What is delirium? What are its symptoms and treatment in cancer patients?

Delirium is a condition dominated by sudden-onset confusion that becomes apparent over hours or days.

Delirium, often accompanied by fluctuating consciousness, confusion, attention and memory problems, restlessness or, conversely, extreme slowing, and findings called hallucinations and delusions described in more detail below, also occurs in our cancer patients and requires urgent medical intervention.

What is delirium?

Our body has a highly complex biological balance that allows survival and is essential for maintaining its functions most efficiently. When this balance is disrupted for some reason, we begin to observe symptoms of various diseases depending on the organs affected. If the disruption affects brain function, delirium may develop, with many symptoms of mental illness occurring together. Although delirium gives the impression of a severe mental illness, it is essentially a cluster of symptoms caused when disrupted bodily balance affects the brain.

Symptoms of delirium

Fluctuating consciousness and disorientation: Consciousness can be described as being awake and fully aware of one’s surroundings. In delirium, wakefulness and awareness fluctuate during the day. Patients fully aware of events around them with a clear mind at one moment may experience marked confusion a few hours later. Deterioration is more frequent at night, and the person may not know the time of day, day, month or year. They may not remember where they are or why they are there, may believe they are somewhere else, and may sometimes fail to recognize or confuse people around them.

Disrupted sleep-wake cycle: During delirium, the day-night cycle may reverse; patients who do not or cannot sleep at night may tend to spend daytime dozing. Failure to obtain regular nighttime sleep is an important factor in worsening the condition.

Attention and memory problems: Although severity varies, patients with delirium have difficulty focusing attention and maintaining concentration. Sometimes inability to sustain attention is so marked that it prevents understanding what others say or finding the right words and forming proper sentences to explain their concerns. Because they are already confused about time, place and people, their speech may sound disorganized and nonsensical to listeners.

Perceptions and thoughts: Because brain function is impaired in delirium, patients may describe stimuli that do not actually exist but which they claim to perceive through their 5 senses. In these situations, called hallucinations, patients may report seeing things others cannot see or hearing sounds others cannot hear. For example, they may say someone is walking around the room, spiders or insects are crawling on the wall, or someone is calling them. They may also hold strange, impossible beliefs in which they are strongly convinced. In these situations, called delusions, thoughts that someone will harm them may predominate. They may therefore think and fear that they could be poisoned while nurses administer treatment or family members feed them.

Emotions and behaviors: Subtle emotional changes occur just before delirium begins. Intense feelings such as inner distress, irritability, excessive anxiety and restlessness, or readily becoming emotional and crying may occur; conversely, extreme inactivity and indifference to surroundings may be observed. Hyperactive delirium describes situations dominated by restlessness and inability to stay still. Inappropriate behaviors can frequently occur, such as constantly wanting to get out of bed, trying to remove intravenous lines and infusions, or trying to leave the hospital because judgment and sound decision-making are impaired. Hypoactive delirium involves patients communicating less, moving less and sometimes spending much of the day asleep.

Only half of our patients can remember this experience. For family members, it can be frightening and also challenging because symptoms are difficult to manage.

What can cause delirium in cancer patients?

Factors that can affect brain function and cause delirium:

1. Infections
2. Dehydration of the body for various reasons (for example diarrhea or vomiting)
3. Imbalances in body minerals such as salt, potassium, calcium and magnesium
4. Impaired oxygenation (when the lungs are inadequate in breathing)
5. Severe, uncontrolled pain
6. Constipation (especially in our older patients)
7. Factors originating directly in the brain (for example brain tumors, cancer metastases to the brain, blocked blood vessels or bleeding in the brain)
8. Certain bodily chemicals secreted by cancer or by the body in response to cancer cells
9. Failure of organs such as kidneys or liver
10. Hormonal imbalances (underactive/overactive thyroid, low blood sugar)
11. Secondary to side effects of chemotherapy or radiotherapy
12. As a side effect of drugs other than cancer treatments (for example strong morphine-derived painkillers, sedatives, cortisone treatments, antiarrhythmic drugs, etc.)
13. Long-term nutritional deficiencies - cachexia

Delirium is not specific to cancer. Apart from cancer and related causes, delirium can occur after major surgery, severe trauma or serious systemic infection. As can be seen, any condition disrupting bodily balance can cause delirium. Once the bodily imbalance is corrected, delirium often resolves as well.

