What is the recommended anti-anxiety medication for a palliative 95-year-old patient with bowel obstruction and Nil Per Os (NPO)?

From the Guidelines

For a palliative 95-year-old patient with bowel obstruction who is NPO, midazolam is the recommended anti-anxiety medication, typically administered via subcutaneous route at a dose of 2.5–5 mg/4 h, as it provides effective anxiolysis with a rapid onset of action 1. Given the patient's condition, the primary goal is to alleviate anxiety and discomfort while minimizing the risk of adverse effects.

• Midazolam's short half-life and ability to be administered subcutaneously make it an ideal choice for this patient population, as it allows for flexible dosing and minimizes the risk of accumulation 1.
• Lorazepam is an alternative option, which can be given sublingually or parenterally at 0.5-1mg every 4-6 hours, but midazolam is preferred due to its faster onset of action and shorter half-life 1.
• It is essential to carefully titrate the dose based on the patient's response and monitor for signs of respiratory depression, while balancing the need for comfort and anxiolysis in end-of-life care.
• Non-pharmacological approaches to anxiety management should also be considered alongside medication therapy to provide comprehensive care.
• The healthcare team should prioritize the patient's comfort and adjust medication accordingly, rather than adhering to strict dosing guidelines 1.

From the FDA Drug Label

Care must be taken to individualize and carefully titrate the dose of midazolam to the patient’s underlying medical/surgical conditions, administer to the desired effect being certain to wait an adequate time for peak CNS effects of both midazolam and concomitant medications, and have the personnel and size-appropriate equipment and facilities available for monitoring and intervention For elderly or debilitated patients, an initial dosage of 1 mg/day to 2 mg/day in divided doses is recommended, to be adjusted as needed and tolerated

The recommended anti-anxiety medication for a palliative 95-year-old patient with bowel obstruction and Nil Per Os (NPO) is midazolam (IV) or lorazepam, but since the patient is NPO, midazolam (IV) is more suitable.

• The dose of midazolam (IV) should be individualized and carefully titrated.
• For lorazepam, an initial dosage of 1 mg/day to 2 mg/day in divided doses is recommended for elderly or debilitated patients, but this may not be suitable for a patient who is NPO. 2 3

From the Research

Management of Anxiety in Palliative Care

For a 95-year-old patient with bowel obstruction and Nil Per Os (NPO), management of anxiety is crucial for improving quality of life.

• The use of anxiolytics such as haloperidol may be considered to manage dyspnea-related anxiety, as mentioned in the study 4.
• However, it is essential to note that the primary focus should be on managing the underlying symptoms and conditions, such as bowel obstruction and constipation, which can contribute to anxiety.
• The study 5 highlights the importance of involving the patient and family in decision-making and prioritizing symptom management, quality of life, and dignity of death.

Pharmacologic Agents for Symptom Management

• Octreotide, metoclopramide, and dexamethasone may be used to manage symptoms of bowel obstruction, as seen in the case study 5.
• Narcotics, octreotide, and Decadron were used in the palliative care group in the study 6, showing improvement in symptom relief.
• The choice of pharmacologic agents should be individualized based on the patient's specific needs and medical condition.

Palliative Care Service

• The study 6 demonstrates that a formal palliative care service can improve the quality of care for patients with stage IV cancer and bowel obstruction, with benefits in symptom management and end-of-life discussion.
• Palliative care consultation can help optimize management strategies for patients with malignant bowel obstruction, as highlighted in the study 7.