Confusion, agitation and restlessness are common towards the end of life due to many factors, and the first question is whether there is an easily reversible cause (e.g. urinary retention). Consider all reversible causes and what treatments are still appropriate at this stage of life.
Agitation may be a sign that life is coming to an end and the best approach may be to focus on keeping the person calm. Careful discussion is needed with care givers to explore options.
Consider the following causes
- Physical causes of discomfort including pain, nausea, constipation, urinary retention, itching due to opioids or organ failure
- Opioid toxicity (myoclonic jerks, confusion, pin-point pupils, hallucinations and respiratory depression). If this is suspected, consider reducing the opioid by 30-50% or an opioid switch
- Metabolic causes (hypoxia, hypercalcaemia, renal and liver failure, nicotine withdrawal)
- Infection with delirium
- Cerebral metastases
- Spiritual and psychological distress
Top Tips
- Always try non-pharmacological methods to relieve agitation e.g. presence of family, calm lighting, quiet, 1:1 care
- Lower starting doses of sedative medication in frail elderly
- Sedation is often more difficult if there is a history of alcohol or substance misuse
- The intention is to relieve suffering, not to hasten death
Symptom management
The following drugs are commonly used for management of agitation at the end of life.
| Haloperidol | 2.5mg S/C Stat | 5mg -10mg per 24h via CSCI |
| Midazolam | 2.5mg-5mg S/C or buccal Stat | 10-60mg per 24h via CSCI |
| Levomepromazine | 12.5-25mg S/C Stat | 25-150mg per 24h via CSCI |
- Starting doses of the above medication will have a calming effect but will not necessarily sedate the patient. The initial aim of treatment is to give the lowest doses to maintain calm
- Do contact the local specialist palliative care team for more specific advice about prescribing if escalating doses of sedation are needed
- Agitation is one of the most difficult symptoms to manage at home and important to manage confidently as families will remember this difficult time.
- Prescribing anticipatory medication to have at home will also help to manage symptoms.
- Haloperidol and Levomepromazine may help more than Midazolam if hallucinations or paranoia are present. Both are also useful as anti-emetics.