What is the best medication for a hospice patient with terminal anxiety and agitation?

Best Medications for Terminal Anxiety and Agitation in Hospice Patients

For hospice patients with terminal anxiety and agitation, benzodiazepines are the first-line treatment, with midazolam being the preferred option for patients unable to swallow and lorazepam for those who can still take oral medications. 1

Medication Selection Algorithm

Step 1: Assess the Patient's Ability to Swallow

• Can swallow: Use oral medications
• Cannot swallow: Use parenteral (subcutaneous/IV) medications

Step 2: Choose Appropriate Medication Based on Swallowing Ability

For Patients Who Can Swallow:

1. First-line: Lorazepam

   • Dosing: 0.5-1 mg orally four times daily as needed (maximum 4 mg/24 hours)
   • For elderly or debilitated patients: 0.25-0.5 mg (maximum 2 mg/24 hours)
   • Advantage: Can be used sublingually if swallowing becomes difficult 1

2. For patients with delirium component:

   • Haloperidol 0.5-1 mg orally at night and every 2 hours as needed
   • Increase in 0.5-1 mg increments as required (maximum 10 mg daily, 5 mg for elderly) 1

For Patients Who Cannot Swallow:

1. First-line: Midazolam

   • Dosing: 2.5-5 mg subcutaneously every 2-4 hours as needed
   • If needed frequently (more than twice daily), consider continuous infusion via syringe driver at 10 mg over 24 hours
   • Reduce to 5 mg over 24 hours if eGFR <30 mL/minute 1, 2

2. For patients with delirium component:

   • Levomepromazine 12.5-25 mg subcutaneously as starting dose, then hourly as needed
   • For elderly patients: 6.25-12.5 mg
   • Maintain with subcutaneous infusion of 50-200 mg over 24 hours 1

Special Considerations

Addressing Underlying Causes

Before initiating medication, assess and address reversible causes of anxiety and agitation:

• Explore patient's concerns and anxieties
• Ensure effective communication and orientation
• Ensure adequate lighting
• Treat physical causes (pain, hypoxia, urinary retention, constipation) 1

Medication-Specific Considerations

Benzodiazepines (Lorazepam, Midazolam)

• Advantages: Rapid onset, effective for anxiety and agitation
• Cautions: May cause respiratory depression, paradoxical agitation
• Monitoring: Level of sedation, respiratory rate, effectiveness for symptom control 1, 2

Antipsychotics (Haloperidol, Levomepromazine)

• Best for: Patients with delirium component to their agitation
• Advantages: Antipsychotic effect for delirious patients
• Cautions: Orthostatic hypotension, extrapyramidal symptoms
• Monitoring: Extrapyramidal symptoms, level of sedation 1

Combination Therapy

For severe or refractory symptoms, consider combining medications:

• Add benzodiazepine to antipsychotic for agitation that persists despite antipsychotic treatment
• Example: Haloperidol plus midazolam or lorazepam 1

Practical Management Tips

1. Titration: Start with lower doses in elderly, debilitated patients, or those with renal/hepatic impairment

2. Continuous Assessment: Regularly evaluate symptom control and adjust medications accordingly

3. Anticipate Needs: If symptoms are recurring, consider scheduled dosing or continuous infusion rather than as-needed administration

4. Medication Administration: For patients losing ability to swallow, transition from oral to parenteral routes proactively 3

5. Avoid Abrupt Discontinuation: When patients have been on long-term antidepressants, consider risks of discontinuation syndrome 4

Common Pitfalls to Avoid

1. Undertreating symptoms due to fear of hastening death - appropriate symptom management is essential for quality of life

2. Failing to reassess regularly - terminal anxiety and agitation may require frequent dose adjustments

3. Relying solely on medications - continue non-pharmacological approaches alongside medication

4. Using antipsychotics as first-line for anxiety without delirium - benzodiazepines are preferred for pure anxiety 1

5. Delaying treatment - prompt management of terminal anxiety and agitation is crucial for patient comfort and family distress

By following this approach, clinicians can effectively manage terminal anxiety and agitation in hospice patients, prioritizing comfort and quality of life during their final days.