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A Prospective Study

Peter G. Lawlor, MB; Bruno Gagnon, MD; Isabelle L. Mancini, MD; Jose L. Pereira, MB; John Hanson, MSc; Maria E. Suarez-Almazor, MD, PhD; Eduardo D. Bruera, MD

Arch Intern Med. 2000;160:786-794.

Context  Delirium impedes communication and contributes to symptom distress in patients with advanced cancer. There are few prospective data on the reversal of delirium in this population.

Objectives  To evaluate the occurrence, precipitating factors, and reversibility of delirium in patients with advanced cancer.

Design  Prospective serial assessment in a consecutive cohort of 113 patients with advanced cancer. Precipitating factors were examined using standardized criteria; 104 patients met eligibility criteria.

Setting  Acute palliative care unit in a university-affiliated teaching hospital.

Main Outcome Measures  Delirium occurrence and reversal rates, duration, and patient survival. Strengths of association of various precipitating factors with reversal were expressed as hazard ratios (HRs) in univariate and multivariate analyses.

Results  On admission, delirium was diagnosed in 44 patients (42%), and of the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%) of the 52 deaths. In univariate analysis, psychoactive medications, predominantly opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration (HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44; 95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR, 0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium had poorer survival rates than controls (P<.001).

Conclusions  Delirium is a frequent, multifactorial complication in advanced cancer.Despite its terminal presentation in most patients, delirium is reversible in approximately 50% of episodes. Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively.

From the Edmonton Palliative Care Program, Grey Nun's Hospital (Drs Lawlor, Gagnon, Mancini, Pereira, and Bruera), the Division of Palliative Medicine, Department of Oncology (Drs Lawlor, Pereira, and Bruera), and the Department of Public Health Services (Dr Suarez-Almazor), University of Alberta, and the Division of Epidemiology, Alberta Cancer Board, Cross Cancer Institute (Mr Hanson), Edmonton, Alberta. Dr Gagnon is now with Palliative Care Service, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec; Dr Mancini, with Unite de Soins Supportifs, Soins Palliatifs et de Rehabilitation, Institut Jules Bordet, Universite Libre de Bruxelles, Brussels, Belgium; Dr Suarez-Almazor, with Department of Medicine, Baylor College of Medicine, Houston, Texas; and Dr Bruera, with Department of Symptom Control and Palliative Care, MD Anderson Cancer Center, Houston.

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