Management of Combative Behaviors in Hospice Patients Using Olanzapine
Olanzapine is recommended at a starting dose of 2.5 mg/day and can be titrated up to a maximum of 10 mg/day for managing combative behaviors in hospice patients, with non-pharmacological interventions implemented concurrently. 1
Dosing and Administration
Initial Approach
- Start with olanzapine 2.5 mg orally at bedtime 1
- For elderly or frail patients, consider starting at the lower end of the dosing range
- Titrate slowly, increasing by 2.5 mg increments as needed
- Maximum recommended dose in hospice patients: 10 mg/day 1
Route of Administration
- Oral administration is preferred for stable patients
- ZYPREXA ZYDIS (orally disintegrating tablets) can be used for patients with difficulty swallowing 2
- For acute situations where oral administration is not possible, intramuscular olanzapine may be considered
Non-Pharmacological Interventions (First-Line)
Implement these strategies before or concurrently with medication:
- Create a calm, familiar environment with personal belongings 1
- Provide structured daily routine and predictable environment 1
- Use simple communication techniques and explain procedures clearly 1
- Implement distraction and redirection strategies 1
- Break complex tasks into simple steps 1
- Apply the ABC (antecedent-behavior-consequences) charting approach to track agitation patterns 1
Monitoring and Follow-up
- Monitor for sedation, orthostatic hypotension, and QT prolongation 1
- Assess for extrapyramidal symptoms (EPS) and cognitive function changes
- Initial follow-up within 1-2 weeks after starting medication 1
- Reassess medication need within 3-6 months, attempting to taper to lowest effective dose 1
- Monitor for common side effects:
- Somnolence
- Weight gain
- Dry mouth
- Constipation
- Dizziness 3
Special Considerations
Benefits Beyond Combative Behavior Control
- Olanzapine can help with:
Cautions
- Avoid in patients with dementia-related psychosis due to increased mortality risk 2
- Use with caution in elderly patients due to increased sensitivity 2
- Consider fall prevention strategies, including home safety evaluation and assistive devices 1
- Monitor for metabolic side effects, particularly weight gain
Overdose Awareness
- Symptoms of overdose include sedation, slurred speech, tachycardia, and agitation 2
- No specific antidote exists; treatment is supportive 2
- Contact Poison Control Center (1-800-222-1222) for management guidance if overdose is suspected 2
Alternative Options When Olanzapine is Contraindicated
- Risperidone: Starting dose 0.25-0.5 mg/day, maximum 2 mg/day 1
- Haloperidol: Starting dose 0.5-1 mg orally at night, maximum 5 mg/day 1
- Avoid benzodiazepines as first-line therapy due to increased risk of falls and cognitive impairment 1
Education and Support
- Educate family and caregivers on:
- Medication administration and expected effects
- Recognition of side effects
- Implementation of non-pharmacological interventions
- Importance of maintaining predictable routines 1
Common Pitfalls to Avoid
- Using excessive doses in elderly or frail patients
- Failing to rule out reversible causes of agitation before starting medication
- Inadequate monitoring for medication side effects
- Not implementing comprehensive non-pharmacological approaches
- Failure to reassess the need for continued medication therapy 1
By following this structured approach, olanzapine can be effectively and safely used to manage combative behaviors in hospice patients while maintaining their dignity and quality of life.