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Conrad Notes
a timely medical meeting newsletter

P. M. Silberfarb, MD, Dartmouth Medical School, Lebanon, NH, emphasized the need to recognize and treat cognitive impairment. In adult cancer patients, delirium is the most common syndrome associated with cognitive impairment. Unfortunately the diagnosis of delirium is missed nearly two-thirds of the time in cancer patients, according to recent survey data from Lebanon and New York City. High dose chemotherapy and radiation often produce cognitive impairment and delirium.

Clinical Syndrome of Delirium Symptoms develop rapidly (hours or days) and fluctuate. Patients do not volunteer problems with cognition. Careful listening discloses impaired memory, orientation, awareness, attention, comprehension, and perception. Heightened efforts by the patient can temporarily overcome a deficit resulting in a fluctuation of mental status.

The delirium syndrome includes insomnia, vivid dreams, increased sensitivity to light and sound, and a subjective sense of difficulty in marshalling one's thoughts. The cerebral damage may lead to:

  • impaired awareness of self, surroundings, and their relationships
  • impaired memory
  • disturbance of attention especially in shifting from one task to another
  • impaired directive and abstract thinking
  • decreased perceptual discrimination with a tendency to delusions and hallucinations
  • impaired spatial/temporal orientation
  • decreased or increased alertness (hyperactivity)
  • disturbed sleep
  • fluctuating awareness
Measuring Cognitive Impairment Few health care workers take the time to estimate cognitive function. A brief questionnaire will uncover subtle changes otherwise missed. The more elaborate assessment scale, proposed by Breitbart et al (unpublished) consists of 10 items: awareness, disorientation, memory, digit span, attention, thinking, delusions, perceptions, psychomotor activity, and arousal.
Management of Delirium Silberfarb stressed the importance of recognizing cognitively impaired patients for prompt initiation of treatment. In addition to therapy, Silberfarb suggested two simple ways to help the patient: (1) have a clock or calendar in the patient's room for time reorientation and (2) assign tasks within the ability of the patient to minimize stress. Symptom scores and electrolyte imbalance (for example, hypercalcemia) help in formulating a treatment timeline.

Haloperidol is the drug of choice for treating delirium in the cancer patient according to the Hypermedia PDQ Project (http://oncolink.upenn.edu). The recent study of Breitbart et al (Am J Psychiatry 153:231,1996) showed halperidol or chlorpromazine, but not lorazepam, useful in managing delirium in AIDS patients. He noted the controversy on whether treatment for the hallucinations of delirium should be given to the near-death patient. Is it more desirable to help achieve a more alert and communicating patient or allow the delirium to persist as a psychological defense?

For professional correspondence, please contact Dr. Silberfarb at: peter.m.silberfarb@dartmouth.edu

Eugene A. Conrad

Presented at Third World Congress of Psycho-Oncology, 5 Oct 1996
CONRAD NOTES, © October 1996 All Rights Reserved
Eugene A. Conrad, PhD, MPH / ISSN 1078 / posted 9-Dec-1996

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