Canterbury DHB
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Confusion, restlessness, and agitation are seen quite commonly in patients at the end of life.
Confusion can be part of an acute delirium, the causes of which are many and include electrolyte imbalance, sepsis, urinary retention, faecal impaction, and numerous medications including opioids.
If delirium is suspected, the underlying cause should be sought. Haloperidol is the drug of first choice to improve symptoms.
An option for the management of restlessness and agitation in the terminal phase includes clonazepam, which is available both subcut and in sublingual drops (0.1 mg per drop) given up to 0.5 mg four times daily PRN. This drug has a long half-life and should be used judiciously with the risk of accumulation in mind, often starting with a single nocte dose of 0.5 mg.
Midazolam given IV or subcut has a much shorter half-life and is generally more rapid-acting than clonazepam (within a few minutes when given subcut) but it wears off more quickly. The doses of both clonazepam and midazolam are not affected by impaired renal function. Both can be given either by subcut injection or by continuous subcut infusion.
If symptom management is problematic, a referral to the Palliative Care Service should be considered, including patients receiving active chemotherapy with curative intent.
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Topic Code: 5063
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