An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients

Psychiatric issues in older cancer patients

Although many patients are surviving longer than in the past, a cancer diagnosis may shatter the dream of a dignified old age for elderly patients. Cancer diagnosis and treatment often produce psychologic stresses resulting from the actual symptoms of the disease, as well as perceptions of the disease and its stigma. Concerns related to cancer have particular meaning for aging individuals who undergo these situations in the context of retirement, widowhood, other medical disabilities and other losses. Today, patients and families are more interested in treatment issues, and quality of life, both during and after treatment. In this article we discuss late life depression, anxiety and delirium as they relate to elderly patients coping with cancer.

A double-blind trial of risperidone and haloperidol for the treatment of delirium

To compare the clinical efficacy of haloperidol and risperidone for the treatment of delirium, the authors performed a double-blind comparative study. Twenty-eight patients with delirium were recruited and randomly assigned to receive a flexible-dose regimen of haloperidol or risperidone over 7 days. The severity of delirium was assessed by using Memorial Delirium Assessment Scale scores. Scores for each group decreased significantly over the study period. However, no significant differences in mean Memorial Delirium Assessment Scale scores between groups were found. The group-by-time effect was not significant. In addition, there was no significant difference in the frequency of response to the drugs between the two groups. One patient in the haloperidol group experienced mild akathisia, but no other patients reported clinically significant side effects. These data show no significant difference in the efficacy or response rate between haloperidol and risperidone in the treatment of delirium.

Delirium: current trends in prevention and treatment

Delirium is a disturbance of consciousness, cognition and perception that occurs frequently in medically ill patients. Although it is associated with increased morbidity and mortality, it is often not recognised and treated by physicians. Predisposing factors are believed to have multiplicative effects and include dementia, advanced age and male gender. Recently developed models allow for the estimation of the risk of developing delirium during a hospitalisation, based on predisposing factors and acute additional stressors. Although it has been shown to be efficacious, the prevention of delirium is underutilised. Prevention consists of aggressive management of known risk factors and early detection. Limited data exist to support specific pharmacological interventions for its treatment. In this article, the avail-able published literature regarding the prevention and treatment of delirium is systematically reviewed.

Psychotic symptoms in patients with medical disorders

Psychotic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. They may be a part of an independent psychiatric illness associated with the underlying medical condition or induced by substance use or medications. The presence of psychotic symptoms can contribute to misdiagnosis or complicate the management of the comorbid medical illness. Psychiatrists must be familiar with the assessment and management of psychotic disorders in patients with comorbid medical disorders. Medications that may be used to treat psychosis include antipsychotic agents, benzodiazepines, or possibly certain anticonvulsants. Selecting the appropriate medication requires knowledge of the pharmacokinetics of different agents and their side effect profile. Understanding the neuropsychiatric effects of medications and drug-drug interactions may help in preventing psychotic symptoms.

Efficacy of risperidone in treating the hyperactive symptoms of delirium

Forty-one delirious patients who received risperidone treatment and 36 who received haloperidol treatment were retrospectively analysed. Ten-point visual analog scales (scored 0 for none to 10 for extremely severe) for hyperactive and hypoactive syndromes of delirium were used for efficacy evaluation. Psychiatrists scrutinized the medical records and determined the global severity of the syndrome for each patient. The results showed that risperidone and haloperidone were both effective for treating hyperactive symptoms of delirium. The liaison psychiatrists tended to recommend haloperidol for patients with severely hyperactive symptoms and risperidone for older patients and patients with moderate hyperactive symptoms. The patients on risperidone needed much less anticholinergic agent. The maximal daily dose of risperidone was in the range 0.5-4.0 mg, with a mean of 1.17+/-0.76 mg, which was much lower than that for schizophrenia. The present study showed that risperidone appears to be effective and safe for the treatment of delirium.

Haloperidol in palliative care

Haloperidol is one of 20 'essential' medications in palliative care. Its use is widespread in palliative care patients. The pharmacology of haloperidol is complex and the extent and severity of some of its adverse effects, particularly extrapyramidal adverse effects (EPS), may be related to the route of administration. Indications for the use of haloperidol in palliative care are nausea and vomiting and delirium. Adverse effects include EPS and QT prolongation. Sedation is not a common adverse effect of haloperidol. It is important that palliative care practitioners have a comprehensive understanding of the indications, doses, adverse effects and pharmacology of haloperidol. This review is intended to address these issues.

