Managing Cancer-Related Mood Shifts & Emotional Distress

Families often describe the same thing in different words. He has become cruel. She says things she would never have said. He is suspicious of me. She cannot be reasoned with. It is frightening. It is also one of the most misread parts of cancer care, because the natural reading is that the person has chosen to become someone else.

Very often, they have not. Anger, suspicion, disinhibition (losing the usual brakes on behavior), flat indifference and sudden agitation are frequently symptoms with medical causes. Those causes can be identified, and in many cases treated. Report the change to the oncology team. That is far more useful than absorbing it.

Delirium is a confused mental state. It involves changes in awareness, thinking, judgement, sleep patterns and behavior. It typically develops over hours or days rather than gradually, and it fluctuates. That is why families often report that the person was fine in the morning and unrecognisable by evening.

It takes three forms. Hyperactive delirium looks like restlessness, anxiety, agitation and refusal to cooperate. Hypoactive delirium looks like sleepiness or depression, and is often missed entirely. Mixed delirium alternates between the two.

Common triggers in cancer include advanced disease and brain tumors. Medicines are another, particularly high doses of opioids. So are dehydration, infection, and stopping or withdrawing a medicine. Older age raises the risk. This part matters: many episodes are caused by medication or dehydration, and they are reversible once the cause is corrected.

Dexamethasone and prednisone are used widely in cancer care. They treat brain swelling and nausea, and they form part of some treatment regimens. Psychiatric effects are common enough to be a recognized clinical problem. Reported rates across studies range from under 2 per cent to over 60 per cent, depending on the definition and the dose.

Dose appears to be the most important risk factor, particularly at 80 mg of oral prednisone or equivalent and above. Reactions do occur at lower doses too. Early signs usually appear within the first five days of starting. They range from insomnia, irritability and restlessness through to agitation, mania, and in some cases hallucinations or delusions. Reduction and tapering resolves symptoms fully in around 92 per cent of patients. So raise this early rather than enduring it.

Cancer in or near the brain can change behavior directly, and so can the swelling around it. What changes depends on where it sits. Frontal involvement in particular can affect judgement, impulse control, empathy and emotional regulation. The person may not be aware anything has changed. Some of this improves when swelling is treated. Some of it persists.

Not everything is neurological. Uncontrolled pain makes people short-tempered. Severe fatigue removes the reserve people normally use to be gracious. Fear, loss of independence and the humiliation of needing help with intimate tasks all come out as irritation. The person nearest is the one who receives it.

Describe the change the way you would describe a fever. What is new. When it started. Whether it comes and goes. What else changed around the same time. Useful details include any new medicine or dose change in the preceding week. Also whether the person is drinking, whether they are constipated or short of breath, whether sleep has reversed, and whether they know the date and where they are.

Ask directly whether delirium has been considered. Ask whether any current medicine could be responsible. Ask whether the steroid dose can be reviewed.

Understanding the medical cause does not mean accepting anything. Driving, access to firearms, wandering, cooking unsupervised and physical aggression are safety issues rather than things to manage at home. The section below sets out who to call, and how fast.

It is also possible to hold both facts at once. The illness is producing the behavior. And the behavior is doing real harm to the people absorbing it. Both deserve attention.

• Call 911 or go to an emergency department if the person strikes someone, threatens someone with a weapon, or is set on driving or leaving the house while confused and cannot be redirected. Move yourself and anyone else out of reach first, then call.
• Call 911 or go to an emergency department if the confusion arrived over a few hours, the person cannot be kept awake or roused, they have a seizure, or a fever of 100.4°F (38°C) or higher appears during chemotherapy. That fever is an emergency by itself (CDC).
• Call the oncology team the same day if confusion, suspicion or agitation came on over days, or comes and goes across the day. Ask outright whether this could be delirium. Say what medicine or dose changed in the week before.
• Call the oncology team the same day if irritability, sleeplessness or agitation began within the first few days of starting or raising a steroid such as dexamethasone. The dose can usually be reviewed.
• Call the oncology team within a day or two if judgement, impulse control or warmth has drifted over weeks, and the person does not seem to notice it themselves. Ask whether the brain has been imaged.
• Call within a day or two if the person has stopped drinking, is newly constipated, or is sleeping in the day and awake all night. Each of these can be feeding the confusion, and each can be treated.

• Palliative Care Network of Wisconsin — Corticosteroid-Induced Psychiatric Symptoms
• NCI — Last Days of Life (PDQ)
• NCI — Emotions and Cancer