agitation , terminal restlessness and confusion in palliative care
Last reviewed 01/2018
- in advanced illness confusion and mild to moderage degrees of terminal restlessness are common
- severe agitation, anguish or aggression with risk to self or others is fortunately rare
- consider and appropriately treat remediable causes:
- adverse effects of medication (e.g. opioids, steroids)
- pain
- constipation
- urinary retention
- hypoxia
- hypercalcaemia
- infection
- uraemia/ hepatic encephalopathy
- primary brain tumour
- cerebral metastases
- spiritual distress
If the patient is distressed or at risk, sedation is the mainstay of treatment
| Oral PRN | SC stat | SC 24-hour syringe driver* | |
|
Midazolam* Especially if anxiety/restlessness predominates |
2.5 - 5 mg | 5 -30 mg ** | |
|
Levomepromazine Especially if features of paranoia or psychosis are present. Also useful as an antiemetic. Very sedative at higher doses. Smaller doses in elderly |
12.5 -25 mg | 12.5 -25 mg | 12.5 -75 **mg |
|
Haloperidol Especially if features of paranoia or psychosis are present. Also useful as an antiemetic. Smaller doses in the elderly |
1.5 - 2.5 mg | 1.5 - 2.5 mg | 2.5 - 5mg |
* Midazolam may cause disinhibition and paradoxical agitation, particularly at high doses.
** Start at lowest dose in the range especially in frail elderly patients; review dose every 24 hours and increase if necessary by 30% -50% according to additional as required doses. Higher doses than this are occasionally necessary - seek Specialist Palliative Care Team advice.
- Patients who are dying with severe agitation may be very resistant to the effects of sedatives and may need repeat doses at 30 -60 minute intervals until settled
- Occasionally the combined administration of an anti-psychotic and benzodiazepine is required
- For patients requiring rapidly escalating doses of sedatives, contact the Specialist Palliative Care Team for advice
NB: benzodiazepines may occasionally have a paradoxical alerting effect and worsen symptoms. Early and frequent review is essential.
Occasionally the combination of an antipsychotic and benzodiazepine is required (seek specialist advice), e.g. levomepromazine 50mg + midazolam 30mg/24hr(1)
The respective summary of product characteristics must be consulted before prescribing any of the drugs detailed.
Reference:
- West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptoms control.
- West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptoms control.