Reversible, Narcotic-Associated Mental Status Impairment in Patients with Metastatic Cancer

Abstract

Pain and mental status were assessed in a series of 35 consecutive hospitalized patients with metastatic cancer receiving narcotics for pain that was difficult to control. Forty-five episodes of mental status impairment were detected in 27 of these patients. Fifteen patients had dose-related oversedation or organic brain syndrome. In only 4 could the narcotic dose be decreased without exacerbating the pain. Eleven patients had mental status impairment associated with factors other than the narcotic dose. These factors were: concurrent CNS-depressant drugs, presence of fever or infection, or changing from parenteral to average oral equianalgesic dose of narcotic. When these factors were corrected, mental function improved and remained stable despite resumption of the previous narcotic dose. Delirium occurred more frequently in patients over 65, while oversedation without delirium was more frequent in the younger group. For some patients with advanced metastatic cancer, pain relief and intact mental status cannot coexist. For others, correction of factors other than narcotics which can impair function can often lead to improved mental status without decreasing narcotic dose or decreasing the degree of pain control.

The panorama of opioid‐related cognitive dysfunction in patients with cancer

“…39 In hospitalized cancer patients, who were on opioids and referred to a supportive care service, Leipzig et al found that 77% (27 of 35) experienced "impaired mental status" at least once when observed prospectively for a minimum of 7 days. 40 The impaired mental status was based on an impaired assessment on a brief modified portion of the Minimental State Examination. 41 The frequency of cognitive impairment on objective testing in patients with cancer on admission to a palliative care unit has been reported in the range of 20 -44%, 3,42-44 whereas 80 -90% show impairment before death.…”

“…The sensitivity and sophistication of neuropsychologic testing is variable, sometimes simple and crude 40 and at other times detailed and sophisticated. 18 Variability in opioid doses, choice of opioid, dosing intervals, administrative routes, and timing of neuropsychologic testing in relation to opioid administration also must be recognized.…”

“…38 Other studies have studied cognitive impairment or delirium from a broader perspective and have variably examined the occurrence rates, the multifactorial etiology, and management aspects of these phenomena. 4,5,39,40 This review explores the literature evidence documenting the prevalence and pattern of opioid-associated cognitive effects and then addresses the pathophysiology, impact, assessment, and specific management of opioid-associated cognitive impairment, largely within the context of delirium.…”

Delirium e demência no idoso: existem fatores de risco comuns?

“…macoterapia, particularmente se, entre as múltiplas medicações em uso, incluem-se drogas com ação anticolinérgica, anti-histamínica, sedativo-hipnóticos ou narcóticos, que conferem risco duas a três vezes maior para o desenvolvimento do delirium (Seymour e Pringle, 1983;Leipzig et al, 1987;Cantu e Korek, 1991).…”

“…Entre eles, desidratação (Levkoff et al, 1986), hipotensão peri-operatória, baixo débito cardíaco, hipóxia no pós-operatório e o uso de medicações com propriedades anticolinérgicas (Millar, 1981;Seymour et al, 1983;Williams et al, 1985b;Gustafson et al, 1988;Schor et al, 1992;Han et al, 2001). O tipo de anestesia (geral ou bloqueio raquimedular) parece não influenciar na incidência do delirium peri-operatório (Riis et al, 1983;Ghoneim, et al, 1988;Warren et al, 1990).…”