Appropriate treatments for agitation and restlessness in hospice patients

As seen in the Consultant Connection June - July 2014 Issue
Matt Alexander Pharm D Candidate , Ohio Northern University

Restlessness and agitation are common issues for the terminally ill patient. There are many different terms used to describe restlessness such as terminal anguish, terminal delirium, and terminal agitation. The signs and symptoms of restlessness vary from patient to patient. Common signs include mood changes, yelling, shouting, a desire to want to move, and non-purpose motor function. The best way to treat restlessness is to first identify possible physical sources such as pain, constipation, nausea, vomiting, dehydration, metabolic disturbances,  withdrawal from nicotine, opioids, or benzodiazepines. Non pharmacological treatments such as cognitive activity, relaxation, breathing exercises, counseling, emotional support, reorientation, and reducing environmental stimuli for restlessness should always be tried first and in conjunction with pharmacological treatment. There are several treatment options for restlessness and agitation once other causes have been ruled out. Treatment options include antipsychotics, benzodiazepines, barbiturates, and opioids. The medication selected should take into account the patient's allergies and medical conditions. Haldol is considered the treatment of choice for restlessness in terminally ill patients showing greater effectiveness with less side effects than many other medications. The minimal dose of haldol should be initiated and titrated to desired effect or until side effects appear. Note that this is only the case for terminal restless associated with the active dying process.
Haldol has a black box warning of increased mortality in patients with dementia related psychosis. Common side effects include extrapyramidal symptoms, tardive dyskinesia, akathisia, insomnia, anxiety, and drowsiness. Olanzapine and risperidone are alternative options of therapy if haldol is contraindicated. These medications also have a black box warning against use in patients with dementia related psychosis. Similar side effects should be monitored for these treatment options. Other treatment options include lorazepam, propofol, and midazolam.

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