Delerium in Pain Patients May Masquerade as Depression

NEW YORK--About 30% of the cancer patients he is asked to evaluatefor depression turn out to have delirium, said Memorial Sloan-Ketteringpsychiatrist William S. Breitbart, MD, at a conference sponsoredby Cancer Care, Inc.

"That's because some patients with delirium are hypoalert,lethargic as opposed to agitated. They're lying in bed curledup in the fetal position, looking sad, but the patients' mentalstatus has not been evaluated," he said. "No one hasasked the patient--Do you know where you are? Do you know thename of this place? Do you know what room you're in?"

Such patients may have trouble talking and naming things, or mayhave frank aphasia. They may hallucinate. "The disturbanceoften develops over a short period of time, and the symptoms mayfluctuate," Dr. Breitbart pointed out.

The delirium usually exists in the context of some physical cause,and is common in cancer patients who are in pain and receivingopiates. He pointed out that most patients on stable doses oforal opioids have completely intact mental function.

"They're oriented, alert, and able to think clearly. Butuncontrolled pain can interfere dramatically with the abilityto concentrate," he said. "Patients are more likelyto get confused and disoriented during periods of rapid dose escalation,whether orally or intravenously."

Intravenous or subcutaneous infusions are often used to get rapidcontrol over exacerbation of pain in the hospital, and sometimesin the home setting. "So it's really during these periodsof rapid escalation of dose that oncologists see delirium,"he said.

Treating the Delirium

Delirium in cancer patients may be treated in several ways, Dr.Breitbart noted. The first step is to attempt to identify thecause and correct it. "If during rapid dose titration, apatient goes into delirium, the first thing to do is to lowerthe intravenous dose. If the pain is not controlled, even at thehigh dose at which delirium developed, then another opioid couldbe tried."

Drugs like haloperidol (Haldol) and other related neurolepticsthat control delirium symptoms can be used, and the combinationof benzodiazepines and haloperidol is quite frequently employed,he said.

Haloperidol can be used to treat patients who are agitated aswell as those who are lethargic, Dr. Breitbart said. "Thedoses we use range from 0.5 mg to 5 mg every 2 to 12 hours. Patientswith advanced cancer might get lower doses. Some patients needonly a small dose at night or twice a day. Others who are moreagitated require higher doses."

Typically, a delirious patient being treated with haloperidolwill get 0.5 mg, and then 1 or 2 mg later on, until they becomenondelirious and calm or fall asleep. "Then we will takethat dose and give it to the patient in divided doses over thenext couple of days," Dr. Breitbart said.

The symptomatic treatment of delirium has to be accompanied bya search for its cause, he stressed. Sorting out the psychologicalcomponents from the physical components in cancer is never easy,he said, but taking a multidisciplinary approach can help.