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Agitation , terminal restlessness and confusion in palliative care

Authoring team

  • 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:

  1. West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptoms control.
  2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptoms control.

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