CONFUSION

Confusion affects about 30% of cancer patients at some stage in their illness. It is especially common in elderly patients when their environment is changed (for example, by admission to a hospital or in-patient hospice).

The features of confusion are reduced level of consciousness, disorientation and misperceptions. Usually the patient appears drowsy, easily startled and frightened, or is rambling and behaving inappropriately. Concentration is poor. Disorientation is easily assessed by simple questions, but remember that not knowing the day or time is common in hospitalized patients. Misperceptions can be elicited by asking “Has anything frightened or puzzled you recently?”

Causes of confusion – The following check-list should be considered in assessing the patient:

• Drugs

• Pain or discomfort

• Full bladder

• Impacted feces

• Brain metastases or cerebrovascular accident

• Infection (pulmonary, urinary, septicemia)

• Heart failure

• Biochemical imbalance (urea, calcium, sodium, glucose)

• Alcohol or benzodiazepine withdrawal (“delirium tremens”)

• Extreme anxiety (facing approaching death)

«  Confusion appears worse if the patient is deaf.

Psychotropic drugs (phenothiazines, benzodiazepines, tricyclics) can cause confusion (due to deteriorating liver or renal function, even if the patient has been on them a long time and the dose has not been changed).

Other drugs that can cause confusion include:

• Pentazocine

• Indomethacin

• Digoxin

• Beta-blockers

• Diuretics

• Atropine

• Anti-Parkinsonian drugs

• Sulfonamides

• Phenytoin

• Cimetidine

Assessment – In severe agitated confusion (delirium) there is exaggeration of underlying emotions and memories. The patient may be aggressive and paranoid or alternatively timid and terrified. Urgent sedation may be needed (for example, haloperidol 10mg IM or chlorpromazine 100mg IM repeated every hour if necessary).

When talking with a confused patient, it may not be possible to understand the content of speech, but it may be possible to sense the person’s mood. (“You seem to be feeling sad.”)

Information needed includes:

• Patient’s previous personality

• Alcohol history

• Fluid balance (examine for a full bladder)

• Bowel history (and rectal examination)

• Capillary blood glucose (if diabetic)

• Signs of infection (fever, sweats, flushing, tachycardia)

• Neurological signs (weakness, poor coordination, dysphasia)

• Mid-stream clean catch urine specimen

• Blood tests (urea, electrolytes, glucose)

Hyponatremia is a rare cause of confusion. Plasma sodium concentration below 120mEq/L [120mmol/L]can be a cause of nausea, drowsiness, confusion or seizures. It can be due to excessive doses of diuretics.

Very rarely, hyponatremia results from the syndrome of inappropriate secretion of anti-diuretic hormone (ADH) in small (oat) cell carcinoma of the bronchus, and is diagnosed by a low plasma osmolality (less than 275mosmol/Kg), a urinary osmolality higher than the plasma level (usually around 500mosmol/Kg), and a urinary sodium above 20mmol/L. Treatment is by restricting fluids or giving demeclocycline 600mg 4 times a day, which inhibits the tubular effect of ADH.

«  Signs of infection can be masked by steroids, and are often absent in the elderly.

Management options:

• Exclude physical causes (pain, retention, infection)

• Explain to patient

• Quiet, well-lit familiar room

• Familiar people (staff or family)

• Stop unnecessary drugs

• Provide alcohol if habitual

• Avoid sedation if possible

• Start drug treatment if confusion is uncontrolled

«  Confusion is the most difficult problem of all to cope with at home.

Confusion is distressing to family members. They usually need detailed explanation and a lot of support. (“It is part of the illness, she is not losing her mind.”) Confusion often fluctuates, so there may be lucid intervals.

Drug treatment – Psychotropic drugs cannot reverse confusion, but may be needed to quiet distressing agitation, paranoia or hallucinations. Haloperidol 5mg 2 to 4 times a day is usually effective and not too sedating. (In the elderly or frail, haloperidol 1.5mg 2 times a day may be sufficient.) Chlorpromazine 10mg to 50mg 3 times a day is more sedating.

If tremor or rigidity become troublesome add trihexyphenidyl 1mg to 2mg 4 times a day (build up dose slowly), which is anti-cholinergic.

Anxiety or agitation not associated with hallucinations or psychosis is best treated with diazepam. Agitated depression requires a tricyclic.

Very occasionally an agitated aggressive patient needs urgent sedation with chlorpromazine 100mg IM repeated if necessary every 1 to 6 hours.

Distressing terminal confusion in the last hours of life is best treated with morphine, chlorpromazine and scopolamine. For severe terminal agitation methotrimeprazine 50mg to 75mg every 4 hours is very useful. (It is a phenothiazine with about twice the potency of chlorpromazine.) (see Terminal Phase)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.