Yesne Alici

Evidence-Based Treatment of Delirium in Patients With Cancer

Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

Pharmacologic treatment options for cancer-related fatigue: current state of clinical research.

Fatigue is a highly distressing symptom of cancer associated with significant psychological morbidity and reduced quality of life. Cancer-related fatigue (CRF) has been underreported, underdiagnosed, and undertreated. Fatigue and depression may coexist in patients with cancer, and considerable overlap of symptoms often occurs. This has led researchers to examine the role of psychotropic medications to treat fatigue. Psychostimulants, wakefulness-promoting agents, antidepressants, and cholinesterase inhibitors have been studied for CRF treatment. Methylphenidate has been studied most and is effective and well tolerated despite common side effects. Some preliminary data support using modafinil for patients with CRF. Antidepressant studies have shown mixed results. Paroxetine shows benefit for fatigue, primarily when it is a symptom of clinical depression. Bupropion sustained release may have psychostimulant-like effects and, therefore, may be beneficial in treating fatigue. Donepezil, a cholinesterase inhibitor, has shown benefit only in open-label trials. Randomized, placebo-controlled trials with specific agents are needed to further assess the efficacy and tolerability of psychotropic medications in CRF treatment.

A comprehensive review of palliative care in patients with cancer

Abstract One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.

Nonalcoholic Thiamine-Related Encephalopathy (Wernicke-Korsakoff Syndrome) Among Inpatients With Cancer: A Series of 18 Cases

BACKGROUND Wernicke-Korsakoff Syndrome (WKS) is a neuropsychiatric syndrome caused by thiamine deficiency. Cancer predisposes to thiamine deficiency through various mechanisms. Although many case reports exist on nonalcoholic WKS in cancer, larger qualitative studies are lacking. METHOD Retrospective study of patients admitted to a cancer hospital and diagnosed with WKS during routine care on a psychiatric consultation service. Only patients with at least 1 additional supporting feature (magnetic resonance imaging findings, low serum thiamine concentrations, or response to treatment) were included. Data pertaining to demographics, risk factors, phenomenology, and outcomes were abstracted from medical records by chart review. RESULTS In all, 18 patients were included. All patients developed WKS during cancer treatment. Hematologic malignancy, gastrointestinal tract tumors, low oral intake, and weight loss were common risk factors. All patients presented with cognitive dysfunction, most commonly impaired alertness, attention, and short-term memory. All were diagnosed by operational criteria proposed by Caine et al., 1997 (where 2 of the following are required: nutritional deficiency, ocular signs, cerebellar signs, and either altered mental status or mild memory impairment). Few exhibited Wernickes classic triad. Diagnostic and treatment delay were common. Only 3 patients recovered fully. CONCLUSION Nonalcoholic WKS can occur during cancer treatment and manifests clinically as delirium. Diagnosis should be made using operational criteria, not Wernickes triad. Most patients were not underweight and had normal serum concentration of vitamin B12 and folate. A variety of mechanisms might predispose to thiamine deficiency and WKS in cancer. Given the high frequency of residual morbidity, studies should focus on decreasing diagnostic and treatment delay.

High rate of thiamine deficiency among inpatients with cancer referred for psychiatric consultation: results of a single site prevalence study

Thiamine deficiency (TD) is increasingly recognized in medically ill patients. The prevalence of TD among cancer patients is unknown. This study aims to characterize the prevalence of TD among inpatients with cancer.

Antipsychotic-induced akathisia in delirium: A systematic review.

OBJECTIVE Akathisia is a neuropsychiatric syndrome characterized by subjective and objective restlessness. It is a common side effect in patients taking antipsychotics and other psychotropics. Patients with delirium are frequently treated with antipsychotic medications that are well known to induce akathisia as a side effect. However, the prevalence, phenomenology, and management of akathisia in patients with delirium remain largely unknown. The purpose of this review was to examine the medical literature in order to establish the current state of knowledge regarding the prevalence of antipsychotic-induced akathisia in patients with delirium. METHOD A systematic review of the literature was conducted using the EMBASE, MEDLINE, PsycINFO, and CINAHL databases. Ten studies addressing the incidence of akathisia in patients taking antipsychotic medication for delirium were identified and included in our review. RESULTS The included studies reported a variable prevalence of antipsychotic-induced akathisia. A higher prevalence was found in patients taking haloperidol. Among atypical antipsychotics, paliperidone and ziprasidone were associated with a higher risk of akathisia. The risk for akathisia appeared to be a dose-related phenomenon. SIGNIFICANCE OF RESULTS Studies using specific scales for evaluation of akathisia in delirium are lacking. Some populations, such as patients with cancer or terminally ill patients in palliative care settings taking antipsychotics for the treatment of delirium, could be at higher risk for development of akathisia as a side effect.

