Terminal Agitation

Management

Agitation, impaired consciousness, distressed vocalising, muscle twitching, myoclonus, convulsions may all be signs of terminal agitation.

Exclude fear, anxiety, pain, impaction, urinary retention, drug, alcohol or nicotine withdrawal as possible causes.
Opioids can aggravate the problem or be the underlying cause – consider dose reduction.
Generally need to treat with sedation.

"Terminal Agitation" may occasionally require complete sedation - the following drugs, administered parenterally, can be considered.

Clonazepam 0.5 – 1 mg q6h prn (PO or subcut) OR 1-6 mg /24 hours subcut via infusion.
Midazolam 2-10 mg subcut hourly prn or via subcut infusion starting at 10-20 mg/24 hours.
Flunitrazepam - if considering using this, please contact the Palliative Care Service.
Methotrimeprazine (Nozinan™) – sedation is a side effect of this drug which may be helpful if benzodiazepines are contraindicated or proving ineffective or if it is already being utilised effectively for nausea and/or pain.
Phenobarbitone is required on rare occasions and prescription must be initiated by the Palliative Care Service.

Newer agents such as olanzapine and risperidone have been found to be useful particularly if extra-pyramidal side effects are encountered but these are only available orally.

Note: If severe and distressing symptoms a referral to the Palliative Care Team is strongly recommended.


Information about this Canterbury DHB document (4148):
Document Owner:	Palliative Care Service (see Who's Who)
Issue Date:	July 2009
Next Review:	July 2010
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document.
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Topic Code: 4148