What medications can be used to manage terminal agitation in a patient with Parkinson's disease in hospice care?

Management of Terminal Agitation in Parkinson's Disease Patients in Hospice Care

For terminal agitation in Parkinson's disease patients in hospice care, quetiapine is the first-line medication due to its effectiveness in controlling psychosis without worsening parkinsonian symptoms.

First-Line Medications

Atypical Antipsychotics

• Quetiapine (Seroquel)

  • Starting dose: 12.5-25 mg orally
  • Usual effective dose: 25-150 mg/day 1, 2
  • Advantages: Well-tolerated in PD patients, minimal extrapyramidal effects, effective for psychosis and agitation 2
  • Common side effects: Sedation and orthostatic hypotension 2

• Olanzapine

  • Starting dose: 2.5 mg orally
  • Usual effective dose: 5-10 mg/day 3
  • Caution: May worsen motor symptoms in some PD patients 2

Benzodiazepines

For agitation with anxiety component or refractory to antipsychotics:

• Lorazepam (Ativan)
  • Dosage: 0.5-2 mg orally, IV, or subcutaneously every 4-6 hours 3
  • Particularly useful when agitation is accompanied by anxiety
  • Caution: May cause paradoxical excitation in approximately 10% of patients 3

Second-Line Medications

For Severe Agitation/Delirium

• Midazolam

  • Starting dose: 0.5-1 mg/hour continuous infusion
  • Usual effective dose: 1-20 mg/hour 3
  • Administration: IV or subcutaneous
  • Advantage: Rapid onset, can be co-administered with morphine or haloperidol 3

• Chlorpromazine

  • IV or IM: 12.5 mg every 4-12 hours, or 3-5 mg/hour IV
  • Rectal: 25-100 mg every 4-12 hours 3
  • Usual effective dose: Parenteral 37.5-150 mg/day 3
  • Caution: Higher risk of extrapyramidal symptoms in PD patients

Special Considerations for Parkinson's Disease

1. Avoid typical antipsychotics (e.g., haloperidol) as they block dopamine receptors and significantly worsen parkinsonian symptoms 2

2. Continue dopaminergic therapy when possible:

   • Rotigotine transdermal patch may be used when oral medications are no longer possible 4
   • Consider maintaining dopaminergic therapy to prevent rigidity and discomfort 4

3. Monitor for specific PD-related symptoms:

   • Terminal rigidity may occur and require specific management 4
   • PD patients with cognitive impairment are 4.67 times more likely to experience agitation at end of life 4

Treatment Algorithm

1. Assess for reversible causes of agitation/delirium:

   • Infection, pain, urinary retention, constipation
   • Medication side effects or interactions
   • Discontinue unnecessary medications 5

2. First-line treatment:

   • Start quetiapine 12.5-25 mg orally
   • Titrate as needed up to 150 mg/day based on response

3. If inadequate response:

   • Add lorazepam 0.5-1 mg every 4-6 hours as needed
   • For severe cases, consider midazolam infusion

4. For refractory agitation:

   • Consider palliative sedation with midazolam infusion after consultation with palliative care specialist 3

Common Pitfalls to Avoid

1. Using typical antipsychotics like haloperidol as first-line treatment in PD patients

   • These medications block dopamine receptors and worsen parkinsonian symptoms 2

2. Abruptly discontinuing all PD medications

   • May lead to severe rigidity, discomfort, and neuroleptic malignant-like syndrome
   • Consider maintaining dopaminergic therapy when possible 4

3. Overlooking non-pharmacological interventions

   • Ensure calm environment, familiar caregivers, adequate lighting
   • Provide reassurance and reorientation 5

4. Failing to address underlying causes

   • Pain is present in 58.82% of PD patients in their final 72 hours 4
   • Constipation, urinary retention, and infection are common reversible causes

By following this approach, terminal agitation in Parkinson's disease patients can be effectively managed while minimizing adverse effects on motor function and maintaining patient comfort at the end of life.