What is the best approach to manage agitation in an elderly patient with heart failure in hospice care, likely due to delirium or dementia?

Management of Agitation in Hospice Heart Failure Patients

For agitation in elderly hospice patients with heart failure and suspected delirium or dementia, use low-dose oral antipsychotics—specifically risperidone (0.5-2 mg/day), quetiapine (50-150 mg/day), or olanzapine (5-7.5 mg/day)—while maximizing non-pharmacologic interventions and treating reversible causes, but be aware that recent high-quality evidence suggests antipsychotics may worsen delirium symptoms and increase mortality compared to supportive care alone. 1, 2, 3

Initial Assessment and Non-Pharmacologic Management

Before initiating medications, assess whether the agitation stems from delirium (acute, fluctuating confusion) versus dementia-related behavioral disturbance, as this distinction guides treatment intensity. 2, 1

Maximize non-pharmacologic interventions first:

• Reorientation techniques, cognitive stimulation, and sleep hygiene measures 2
• Environmental modifications: sitting upright positioning, hand-held fans for breathlessness, relaxation techniques 2
• Address reversible causes: pain, constipation, urinary retention, medication toxicity, infections, metabolic disturbances 1, 2

Critical medication review:

• Eliminate or reduce deliriogenic medications, particularly steroids and anticholinergics 2, 1
• Consider opioid rotation if patient is on opioids 1
• Optimize heart failure medications (ACE inhibitors, beta-blockers) as these continue to provide symptom relief even at end of life 2, 4

Pharmacologic Management Algorithm

For Moderate Agitation (Patient Redirectable)

First-line oral antipsychotics (choose one): 2, 1, 5

• Risperidone 0.5-2 mg/day (start 0.5 mg twice daily)
• Quetiapine 50-150 mg/day (start 25 mg twice daily)
• Olanzapine 5-7.5 mg/day (start 2.5 mg at bedtime)

Risperidone is preferred as first-line based on expert consensus for agitated dementia with delusions. 5 Quetiapine may be preferable if the patient has Parkinson's disease or significant cardiovascular comorbidities. 5

Important caveat: A 2017 randomized controlled trial in palliative care patients found that both risperidone and haloperidol resulted in worse delirium symptoms and haloperidol increased mortality compared to placebo plus supportive care. 3 This suggests antipsychotics should be reserved for severe agitation threatening patient or caregiver safety, not mild-moderate symptoms.

For Severe Agitation (Patient Combative, Safety Risk)

Parenteral antipsychotics for acute control: 2, 1

• Haloperidol 2-5 mg IM/IV combined with midazolam 1-5 mg IM/IV for immediate control
• Alternatively, haloperidol, olanzapine, or chlorpromazine parenterally 2

Caution with chlorpromazine: Use only in bed-bound patients due to significant hypotensive effects, which is particularly relevant in heart failure patients. 2

Refractory Agitation Management

If agitation persists despite adequate antipsychotic dosing: 1, 2

1. Increase the dose and/or change route (oral to parenteral) before adding additional agents 1
2. Add lorazepam 0.5-2 mg only after therapeutic neuroleptic levels are achieved, as benzodiazepines alone can cause paradoxical excitation in delirious patients 2, 1
3. Never use benzodiazepines as monotherapy for delirium—they worsen confusion 1

For truly refractory cases in actively dying patients, consider palliative sedation with phenobarbital after consultation with palliative care specialists. 1

Critical Safety Considerations

Avoid benzodiazepines in elderly patients with cognitive impairment as they decrease cognitive performance and increase fall risk. 2 The exception is adding lorazepam to high-dose neuroleptics for refractory agitation. 2, 1

Monitor for extrapyramidal symptoms (EPS): Both haloperidol and risperidone increase EPS risk compared to placebo in palliative care patients. 3 Quetiapine and olanzapine have lower EPS risk. 5

Cardiovascular considerations in heart failure patients: 5

• Avoid clozapine, ziprasidone, and low-potency conventional antipsychotics in patients with QTc prolongation or congestive heart failure
• Quetiapine and risperidone are preferred options given cardiac comorbidities

Mortality risk: Haloperidol was associated with 73% increased mortality risk compared to placebo in the largest palliative care RCT (hazard ratio 1.73,95% CI 1.20-2.50). 3 This underscores the importance of using the lowest effective dose for the shortest duration necessary.

Duration of Treatment

If antipsychotics are initiated and patient responds: 2

• For delirium: attempt to taper within 1 week of symptom resolution
• For agitated dementia: taper within 3-6 months to determine lowest effective maintenance dose
• Reassess need for continuation regularly, especially as goals of care evolve toward comfort

Heart Failure-Specific Symptom Management

Continue addressing the underlying heart failure symptoms that may contribute to agitation: 2

For breathlessness: Low-dose morphine (2.5 mg PO four times daily, titrate to 30 mg/24h maximum) is more appropriate than antipsychotics for dyspnea-related distress 2, 6

For volume overload: Continue diuretic therapy (IV or subcutaneous) as volume management improves function and comfort even at end of life 2

For anxiety related to breathlessness: Consider benzodiazepines specifically for anxiety (not delirium), though evidence is limited 2

Common Pitfalls to Avoid

• Do not reflexively prescribe antipsychotics for mild agitation—the 2017 JAMA trial showed harm. Maximize supportive care first. 3
• Do not use haloperidol as first-line in hospice patients given mortality signal; reserve for severe acute agitation requiring parenteral administration 3, 1
• Do not combine multiple sedating agents without first optimizing single-agent dosing 1
• Do not forget to address pain, constipation, and urinary retention—these are common reversible causes of agitation in dying patients 2, 1
• Do not discontinue heart failure medications prematurely—ACE inhibitors and beta-blockers continue to palliate symptoms until very close to death 2, 4