Delirium in advanced cancer patients

Delirium in advanced cancer is often poorly identified and inappropriately managed. It is one of the most common causes for admission to clinical institutions and is the most frequently cited psychiatric disorder in terminal cancer. Diagnosis of delirium is defined as a disturbance of consciousness and attention with a change in cognition and/or perception. In addition, it develops suddenly and follows a fluctuating course and it is related to other causes, such as cancer, metabolic disorders or the effects of drugs. Delirium occurs in 26% to 44% of cancer patients admitted to hospital or hospice. Of all advanced cancer patients, over 80% eventually experience delirium in their final days. In advanced cancer, delirium is a multifactorial syndrome where opioids factor in almost 60% of episodes. Delirium in such patients, excluding terminal delirium, may be reversible in 50% of cases. Providing adequate end-of-life care for a patient with delirium is the main challenge. The family needs advice and it is important to create a relaxing environment for the patient. The primary therapeutic approach is to identify the reversible causes of delirium. Some therapeutic strategies have been shown to be effective: reduction or withdrawal of the psychoactive medication, opioid rotation, and hydration. Haloperidol is the most frequently used drug, and new neuroleptics such as risperidone or olanzapine are being tested with good results. Methylphenidate has been used for hypoactive delirium.

Olanzapine vs haloperidol: treating delirium in a critical care setting

OBJECTIVE

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

DESIGN

Prospective randomized trial.

SETTING

Tertiary care university affiliated critical care unit.

PATIENTS

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

INTERVENTIONS

Patients were randomized to receive either enteral olanzapine or haloperidol.

MEASUREMENTS

Patient's delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

MAIN RESULTS

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

CONCLUSIONS

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

Drug therapy for delirium in terminally ill patients

BACKGROUND

Delirium is a common disorder that often complicates treatment in patients with life-limiting disease. Delirium is described using a variety of terms such as agitation, acute confusional states, encephalopathy, organic mental disorders, and terminal restlessness. Delirium may arise from any number of causes, and treatment should be directed at addressing these causes. In cases where this is not possible, or does not prove successful, the use of drug therapy may become necessary.

OBJECTIVES

The primary objective of this review was to identify and evaluate studies examining medications used to treat patients suffering from delirium during the terminal phases of disease.

SEARCH STRATEGY

We searched the following sources: MEDLINE (1966 to July 2003), EMBASE 1980 to July 2003), CINAHL (1982 to July 2003), PSYCH LIT (1974 to July 2003), PSYCHINFO (1990 to July 2003) and the Cochrane Library Volume 2, 2003) for literature pertaining to this topic.

SELECTION CRITERIA

Prospective trials with or without randomization and/or blinding involving the use of pharmacological agents for the treatment of delirium at the end of life were considered.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality using standardized methods and extracted data for evaluation. Outcomes related to both efficacy and adverse effects were collected.

MAIN RESULTS

Thirteen potential studies were identified by the search strategy. Of these, only one study met the criteria for inclusion in this review. This study evaluated 30 hospitalized AIDS patients receiving one of three different agents: chlorpromazine, haloperidol, and lorazepam. Analysis of this trial found chlorpromazine and haloperidol to be equally effective. Chlorpromazine was noted to slightly worsen cognitive function over time but this result was not significant. The lorazepam arm of the study was stopped early as a consequence of excessive sedation.

REVIEWERS' CONCLUSIONS

The data from one study of 30 patients would perhaps suggest that haloperidol is the most suitable drug therapy for the treatment of patients with delirium near the end of life. Chlorpromazine may be an acceptable alternative if a small risk of slight cognitive impairment is not a concern. However, there is insufficient evidence to draw any conclusions about the role of pharmacotherapy in terminally ill patients with delirium, and further research is essential.

Psychiatric considerations in the patient receiving organ transplantation: a clinical case conference

Psychiatric consultations to evaluate a patient's suitability to receive organ transplantation can require the integration of multiple types and sources of information. A patient's social support network, history of treatment compliance, ongoing Axis I and Axis II disorders, and understanding of the procedure and follow-up required must all be evaluated during such a consultation. This article presents the case of a woman with borderline personality disorder who developed hepatic failure following a drug overdose, and discusses her evaluation for liver transplantation. The discussion frames the pertinent issues in the transplant evaluation and describes the perioperative (transplant) management of the borderline patient.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Impaired communication capacity and agitated delirium in the final week of terminally ill cancer patients: prevalence and identification of research focus

