What is the role of medications like Haldol (haloperidol), Ativan (lorazepam), and Seroquel (quetiapine) in managing agitation in hospice patients?

Medication Management for Agitation in Hospice Patients

For hospice patients with agitation, a stepwise approach should be used, starting with non-pharmacological interventions, then using haloperidol (Haldol) as first-line medication for delirium-related agitation, with lorazepam (Ativan) added for refractory cases, and quetiapine (Seroquel) as an alternative when haloperidol is contraindicated or ineffective. 1

First Steps: Addressing Reversible Causes

Before initiating medication:

• Identify and treat reversible causes of agitation:
  • Explore patient concerns and anxieties
  • Ensure effective communication and orientation
  • Provide adequate lighting
  • Address hypoxia, urinary retention, constipation
  • Treat pain, infection, or CNS events
  • Review medications for potential contributors 1

Medication Algorithm for Agitation Management

1. Delirium-Related Agitation

First-line: Haloperidol (Haldol)

• For patients able to swallow:

  • Start with 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 in elderly patients) 1

• For patients unable to swallow:

  • Same dose subcutaneously as required
  • Consider subcutaneous infusion of 2.5-10 mg over 24 hours 1

For severe delirium:

• Haloperidol 0.5-2 mg every 1 hour until episode is controlled 1

Alternative agents if haloperidol is ineffective or contraindicated:

• Quetiapine (Seroquel) 50-100 mg PO/SL twice daily
• Risperidone 0.5-1 mg twice daily
• Olanzapine 2.5-15 mg daily 1

2. Anxiety-Related Agitation

First-line: Lorazepam (Ativan)

• For patients able to swallow:

  • 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours)
  • Reduce to 0.25-0.5 mg in elderly/debilitated patients (maximum 2 mg in 24 hours)
  • Oral tablets can be used sublingually (off-label) 1

• For patients unable to swallow:

  • Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed
  • For frequent use (more than twice daily), consider subcutaneous infusion via syringe driver starting with 10 mg over 24 hours
  • Reduce to 5 mg over 24 hours if eGFR <30 mL/minute 1

3. Refractory Agitation

For agitation refractory to haloperidol:

• Add lorazepam 0.5-2 mg every 4-6 hours 1

For patients unable to swallow with delirium:

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

Special Considerations

Timing and Life Expectancy Considerations

• For patients with weeks to days of life expectancy:

  • Focus on symptom control and family support
  • Consider rectal or intravenous haloperidol if oral route unavailable
  • Remove unnecessary medications and tubes 1

• For iatrogenic agitation:

  • Treat underlying cause if possible
  • Note that agitation may be mistaken for pain, leading to higher opioid doses that can exacerbate delirium
  • Consider opioid rotation if opioid-induced delirium is suspected 1

Monitoring and Dose Adjustments

• Titrate starting doses to optimal effect
• Decrease doses in hepatic or renal failure
• Monitor for:
  • Extrapyramidal symptoms with haloperidol
  • Excessive sedation with benzodiazepines
  • QT prolongation with antipsychotics 1, 2

Common Pitfalls to Avoid

• Using benzodiazepines as first-line therapy for delirium (can worsen confusion)
• Failing to address underlying reversible causes before medication
• Inadequate monitoring for medication side effects
• Using excessive doses in elderly or frail patients
• Not reassessing the need for continued medication 2

Remember that the goal of treatment is to provide adequate symptom control, reduce patient/family distress, and optimize quality of life while minimizing medication side effects. Regular reassessment of medication needs and effectiveness is essential in the dynamic hospice care environment.