From the Guidelines
Muscle spasms and twitching in end-of-life patients on medication pumps should be treated by addressing the underlying cause and using symptomatic management with benzodiazepines, antispasmodics, or anticonvulsants as needed, prioritizing patient comfort and minimizing side effects. The causes of muscle spasms and twitching in these patients can be multifactorial, including metabolic disturbances, medication side effects, dehydration, or neurological deterioration as part of the dying process 1.
Symptomatic Management
For symptomatic management, first-line medications include benzodiazepines such as midazolam or lorazepam. Midazolam can be administered subcutaneously every 4 hours as needed, or via continuous infusion, while lorazepam can be given sublingually or IV every 4-6 hours. For severe or persistent symptoms, adding an antispasmodic like baclofen or increasing the dose of existing sedatives may help. Anticonvulsants such as gabapentin or levetiracetam can be beneficial, especially for myoclonic jerks.
Non-Pharmacological Approaches
Non-pharmacological approaches are also crucial and include gentle massage, repositioning, and ensuring the patient is comfortable. It's essential to explain to family members that muscle twitching is often part of the natural dying process and doesn't necessarily indicate pain or distress. Regular reassessment is vital, as medication needs may change rapidly during end-of-life care, with the goal being to maximize comfort while minimizing side effects.
Evidence-Based Practice
The American College of Physicians recommends using therapies of proven effectiveness to manage pain, dyspnea, and depression in patients with serious illness at the end of life 1. While these guidelines primarily focus on pain, dyspnea, and depression, the principle of using evidence-based therapies to manage symptoms applies broadly, including the management of muscle spasms and twitching.
Prioritizing Patient Comfort
In the context of end-of-life care, prioritizing patient comfort and minimizing distress is paramount. This involves a holistic approach, considering both pharmacological and non-pharmacological interventions tailored to the individual patient's needs and circumstances. By focusing on comfort and symptom management, healthcare providers can improve the quality of life for patients with serious illnesses at the end of life.
From the Research
Causes of Muscle Spasms and Twitching in End of Life Care Patients
- Terminal restlessness, also known as agitated delirium, is a common occurrence at the end of life, characterized by thrashing, agitation, involuntary muscle twitching or jerks, fidgeting, and yelling or moaning 2
- Spasticity, a condition characterized by abnormal muscle tightness due to prolonged muscle contraction, can also cause muscle spasms and twitching 3
- Combination opioid, benzodiazepine, and muscle relaxant usage can increase the risk of adverse events, including muscle spasms and twitching 4
Treatment of Muscle Spasms and Twitching in End of Life Care Patients
- Magnesium supplements have been studied as a potential treatment for skeletal muscle cramps, but the evidence is unclear, and it is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps 5
- Antispastic drugs such as baclofen and tizanidine can reduce stretch reflex activity and may be effective in reducing muscle spasms and twitching, but their effects on strength and volitional torque vary across participants 6
- A comprehensive approach to managing terminal restlessness, including assessment, palliation, and symptom management, is necessary to effectively manage muscle spasms and twitching in end of life care patients 2
Pharmacological Treatments
- Diazepam, baclofen, and tizanidine are commonly prescribed drugs for the treatment of spasticity 3
- Intrathecal baclofen and local infiltration of botulin toxin may be added values in selective patients 3
- Gabapentin and dantrolene sodium are also potential treatments for spasticity, but their use may be limited by adverse effects 3