctor. The decision to use drugs that sedate the patient will be made in cooperation with family members after efforts have been made to reverse the delirium.

The decision to use drugs to sedate the patient who is near death and has symptoms of delirium, pain, and difficult breathing presents ethical and legal issues for both the doctor and the family. When the symptoms of delirium are not relieved with standard treatment approaches and the patient is experiencing severe distress and suffering, the doctor may discuss the option to give drugs that will sedate the patient. This decision is guided by the following principles:

• Healthcare professionals who have experience in palliative care make repeated assessments of the patient’s response to treatments. The family is always included.



• The need to use drugs that sedate the patient is evaluated by a multidisciplinary team of healthcare professionals.



• Temporary sedation should be considered.



• A multidisciplinary team of healthcare professionals will work with the family to ensure that the family's views are assessed and understood.

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Changes to This Summary (9/22/2008)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

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About PDQ

PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site ². PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ contains cancer information summaries.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

The PDQ cancer information summaries are developed by cancer experts and reviewed regularly.

Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.

PDQ also contains information on clinical trials.

A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.

Listings of clinical trials are included in PDQ and are available online at NCI's Web site ⁵. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

Glossary Terms

Cancer that has spread to other places in the body and usually cannot be cured or controlled with treatment.

A condition in which a person is unable to relax and be still. The person may be very tense and irritable, and become easily annoyed by small things. He or she may be eager to have an argument, and be unwilling to work with caregivers to make the situation better.

A brain disorder that usually starts in late middle age or old age and gets worse over time. Symptoms include loss of memory, confusion, difficulty thinking, and changes in language, behavior, and personality. Also called Alzheimer dementia.

A drug used to treat infections caused by bacteria and other microorganisms.

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

In healthcare, a process used to learn about a patient’s condition. This may include a complete medical history, medical tests, a physical exam, a test of learning skills, tests to find out if the patient is able to carry out the tasks of daily living, a mental health evaluation, and a review of social support and community resources available to the patient.

The organ that stores urine.

A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.

The long, tube-shaped organ in the abdomen that completes the process of digestion. The bowel has two parts, the small bowel and the large bowel. Also called intestine.

A mineral needed for healthy teeth, bones, and other body tissues. It is the most common mineral in the body. A deposit of calcium in body tissues, such as breast tissue, may be a sign of disease.

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

The brain and spinal cord. Also called CNS.

The mental process of thinking, learning, remembering, being aware of surroundings, and using judgment.

A mental state in which one is not thinking clearly.

A condition caused by the loss of too much water from the body. Severe diarrhea or vomiting can cause dehydration.

A mental state in which a person is confused, disoriented, and not able to think or remember clearly. The person may also be agitated and have hallucinations, and extreme excitement.

A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes and emotional problems. There are many causes of dementia, including Alzheimer disease, brain cancer, and brain injury. Dementia usually gets worse over time.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

The process of identifying a disease, such as cancer, from its signs and symptoms.

In medicine, a disturbance of normal functioning of the mind or body. Disorders may be caused by genetic factors, disease, or trauma.

A mental state marked by confusion about time, place, or who one is.

Refers to cancer that has spread from the original (primary) tumor to distant organs or distant lymph nodes. Also known as distant metastasis.

Extreme mental or physical pain or suffering.

The amount of medicine taken, or radiation given, at one time.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

A substance that breaks up into ions (particles with electrical charges) when it is dissolved in water or body fluids. Some examples of ions are sodium, potassium, calcium, chloride, and phosphate. These ions help move nutrients into cells, help move waste out of cells, and help nerves, muscles, the heart, and the brain work the way they should.

A substance that flows smoothly and takes the shape of its container. Liquids and gases are fluids.

Higher than normal levels of calcium in the blood. Some types of cancer increase the risk of hypercalcemia.

A loss of part or all of a physical or mental ability, such as the ability to see, walk, or learn.

Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).

Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.

Redness, swelling, pain, and/or a feeling of heat in an area of the body. This is a protective reaction to injury, disease, or irritation of the tissues.

One of a pair of organs in the abdomen. Kidneys remove waste from the blood (as urine), produce erythropoietin (a substance that stimulates red blood cell production), and play a role in blood pressure regulation.

An invasive malignant cancer confined entirely to the organ where the cancer began.

A legal drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition.

In medicine, a mineral is a nutrient that is needed in small amounts to keep the body healthy. Mineral nutrients include the elements calcium, magnesium, and iron.

In medicine, to regularly watch and check a person or condition to see if there is any change. Also refers to a device that records and/or displays patient data, such as for an electrocardiogram (EKG).

In medicine, a term used to describe a treatment planning approach or team that includes a number of doctors and other health care professionals who are experts in different specialties (disciplines). In cancer treatment, the primary disciplines are medical oncology (treatment with drugs), surgical oncology (treatment with surgery), and radiation oncology (treatment with radiation).

A bundle of fibers that receives and sends messages between the body and the brain. The messages are sent by chemical and electrical changes in the cells that make up the nerves.

A part of the body that performs a specific function. For example, the heart is an organ.

Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of palliative care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called comfort care, supportive care, and symptom management.

A group of symptoms that may develop when substances released by some cancer cells disrupt the normal function of surrounding cells and tissue.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

Having to do with or containing the element phosphorus.

An exam of the body to check for general signs of disease.

A metallic element that is important in body functions such as regulation of blood pressure and of water content in cells, transmission of nerve impulses, digestion, muscle contraction, and heartbeat.

In medicine, action taken to decrease the chance of getting a disease or condition. For example, cancer prevention includes avoiding risk factors (such as smoking, obesity, lack of exercise, and radiation exposure) and increasing protective factors (such as getting regular physical activity, staying at a healthy weight, and having a healthy diet).

A molecule made up of amino acids that are needed for the body to function properly. Proteins are the basis of body structures such as skin and hair and of substances such as enzymes, cytokines, and antibodies.

In medicine, an improvement related to treatment.

Something that may increase the chance of developing a disease. Some examples of risk factors for cancer include age, a family history of certain cancers, use of tobacco products, certain eating habits, obesity, lack of exercise, exposure to radiation or other cancer-causing agents, and certain genetic changes.

Checking for disease when there are no symptoms. Since screening may find diseases at an early stage, there may be a better chance of curing the disease. Examples of cancer screening tests are the mammogram (breast), colonoscopy (colon), Pap smear (cervix), and PSA blood level and digital rectal exam (prostate). Screening can also include checking for a person’s risk of developing an inherited disease by doing a genetic test.

A drug or substance used to calm a person down, relieve anxiety, or help a person sleep.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

A column of nerve tissue that runs from the base of the skull down the back. It is surrounded by three protective membranes, and is enclosed within the vertebrae (back bones). The spinal cord and the brain make up the central nervous system, and spinal cord nerves carry most messages between the brain and the rest of the body.

In medicine, treatment that experts agree is appropriate, accepted, and widely used. Health care providers are obligated to provide patients with standard therapy. Also called best practice and standard of care.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

Disease that cannot be cured and will cause death.

An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.