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Delirium Affects Circadian Rhythm of Breakthrough Pain

Delirium Affects Circadian Rhythm of Breakthrough Pain

MONTREAL—Delirium in patients with advanced cancer appeared to be
associated with changes in the circadian distribution of analgesia for
breakthrough pain and may be due to a reversal of the normal circadian rhythm
in these patients, reported Bruno Gagnon, MD, of McGill University and Montreal
General Hospital.

The study was conducted as part of a prospective study of delirium in
advanced cancer patients in the acute palliative care unit at Grey Nuns
Community Hospital & Health Centre, Edmonton, Alberta. The patient charts
were retrospectively analyzed for breakthrough analgesia use; however, the
patients, nurses, and physicians were blinded to the fact that the review would
be carried out.

Breakthrough analgesia use was divided into three time periods: 11:30 pm to
7:30 am (night); 7:30 am to 3:30 pm (day), and 3:30 pm to 11:30 pm (evening),
corresponding to the length of the nursing shifts.

The study included 104 eligible patients categorized into three groups based
on delirium status: Group 1 (n = 33) had no delirium on admission or during
their hospital stay; group 2 (n = 22) had terminal or nonreversible delirium;
and group 3 (n = 49) had a changing delirium status (at least one period of
delirium in addition to one or more delirium-free periods).

A total of 1,677 patient admission days were analyzed for circadian
distribution of breakthrough analgesia doses: 1,254 days without delirium and
423 days with delirium. The researchers found that the circadian distribution
of breakthrough analgesia doses differed significantly from a random
distribution in both patients with and without delirium (J Pain Symptom Manage
22:826-833, 2001).

During delirium-free days, patients required more breakthrough analgesia
doses during the daytime, compared with a random distribution, whereas when
delirium was present, more breakthrough analgesia was used during the evening
and at night (see Table).

Similarly, the group 2 patients (terminal delirium) received more
breakthrough analgesic doses during the evening, compared with the group 1 (no
delirium) patients. Furthermore, among the group 3 patients (changing delirium
status), the highest breakthrough analgesia use was during the evening when
delirium was present and during the day when delirium was absent.

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