Chemo Care

Confusion and Cancer Treatments:

Description: Confusion is a temporary or permanent state of brain dysfunction. It may also be referred to as delirium. Confusion may range from a slight difficulty in recalling information and focus attention, or it may include severe changes in a person's behavior.

Symptoms:

• You may be unable to remember things, and have difficulty concentrating and following directions. You may feel "disoriented"
• You may have trouble learning new things, or you may forget how to do things that you have done over and over again.
• You may have trouble handling money, or may forget what happened in a day.
• You may feel agitated, or "jumpy", with abrupt changes in your mood and behavior (mood swings)
• You may be more drowsy than usual. You may be overly tired, or very weak (fatigued). It may be hard for you to do any kind of your normal activities.
• You could have trouble falling asleep at night, or staying asleep. You may not feel rested after a long night of sleep.
• With severe confusion, you may not notice that your behavior is inappropriate. Your family and friends may notice the difference.
• You may have fever, or chills, if you have an infection

It is important to treat the underlying cause of the confusion, whether it is due to medications, illness, or your disease. Episodes of confusion may last minutes, to days, or longer. This can affect your quality of life.

Cancer Therapies Associated with Confusion:

• Chemotherapy medications such as: hydroxyurea, high dose ifosfamide, or methotrexate.
• Biologic therapy such as: high dose interleukin-2, interferon.

Physical Conditions That Can Cause Confusion:

• Dehydration
• Electrolyte disorders, such as high blood calcium levels (hypercalcemia); high or low blood sodium levels (hypernatremia or hyponatremia)
• Anemia, or low blood hemoglobin concentration, may cause impaired memory. Hemoglobin carries oxygen to your tissues. With less oxygen to your brain especially, it becomes harder to concentrate.
• Heart problems (your heart isn't pumping properly, causing less oxygen to travel to your tissues)
• A severe infection in your blood, or central nervous system.
• Brain cancer, or cancer cells in your central nervous system (such as lymphoma, or cancer that has spread to the brain)
• Endocrine or metabolism disorders - such as extremely high or low blood sugar levels in those with diabetes, or thyroid disorders

Other medications that can cause confusion are used to treat:

• Pain
• Anxiety and sleep disorders (such as insomnia, or an inability to sleep)
• Heart problems
• Stomach upset.

Other causes of confusion:

• Depression and lack of sleep can cause you to feel confused.
• Alcohol use or abuse- the use of alcohol, and withdrawal from alcohol

Symptom Management:

Things you can do (the patient):

• Any changes in your thinking or behavior should be evaluated if they begin to affect your lifestyle. If you have any changes in memory, thinking, or concentration, discuss them with your healthcare provider

If you are mildly confused, or if you notice that you are starting to have difficulty with details:

• Keep one note pad or diary in your possession at all times. Write down everything that is important to you. Keep lists of things you need to do in the same place.
• Keep a detailed calendar of events at all times.
• With the help of friends or family members, try to keep a timeline, as to when you started having difficulty remembering things, and doing certain activities.
• Take a friend or family member with you to all your doctor's appointments. It helps to have someone else present, to clarify questions during and after the visit.
• Ask your family and friends for help. If you need assistance with certain activities, such as cooking, cleaning, and the laundry. It is okay to ask, especially if they have offered. You may need assistance in the home form awhile.
• Try to form a daily routine, and stick to it. Inform family and friends of your routine.
• If you are having trouble remembering names, ask a friend or family member, and repeat the name a few times. Although you may feel embarrassed, it is okay to admit that you are "forgetful", and ask the person for their name. (Ex: "Hi, I am ______. I know we have met before, but I am a little forgetful. What is your name again?")
• Keep your mind busy with crossword puzzles, or reading. Exercise your brain, just as you should exercise your body,
• If you take any new medications, or change your diet, make sure you tell all your healthcare providers. Certain medications may interact with one another, causing you to be confused.

If you are experiencing more periods of confusion:

• Do not be left alone by yourself. It is important to have friends or family members around to assist you, when you need it.
• Make sure to keep familiar people around, to help re-orient you to your surroundings.
• Make sure you keep your environment quiet. Eliminate background TV or radio noises. Try to focus your attention while performing your tasks.
• If you are upset or agitated, your healthcare provider may prescribe certain medications to relax you.
• Wearing hearing aids and glasses may help to decrease the amount of confusion you are experiencing.
• Hallucinations are common. Discuss what you are experiencing. It helps to have someone around to explain or make "sense" of your possible visions and illusions. The visions that you see are very real to you, and may cause you to be frightened.
• If your hallucinations were an unfavorable side effect of medications, record the suspected name of the drug to tell other healthcare providers in the future.
• Pneumonia and the flu are common sources of confusion in adults. If you are over the age of 65 years, or have an altered immune system due to chemotherapy, chronic disease or steroid use, the Centers for Disease Control (CDC) recommends that you receive a flu vaccine every year, and a pneumonia vaccine every 5 years. Discuss this with your healthcare provider if this is right for you.
• Also to prevent pneumonia and lung infections: You need to circulate air from the bottom of their lungs and out of your lungs (oxygenation). Using an incentive spirometer for 15 minutes a day, twice a day, can help promote oxygenation.
• If you are still smoking, you should quit. Discuss with your healthcare provider techniques that can help you quit.
• Physical therapy is important if you are recovering from an illness or period of confusion, when you were less active. Try to exercise, as tolerated, to maintain your optimal level of functioning, or recover strength.
• People who are confused may forget to exercise. Make a daily walk with a friend or family member a part of your routine. Even light walking may help you to promote the flow of oxygen in your lungs and blood (oxygenation), which will help your cognition. .
• Make sure to get enough sleep at night. People who do not sleep well at nighttime may feel confused in the daytime. If you have trouble sleeping:
• Do not eat or exercise within 2 hours of bedtime
• Make the room dark
• If you have an electronic clock, or one with an illuminated face, turn the face away from you.
• Use the bed only for sleeping
• Keep a consistent schedule. Make sure you go to bed each night and wake up each morning, at the same time.
• Minimize daytime naps. If you must take a nap, do not sleep for more than an hour at a time. Longer naps will make you feel more tired, and interrupt nighttime sleep.
• If these techniques do not work, consult your healthcare provider.
• If you feel anxious, use relaxation techniques to decrease the amount of anxiety you have. Place yourself in a quiet environment, and close your eyes. Take slow, steady, deep breaths, and try to concentrate on things that have relaxed you in the past. This is called behavioral therapy.
• Participating in support groups may be helpful to discuss with others what you are going through. Ask your healthcare provider if he or she is aware of any support groups that would benefit you.
• If you are ordered a medication to treat your confusion, do not stop taking this, or any medications unless your healthcare provider tells you to.
• Take the medication exactly as directed.
• Do not share your pills with anyone.
• Many medications to treat pain may cause you to feel dizzy or drowsy. Do not operate any heavy machinery unless you know how the medication will affect you.
• If you miss a dose of your medication, discuss with your healthcare provider what you should do.
• If you experience symptoms or side effects or therapy, especially if severe, be sure to discuss them with your health care team. They can prescribe medications and/or offer other suggestions that are effective in managing such problems.

