What are the recommendations for managing agitation in Parkinson's disease (PD) patients receiving palliative care?

Management of Agitation in Parkinson's Disease for Palliative Care Patients

For managing agitation in Parkinson's disease patients receiving palliative care, atypical antipsychotics such as quetiapine should be used as first-line pharmacological treatment, with careful consideration of potential adverse effects.

Assessment and Non-Pharmacological Approaches

Before initiating medication:

• Address reversible causes of agitation and delirium first by:

  • Exploring patient concerns and anxieties 1
  • Ensuring effective communication and orientation 1
  • Providing adequate lighting 1
  • Explaining to caregivers how they can help 1

• Treat underlying reversible causes such as:

  • Hypoxia, urinary retention, and constipation 1
  • Medication effects (especially anticholinergics and dopaminergics) 1
  • Pain (present in 58.82% of Parkinson's patients in the final 72 hours of life) 2

Pharmacological Management

First-Line Treatment

• Atypical antipsychotics:
  • Quetiapine: 50-100 mg PO/SL twice daily 1
    • Preferred in Parkinson's disease due to lower risk of worsening motor symptoms
  • Olanzapine: 2.5-15 mg daily 1
    • Use with caution as it may worsen motor symptoms

Second-Line Treatment

• Haloperidol (typical antipsychotic):
  • For moderate delirium: 0.5-1 mg orally twice daily 1
  • For severe agitation: 0.5-2 mg every hour until episode is under control 1
  • Use with caution as it may worsen parkinsonian symptoms

For Refractory Agitation

• If agitation is refractory to high doses of neuroleptics, consider adding:

  • Lorazepam: 0.5-2 mg every 4-6 hours 1
  • Start with lower doses (0.25-0.5 mg) in elderly or debilitated patients 1

• For patients unable to swallow:

  • Midazolam: 2.5-5 mg subcutaneously every 2-4 hours as required 1
  • If needed frequently, consider subcutaneous infusion via syringe driver starting with 10 mg over 24 hours 1
  • Reduce dose to 5 mg over 24 hours if eGFR <30 mL/minute 1

Special Considerations for Parkinson's Disease

• Patients with Parkinson's disease and cognitive impairment are 4.67 times more likely to experience agitation at the end of life 2

• Avoid typical antipsychotics when possible as they can worsen motor symptoms by blocking dopamine receptors 3

• Consider continuing dopaminergic therapy even at end of life:

  • Transdermal rotigotine is often used when patients can no longer take oral medications 2
  • Recommended dose should be maintained to prevent worsening of motor symptoms 2

• Terminal stiffness, though infrequently documented, can be an important symptom to address 2

Monitoring and Titration

• Titrate starting doses to optimal effect 1

• Monitor for:

  • Worsening of parkinsonian symptoms 3
  • QT prolongation with antipsychotics 1
  • Excessive sedation 1

• For patients with severe delirium who are unable to swallow:

  • Consider levomepromazine 12.5-25 mg subcutaneously (6.25-12.5 mg in elderly patients) 1
  • Maintain with subcutaneous infusion of 50-200 mg over 24 hours 1

Caregiver Support

• Support caregivers in caring for their loved one and coping with this distressing condition 1

• Educate family and caregivers about expected symptoms and management approaches 1

• Provide resources for caregiver respite and emotional support 4

Remember that Parkinson's disease patients have a high palliative symptom burden throughout their disease course, equivalent to advanced malignancy 2, making appropriate symptom management crucial for quality of life.