How is delirium diagnosed?

Delirium is diagnosed through history obtained from patients and family members and psychiatric examination. In people with serious or chronic illness, the sudden-onset cluster of symptoms detailed above, involving fluctuating consciousness, disrupted communication with surroundings and reduced awareness of time, place and surrounding people, should be reported to their doctor immediately.

Your physician and psychiatrist may also ask family members about past mental illness to distinguish delirium from other conditions. Patients with dementia, a history of head trauma or alcohol dependence are known to be more prone to delirium, and their treatments differ. During examination, doctors may perform short tests measuring cognitive functions.

How is delirium treated?

Because delirium is the manifestation of bodily problems in the form of mental illness, its fundamental treatment is identifying and treating the underlying physical problem. In addition to physical examination, blood tests may be requested to identify the problem. Depending on the suspected disease, radiological imaging (chest X-ray, tomography, MRI) may sometimes be ordered.

Treatment targets the problem identified through investigations. If delirium is due to water, salt or mineral imbalance, fluid supplementation and replacement of deficient minerals are options. If infection is the underlying problem, antimicrobial treatment takes priority. If pain is responsible, relieving it may improve the condition; if painkillers are responsible, simplifying medication or reducing the dose may help. Identifying and treating whatever the problem is constitutes the main treatment for delirium. How long does delirium take to resolve is also a question whose answer depends on treatment of the underlying condition. Unfortunately, despite all efforts, the problem causing delirium cannot be clearly identified in many patients.

While treating the underlying illness, improving quality of life, establishing a sleep-wake pattern and reducing the risk of unintentional harm to oneself or others are also primary aims.

For this reason, patients should

1. if possible be observed in a quiet, uncrowded room where they can receive individual care and be monitored closely by both relatives and the treatment team.
2. Dimming or turning off lights at night and allowing daylight into the room during the day will support restoration of the day-night cycle.
3. Because patients may be confused, caregivers introducing themselves before speaking, care by the same nurses and caregivers when possible, and frequent reminders of where the patient is, why they are there, the day of the week and how long they have been in hospital will improve awareness of surroundings (reorientation).
4. Similarly, having a calendar, clock or familiar belongings in the room supports awareness of surroundings.
5. Patients should be reassured when restless and distressed. Hallucinations or hearing voices may sometimes make them very upset. Family members should neither agree with and join the hallucinations (for example: “Yes, Mom, I see those spiders too. I’ll have them cleaned away; don’t worry”), nor try to convince the patient they do not exist (for example: “There’s nothing there; come and try touching it if you want”). Instead, acknowledge the patient’s distress and try to redirect attention (for example: “I don’t see the spiders you see, but I can see you are very upset. This can sometimes happen when someone is ill. If you like, watch some television or close your eyes and try to sleep; I’ll be here…”).
6. Sometimes the behavioral methods above may not help. Medication may then be given to reduce restlessness and inability to stay still, restore sleep patterns and alleviate hallucinations. Antipsychotic drugs are often the first treatment option. In severe cases, adding sedative drugs called benzodiazepines may be necessary.

Conclusion

Delirium is still insufficiently recognized. This causes distress to both patients and relatives, accidental injuries through falls and similar events, and reduced quality of life. Above all, because delirium is an alarm for an underlying physical problem, failure to identify and treat it means the underlying problem remains untreated and brings a risk of death. Reporting sudden-onset confusion to your doctors without delay is very important and necessary.

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