Medications to Minimize Chemo-Induced Confusion:

Treatment of a confused state is based upon getting rid of the underlying cause.

Antibiotics - If your doctor or healthcare provider suspects that you have an infection, he or she may order antibiotic pills or intravenous (IV).

• Commonly prescribed antibiotics for infections include azithromycin (Zithromax®), and levofloxacin (Levaquin®). These medications have broad-spectrum coverage, and are specifically good for lung infections, or pneumonia, that may have caused your confusion.
• If you are prescribed antibiotics, take the full prescription. Do not stop taking pills once you feel better.

Antidepressants - are used to treat depression in adults. People who are tired and depressed are at a higher risk for health problems. Depression may also lead to confusion.

Antidotes - People who have experienced drug toxicity from narcotics, anti-anxiety medications, or chemotherapy drugs may receive an "antidote", to reverse these effects. A side effect of these medications may be confusion.

Bisphosphonates - Cancer cells that spread to the bone can secrete (produce) substances that can cause other cells found in the bone, called osteoclasts, to dissolve or "eat away" a portion of the bone. These tumors or lesions weaken the bone and can lead to complications. Some of the complications resulting from this bone breakdown are bone pain, fractures and hypercalcemia, (increased levels of calcium in the blood). Hypercalcemia can lead to confusion.

• Bisphosphonates, such as pamidronate (Aredia®), and zoledronate (Zometa®) may be used to treat hypercalcemia (high blood calcium), and to decrease pain.

Corticosteroids - Corticosteroids work by decreasing inflammation (swelling) in many areas of the body. The corticosteroids prevent infection- fighting white blood cells (polymorphonuclear leukocytes) from traveling to the area of swelling in your body. This means you are more prone to infection while on steroids.

• You may be taking steroids if you have cancer that has spread to your brain. The swelling in the areas where the tumors are located could be causing your confusion.
• You may take steroids if you have a lung problem, such as Chronic Obstructive Lung Disease (COLD), and it has become worse, altering your blood oxygen levels. Lowered blood oxygen levels may cause confusion.
• It is important to note that while steroids are used to treat certain things that cause confusion, a side effect of this medication is "mood swings". If you, a friend or a family member notice any changes in your behavior, notify your healthcare provider.

Narcotics -Long-periods of pain can cause you to be confused. However, a side effect of narcotics may be a confused state as well. It is important to control your pain, to decrease your chances of being confused or disoriented from the pain. However, be careful of narcotic medications that may cause you to be confused as a side effect of the medication.

• Opiates such as Morphine Sulfate may cause hallucinations.
• Make sure you discuss with your healthcare provider common side effects, such as confusion, constipation, drowsiness, nausea and vomiting, and how to control these side effects. If you discuss your concerns with your healthcare provider, they are likely able to help.

Non-steroidal anti-inflammatory (NSAID) agents and acetaminophen - such as naproxen sodium, ibuprofen and acetaminophen (Tylenol®), may provide relief of headaches, and generalized pain. These may be appropriate medications in people with pain, who may feel confused, alone or in addition to other medications. Unlike narcotics, NSAIDS and acetaminophen rarely cause confusion.

• If you are to avoid NSAID drugs, because of your type of cancer or chemotherapy you are receiving, acetaminophen up to 4000 mg per day (two extra-strength tablets every 6 hours) may help.
• It is important not to exceed the recommended daily dose of acetaminophen, as it may cause liver damage. Discuss this with your healthcare provider.

If you are suffering from impaired cognitive skills as a result of chemotherapy, the following guidelines suggest when to call your doctor or health care provider:

• Fever of 100.5° F (38° C), chills or sore throat (possible signs of infection if you are receiving chemotherapy).
• Increased confusion, or falling "down"
• Begin to become more confused, have trouble handling money, or lose track of the days.
• If you have more trouble learning things than you usually do, or if you forget things that you have done repeatedly in the past.
• Feeling your heart beat rapidly, or experience palpitations
• Bleeding that does not stop after a few minutes; black or tarry stools, or blood in your stools or urine
• Dizziness or lightheadedness, "feeling faint", especially if severe.