Confusion / Agitation in Palliative Care

Lothian Palliative Care Guidelines Confusion / Agitation in Palliative Care

Recognition 1 Acute onset and fluctuating course 2 Inattention - easily distracted 3 Disorientated to time/ place/ person 4 Disorganised thinking - rambling or irrelevant conversation, switching topics 5 Altered level of consciousness - hyperactive or hypoactive

Causes - often multiple • Can the cause(s) be identified? • Is the cause(s) reversible? What is the patient’s prognosis? • Is investigation or treatment of the cause(s) appropriate? PAST HISTORY • Dementia, other mental illness • Alcohol/ drug abuse or • Cerebrovascular disease withdrawal (including nicotine) • Brain tumour/secondary

DRUGS (many including:-) Opioid toxicity (see Pain Guideline ) • Corticosteroids • Benzodiazepines • Tricyclics and other antidepressants • Anticholinergics • Neuroleptics • Acute withdrawal of alcohol, nicotine, antidepressants, benzodiazepines, steroids etc.

PHYSICAL • Uncontrolled pain • Constipation • Urinary retention • Deafness / blindness • Bleeding

METABOLIC • Infection • Hypercalcaemia • Hypoxia • Glucose (high or low) • Uraemia • Low sodium, low magnesium • Liver failure • Dehydration

PSYCHOLOGICAL DISTRESS → explore concerns of patient / family, if possible

General Care • Maintain hydration – use SC fluids if appropriate • Try to nurse in a quiet, well lit environment and limit staff changes if possible • Involve key family members and offer support and information • Use lucid intervals to establish rapport and address fears/concerns • Gentle, repeated reorientation where possible - use clock, calendar, schedule of daily routines • Don’t confront deficits and communicate in a simple, clear, concise manner. • Try to maintain a normal sleep-wake cycle • Correct hypoxia, if possible

Medication for treatment of confusion • Review all medication and discontinue any non-essential drugs • Use the minimum sedative medication necessary and regularly review the prescription • Use the oral route if possible • Withdraw sedative medication as the episode of confusion settles • Use prophylactic treatment with a benzodiazepine in acute alcohol withdrawal Lothian Palliative Care Guidelines

NB If the patient is very disturbed or fails to settle → seek advice Do not assume the patient’s agitation is due to pain. Consider other causes. Assess carefully – if evidence of opioid toxicity (see pain guideline)→ reduce opioid dose by 1/3 + consider adjuvant therapies, if patient is in pain. Seek advice.

A Emergency sedation of an acutely agitated /disturbed patient • sedate with haloperidol 2.5-5mg IM +/- benzodiazepine eg. midazolam 2.5mg IM or diazepam (rectal solution) 5-10mg, PR • repeat after 30 –60 minutes if needed • maintenance treatment may be needed based on stat doses used (Patients who are larger and physically fit may need higher doses) B Delirium - may be hyperactive, hypoactive or mixed state (Benzodiazepines alone do not improve cognition in delirium, and may worsen it) • use haloperidol:- stat+ prn ; 1.25-5mg, SC or 0.5-5mg, oral maintenance ; 2.5-10mg/ 24hrs, SC via a syringe driver or 0.5-3mg b.d, oral C Acute on chronic confusion eg in dementia, cerebrovascular disease • delirium – haloperidol as above • chronic confusion - risperidone 0.25-1mg nocte, increasing gradually to 1mg bd, oral • insomnia – trazodone 50-100mg nocte. (should be withdrawn gradually)

D Distressing restless/ agitation in the last days of life Sedation may be the most appropriate management Opioid analgesics should not be used to sedate patients in the last days of life.

Patient is confused / agitated / hallucinating Patient is anxious / frightened but lucid → haloperidol 2.5mg SC stat → try to explore fears + haloperidol 5-10mg/24hrs, SC in a driver + lorazepam 0.5mg oral or SL, 2-4 hourly prn + haloperidol 2.5mg 4hrly, SC, prn or midazolam 2.5-5mg 1-2hrly, SC, prn Patient is still confused / agitated Patient has continuous or worsening anxiety ↑ haloperidol to 10mg/24hrs, SC in the driver → oral diazepam 2mg tds OR + give a stat dose of haloperidol 2.5mg, SC → midazolam 10mg/24hrs, SC in a driver If patient is still agitated and distressed, consider increase midazolam dose in 30-50% steps up to 80mg adding midazolam to the driver + use midazolam 2.5-5mg, 1-2hrly, SC, prn OR use diazepam (rectal solution) 10mg PR, 6-8hrly, regularly or prn Patient is still agitated / distressed → Give a stat dose of levomepromazine 12.5mg SC and repeat 2-4 hourly, prn Consider changing haloperidol + midazolam to levomepromazine 25-100mg/24hrs, SC in driver (If patient at risk of seizures, continue a regular benzodiazepine – midazolam or rectal diazepam) Seek advice from a Palliative Care specialist

1. Zinberg M, Berenson S. Delirium in patients with cancer: nursing assessment and intervention. Oncology Nursing Forum 1990; 17(4): 529-538 2. Macmillan Practice Development Unit. A nursing approach to managing confusion and terminal restlessness in cancer and palliative care settings. Institute of Cancer Research. The Royal Marsden NHS Trust. 3. Breitbart W, Sparrow B. Management of delirium in the terminally ill. Progress in Palliative Care 1998; 6(4):107-113. 4. MacLeod AD. The management of delirium in hospice practice. European Journal of Palliative Care 1997; 4(4): 116-120. 5. Lothian Psychogeriatric Consensus Guidelines. July 2000.

Issue date: January 2002 (Revised June 2002) Review date: December 2003