The maintenance of intellectual activity is an important area in the "good death" concept. To clarify the communication capacity levels of terminally ill cancer patients in their final week, and to identify factors contributing to the development of communication capacity impairment and agitated delirium, a retrospective study was performed on 284 consecutive hospice inpatients. The data were collected by chart review, and two independent raters measured the degree of communication capacity and agitation in the last week, using multiple items from the Memorial Delirium Assessment Scale, the Communication Capacity Scale, and the Agitation Distress Scale. The percentages of patients who could achieve complex communication were 43%, 28%, and 13% at 5 days, 3 days, and 1 day before death, respectively. Agitated delirium was identified in 20%. Patients receiving opioids at a dose of > or =120 mg oral morphine equivalents/day one week before death were significantly unable to communicate clearly 3 days before death (0.48 [0.28-0.84], P=0.011). Male gender and the presence of icterus were identified as significant contributors to the development of agitated delirium (odds ratios [95% C.I.]=2.6 [1.4-5.0], P<0.01; 2.4 [1.3-4.4], P< 0.01). These findings demonstrate that communication capacity impairment and agitated delirium are frequently observed in terminally ill cancer patients, and are significantly correlated with a higher dose requirement of opioids and the presence of icterus. To explore the best management to maintain the intellectual activity of dying patients, research should focus on a homogeneous sample of patients receiving high-dose opioids and those with hepatic encephalopathy. In the meanwhile, clinicians should educate patients and family members about the nature of the dying process and help facilitate the completion of life purposes requiring complex mental activities before the latest stages of cancer.

Treatment for delirium with risperidone: results of a prospective open trial with 10 patients

Delirium is a common psychiatric illness among medically compromised patients. There is an increasing opportunity to use atypical antipsychotics to treat delirium. The effects of these drugs on delirium, however, the most appropriate way to use them, and the associated adverse effects remain unclear. To clarify these points, a prospective open trial on risperidone was carried out in 10 patients with delirium. At a low dose of 1.7 mg/d, on average, risperidone was effective in 80% of patients, and the effect appeared within a few days. There were no serious adverse effects. However, sleepiness (30%) and mild drug-induced parkinsonism (10%) were observed; the symptom of sleepiness was a reason for not increasing the dose. One patient responded to a dose as low as 0.5 mg/d, so it is recommended that treatment start at a low dose, which may then be increased gradually. This trial is a preliminary open study with a small sample size, and further controlled studies will be necessary.

Preventing Delirium at the End of Life: Lessons From Recent Research

Preservation of the ability to think clearly, in comfort, is a goal of end-of-life care. Recent research on delirium at the end of life suggests clinical strategies for prevention of cognitive impairment. Clinicians should consider early warnings of mild delirium such as impairment in attention and short-term memory by following the patient's ability to remember 3 words or to attend to digit span before the patient is disoriented. If cognitive impairment is noted, clinicians should pay attention to reversible causes. This article reviews clinical concerns about opiates, benzodiazepines, steroids, hepatic encephalopathy, timely use of neuroleptic medications, and caretaking strategies at home.

Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer

Nausea and vomiting are difficult symptoms to manage in patients with advanced cancer. Several classes of antiemetics are available, including phenothiazines, butyrophenones, substituted benzamides and selective serotonin antagonists, as well as corticosteroids. Most patients will respond to either single agents or combinations that frequently include corticosteroids. A minority of patients will have nausea that fails to respond. The atypical antipsychotic, olanzapine, relieves nausea in some patients failing to respond to the usual antiemetics. Two case reports are presented and the rationale for olanzapine's benefit is discussed.

The controversy over "chemical restraint" in acute care psychiatry

In many healthcare settings, medications are considered a less invasive alternative to the use of physical restraint for agitated patients experiencing a behavioral crisis, a practice that is often referred to as "chemical restraint." However, recent federal regulations appear to equate chemical and physical restraint and to characterize both as extraordinary practices that should not be undertaken lightly. Although many clinicians consider the term "chemical restraint" pejorative, since it does not reflect the possibility that forced medication may be clinically necessary and have a beneficial effect, the term is embedded in recent regulatory language. The author first reviews the controversy over the concept of chemical restraint as it has developed in the mental health literature and regulatory policy. As yet there is no consensus among clinicians or policy makers whether such use of medications is a form of coercion or a form of patient-focused intensive care. The author then discusses precipitants of emergency care and clinical factors and situations that may lead to the use of medications in a way that might be considered chemical restraint. Such factors include clinical and demographic characteristics of patients, institutional characteristics, and staff perception and attitudes. In the final section of the article, the author reviews the recommendations concerning the emergency use of medications given in the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies and discusses treatment developments that have occurred since the time of the survey on which those guidelines were based.

The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses

We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.