Prevention of post-operative delirium in older patients with cancer undergoing surgery

Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.

Ethical Waves of the Silver Tsunami: Consent, Capacity, and Surrogate Decision-Making

In the coming decades, the United States and other developed countries will continue to experience an increase in their older populations. With this demographic shift, the numbers of older adults with disorders characterized by impaired cognition—from mild cognitive impairment to various forms of dementia—will grow significantly. Already, Alzheimer disease is the sixth leading cause of death in the United States. 1 The impact of these disorders is already immense, particularly for families and other informal caregivers. Without major improvements in treatment, the effects of dementia and other cognitive disturbances would be staggering in their costs to individuals, families, and society. 2 Calls for major research investment into Alzheimer disease and other dementias have become louder—with dire predictions of economic and personal consequences on a grand scale. 3 The importance of these concerns is urgent and undeniable. Another set of concerns has quietly but insistently emerged alongside dementia’s increasing toll, however. These concerns do not have their own national institute or advocacy organization, and often are added to meetings or reports—if added at all—as “extras”orafterthoughts.Ifleftunaddressed,however, they pose a major threat to dementia research and treatment. The intersecting ethical, clinical, and legal implications of dementia present major challenges in helping families navigate the rocky shores of declining or fluctuatingcognition.It is the collisionof theoryand reality: as abstract ethical principles like “autonomy” slam up against impaired judgment and declining self-care; and as financial exploitation of an impaired elder challenges our desire to help patients live independently as long as possible. It is the difficulty of determining what a loved one “would have wanted,” as idealized notions such as substituted judgment confront the daily experience of family caregivers who must make decisions for their relative.

Prevalence and predictors of depression, pain, and fatigue in older- versus younger-adult cancer survivors

As the number of older adults in the United States continues to grow, there will be increasing demands on health care providers to address the needs of this population. Cancer is of particular importance, with over half of all cancer survivors older than 65 years. In addition, depression, pain, and fatigue are concerns for older adults with cancer and have been linked to poorer physical outcomes.

Antipsychotic‐induced akathisia in cancer settings

Akathisia is a neuropsychiatric syndrome characterized by a subjective inner feeling of restlessness and a compulsion to move accompanied by repetitivemovement of the legs that can also affect the trunk and arms. In clinical settings akathisia occurs as an adverse effect of medications. The Diagnostic and Statistical Manual for Mental Disorders fifth edition defines medication‐induced akathisia as a subjective complaint of restlessness, often accompanied by excessive movements, developed within a few weeks of starting or raising the dosage of a medication or after reducing the dosage of a medication used to treat extrapyramidal symptoms. While several drugs can cause akathisia, antipsychotics are most commonly associated with this adverse effect. These drugs are thought to block D2/D3 receptors at the ventral striatum in the central nervous system causing akathisia. High‐ potency, first‐generation antipsychotics have a higher prevalence of akathisia, compared with low‐ to intermediate‐potency first‐ and second‐generation atypical antipsychotics. Second‐generation antipsychotics differ in terms of their propensity for akathisia as well, with higher rates reported for aripiprazole and lurasidone compared with iloperidone, quetiapine, and clozapine. The prevalence, phenomenology, and management of antipsychotic‐induced akathisia in delirium and palliative care settings have not been vigorously studied. In a recent systematic review, a total of 10 studies that reported incidence of antipsychotic‐induced akathisia in delirium settings were found. Neither of these studies used objective scales for the assessment of akathisia. Among those studies, the prevalence of akathisia varied from 0% to 28.5%, depending on the antipsychotic used and the dose of antipsychotic. A higher incidence was found in patients taking haloperidol and ziprasidone. In a study published in 2013, Crawford and colleagues found an incidence of akathisia of 11% in hospice and palliative care settings at a dose of 2.1 mg of haloperidol daily. The authors concluded that patients with terminal illnesses may be at higher risk for development of this extrapyramidal adverse effect. A Japanese study found a prevalence of akathisia of 4.8% in 483 patients with cancer who met criteria for different psychiatric diagnoses.