What is the treatment for agitation in hospice patients with terminal illness?

From the Guidelines

I strongly recommend using haloperidol as the first-line medication for agitation in hospice care, starting with 0.5-1mg orally every 4-6 hours as needed, or 0.5-1mg subcutaneously/intravenously for more severe agitation, as supported by the most recent guidelines 1. The treatment of agitation in hospice patients with terminal illness requires a comprehensive approach that prioritizes symptom control and quality of life.

• The symptoms of delirium, which can manifest as agitation, should be controlled with antipsychotic, neuroleptic drugs such as haloperidol, risperidone, olanzapine, or quetiapine fumarate 1.
• For patients who don't respond adequately to haloperidol, consider increasing the dose gradually or adding lorazepam 0.5-1mg every 4-6 hours, as lorazepam can be effective in managing agitation that is refractory to high doses of neuroleptics 1.
• Alternative options include chlorpromazine, olanzapine, or quetiapine if haloperidol is contraindicated or ineffective, and non-pharmacological approaches such as maintaining a calm environment, ensuring adequate pain control, and providing reassurance through familiar faces and voices should be implemented alongside medication 1.
• It's essential to start with low doses in hospice patients who are often frail and more sensitive to medication side effects, and to regularly reassess the need for continued treatment as the patient's condition changes, as delirium in patients with advanced cancer and limited life expectancy may shorten prognosis 1.
• Opioid dose reduction or rotation can also be considered for patients with severe delirium, and caregivers should be supported in caring for their loved one and coping with this distressing condition 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Parenteral medication, administered intramuscularly in doses of 2 to 5 mg, is utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms Depending on the response of the patient, subsequent doses may be given, administered as often as every hour, although 4 to 8 hour intervals may be satisfactory. The maximum dose is 20 mg per day.

The treatment for agitation in patients, as per the label for haloperidol (IV), involves the administration of the drug intramuscularly in doses of 2 to 5 mg for prompt control of acute agitation.

• The dose may be repeated as often as every hour, with intervals of 4 to 8 hours being satisfactory in some cases.
• The maximum dose is 20 mg per day.
• It is essential to note that the label does not explicitly mention hospice patients with terminal illness, but it does provide general guidance for the treatment of agitation. 2

From the Research

Treatment Options for Agitation in Hospice Patients

The treatment for agitation in hospice patients with terminal illness can be managed through various protocols and pharmacological interventions.

• A protocol for the acute control of agitation in palliative care was developed, which includes a combination of haloperidol and midazolam 3.
• The protocol was used 86 times in 27 patients, with a median time of 15 minutes to control agitation, and no significant complications were reported 3.
• Another study found that a protocol for the control of agitation in palliative care was effective and safe, with 91% of agitation episodes controlled with only the first dose 4.

Pharmacological Interventions

Pharmacological interventions for agitation in hospice patients can include:

• Haloperidol, which can control agitation without inducing sedation, but may be associated with extrapyramidal symptoms 5.
• Benzodiazepines, such as lorazepam, diazepam, and midazolam, which have a more pronounced sedating activity 5.
• Atypical antipsychotics, such as aripiprazole, ziprasidone, and olanzapine, which may be better tolerated and have sedative properties 5.
• The combination of haloperidol and promethazine, which may be the best choice based on empirical evidence 5.

Management of Agitation

The management of agitation in hospice patients should be tailored to the individual patient, taking into account their underlying medical condition, autonomy, and safety 6.

• Non-coercive de-escalation strategies should be used first, followed by pharmacologic interventions and physical restraints as necessary 6.
• Face-to-face examination, monitoring, and documentation by the physician are essential in managing agitation 6.
• Patient autonomy, safety, and medical well-being should be paramount in the management of agitation 6.