Delirium as a contributing factor to “crescendo” pain: Three case reports

Coyle, Nessa; Breitbart, William; Weaver, Susan H.; Portenoy, Russell K.

doi:10.1016/0885-3924(94)90146-5

Cited by 82 publications

(39 citation statements)

References 11 publications

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“…45,46 When one or more of these components is unclear, a physician specialist, with relevant expertise and experience, should be consulted to clarify the assessment.…”

Section: Assessmentmentioning

confidence: 99%

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Irwin

Pirrello

Hirst

et al. 2013

Journal of Palliative Medicine

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Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.

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“…45,46 When one or more of these components is unclear, a physician specialist, with relevant expertise and experience, should be consulted to clarify the assessment.…”

Section: Assessmentmentioning

confidence: 99%

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Irwin

Pirrello

Hirst

et al. 2013

Journal of Palliative Medicine

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“…Specifically, many surveys have demonstrated that opioid doses typically stabilize during long term administration (17,24,62,(64)(65)(66)69,99,(109)(110)(111)(112)(113). When the need for dose escalation occurs, it is usually readily explained by a worsening physical lesion (24,114) or a changing psychological state (115). Analgesic tolerance, therefore, seldom compromises the efficacy of therapy, and concern about tolerance does not justify a decision to withhold or delay a therapeutic opioid trial.…”

Section: Therapeutic Efficacymentioning

confidence: 99%

Opioid Therapy for Chronic Nonmalignant Pain

Portenoy

1995

Pain Research and Management

123

145

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RK Portenoy.Opioid therapy for chronic nonmalignant pain. Pain Res Manage 1996;1(1):17-28. Long term administration of an opioid drug for chronic nonmalignant pain continues to be controversial, but is no longer uniformly rejected by pain specialists. This is true despite concerns that the regulatory agencies that oversee physician prescribing of opioid drugs continue to stigmatize the practice. The changing clinical perspective has been driven, in part, by widespread acknowledgement of the remarkably favourable outcomes achieved during opioid treatment of cancer pain. These outcomes contrast starkly with popular teaching about chronic opioid therapy and affirm the potential for prolonged efficacy, tolerable side effects, enhanced function associated with improved comfort and minimal risk of aberrant drug-related behaviours consistent with addiction. A large anecdotal experience in populations with nonmalignant pain suggests that these patients are more heterogeneous and that opioid therapy will greatly benefit some and will contribute to negative outcomes for others. The few controlled clinical trials that have been performed support the safety and efficacy of opioid therapy, but have been too limited to ensure generalization to the clinical setting. A critical review of the medical literature pertaining to chronic pain, opioid pharmacology and addiction medicine can clarify misconceptions about opioid therapy and provide a foundation for patient selection and drug administration. The available data support the view that opioids are no panacea for chronic pain, but should be considered in carefully selected patients using clinically derived guidelines that stress a structured approach and ongoing monitoring of efficacy, adverse effects, functional outcomes and the occurrence of aberrant drug-related behaviours. Key Words: Addiction, Drug dependence, Nonmaligant pain, Opioids, Pain therapyThérapie opioïde pour la douleur chronique non cancéreuse RÉSUMÉ : L'administration à long terme d'un médicament opioïde pour traiter la douleur chronique non cancéreuse reste sujet à controverse mais n'est plus rejetée de façon uniforme par les spécialistes de la douleur. Ceci est vrai même si l'on s'inquiète de ce que les organismes régulateurs qui supervisent la prescription médicale d'agents opioïdes persistent à stigmatiser cette pratique. Le changement de perspective clinique a été motivé en partie par une reconnaissance généralisée des résultats remarquablement favorables obtenus lors du traitement opioïde de la douleur cancéreuse. Ces résultats contrastent carrément avec ce qui est généralement enseigné sur l'administration à long terme d'un médicament opioïde et, confirment un potentiel d'efficacité durable, des effets secondaires supportables, une augmentation de la capacité fonctionnelle associée à une amélioration du bienêtre et, un risque minimal de comportements aberrants liés au médicament compatibles avec une toxicomanie. Une vaste expérience anecdotique chez des populations souffrant d'une douleur non cancéreus...

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“…1 Delirium in patients with cancer has been associated with adverse outcomes, including decreased performance status 2 ; increased pain and use of breakthrough analgesia 3,4 ; longer length of hospital stay 5,6 ; increased distress for the patient, spouse, caregivers, and nurses [7][8][9] ; and decreased survival.…”

Section: Introductionmentioning

confidence: 99%

Pre- and Post-Transplantation Risk Factors for Delirium Onset and Severity in Patients Undergoing Hematopoietic Stem-Cell Transplantation

Fann

Hubbard

Alfano

et al. 2011

JCO

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A B S T R A C T PurposeTo determine pre-and post-transplantation risk factors for delirium onset and severity during the acute phase of myeloablative hematopoietic stem-cell transplantation (HSCT). Patients and MethodsNinety adult patients with malignancies admitted to the Fred Hutchinson Cancer Research Center for their first HSCT were assessed prospectively from 1 week before transplantation to 30 days after transplantation. Delirium was assessed three times per week using the Delirium Rating Scale and the Memorial Delirium Assessment Scale. Potential risk factors were assessed by patient self-report, charts, and computerized records. Multivariable analysis of time to onset of a delirium episode was undertaken using Cox proportional hazards regression with time-varying covariates. Analysis for delirium severity was carried out using a linear mixed effects model. Validation and sensitivity analyses were performed on the final models. ResultsForty-five patients (50%) experienced a delirium episode. Pretransplantation risk factors for onset and higher severity of delirium were higher mean alkaline phosphatase and blood urea nitrogen (BUN) levels. Poorer pretransplantation executive functioning was also associated with higher delirium severity. Higher doses of opioid medications were the only posttransplantation risk factor for delirium onset (hazard ratio, 1.05; 95% CI, 1.02 to 1.08). Higher opioid doses, current and prior pain, and higher BUN levels were post-transplantation risk factors for greater delirium severity (all P Ͻ .01). ConclusionPre-and post-transplantation factors can assist in identifying patients who are at risk for delirium during myeloablative HSCT and may enable clinical interventions to prevent delirium onset or decrease delirium symptoms. J Clin

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Delirium as a contributing factor to “crescendo” pain: Three case reports

Cited by 82 publications

References 11 publications

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Clarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical Practice

Opioid Therapy for Chronic Nonmalignant Pain

Pre- and Post-Transplantation Risk Factors for Delirium Onset and Severity in Patients Undergoing Hematopoietic Stem-Cell Transplantation

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