Assessing Delirium, Depression, and Hopelessness

In looking for evidence of delirium, depression and hopelessness in cancer patients, asking the right questions and noticing subtle symptoms is crucial.

Delirium is a common problem. The majority of the population will experience it at some point. And it is particularly common among cancer patients, particularly hospice patients. So why do we fail to recognize it, asked Robin Fainsinger, professor and director, division of palliative care medicine, University of Alberta, Canada.

“Sometimes the delirious patient is so quiet and we are in such a hurry that we don’t notice our interaction with the patient is kind of one-sided. Sometimes we are so technologically focused on care that we don’t assess correctly,” Fainsinger says.

There are traps to avoid in assessing whether there is underlying dementia, says Fainsinger, who spoke at the 2010 Supportive Oncology Conference in Chicago.

“We sometimes miss the reason that the patient is agitated. We’re trying to treat the delirium and may be missing the fact that their bladder is distending toward their tonsils. If we would just put the catheter in, perhaps the agitation would stop.”

Constipation is another underlying reason for a patient’s agitation. Agitation may be the only way they can express the problem, Fainsinger says. He summarized the key points in managing delirium:

Discontinue the offending drugs
Switch opioids or reduce opioid use
Hydrate
Treat infection
Treat hypercalcemia
Exclude urinary retention and constipation as underlying factors

Environmental manipulation can also help the patient with delirium, such as comfortable lighting, presence of a family member, and minimizing noise levels and staff changes.

Fainsinger points out the need to screen for underlying dementia, the need to recognize that delirium is superimposed on dementia, and the need to understand the limits of screening tools, such as the Mini-Mental State Exam (MMSE). He recommends the Montreal Cognitive Assessment (MoCA) which was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses attention and concentration, executive functions, memory, language, conceptual thinking, calculations and orientation. It takes about 10 minutes, is available free online and may be used and reproduced withoutpermission.

Harvey M. Chochinov, MD, PhD, professor at the Department of Psychiatry, University of Manitoba, echoed the need for thorough assessment in finding depression, hopelessness and suicidal tendencies. Dr. Chochinov led the Manitoba Palliative Care research unit in developing the Patient Dignity Inventory (PDI) — an assessment tool for asking a patient about a list of 25 feelings. They are asked to rate the feelings from 1-5 where 1 is not a problem and 5 is an overwhelming problem.

Some of the questions are more obvious but others call for a deeper look such as “feeling I am no longer who I was” or “feeling that I am a burden to others.” They can help discover sources of anguish for patients. Chochinov said his team’s research has found that hopelessness is a good predictor of suicide, even moreso than depression.

By applying the PDI in palliative care, researchers found that many feelings registered higher in importance than feeling depressed or anxious. Number one for patients was “Not being able to carry out tasks associated with daily living (e.g. washing myself, getting dressed) and the second greatest concern was “not being able to attend to my bodily functions.”

Chochinov said the PDI was used in a study of 120 Canadian psychosocial oncology experts from across the country that were asked to begin using it their practices. One key finding in that study was improvement in facilitating conversations between the clinicians and their patients.

“In 79% of instances, when the clinician used this instrument they ended up saying that the patient disclosed one or more issues that was previously unknown to them,” Chochinov said.