Care at the Close of Life: Evidence and Experience
Stephen J. McPhee, Margaret A. Winker, Michael W. Rabow, Steven Z. Pantilat, Amy J. Markowitz
Part B Symptom Management
Chapter 11. Agitation and Delirium at the End of Life: “We Couldn’t Manage Him”
William Breitbart, MD, Yesne Alici, MD
Cholinesterase Inhibitors
Topics Discussed:
agitation, antipsychotic agents, chlorpromazine, delirium, haloperidol, olanzapine, psychostimulant, randomized controlled trials, risperidone, sedative, summarizing the evidence
Excerpt:
"Treatment with antipsychotic or sedative medications is often
essential to control the symptoms of delirium (Table 11-2 and Table
11-3).No medications have been approved by the US Food and Drug Administration
(FDA) for treatment of delirium. Haloperidol is the usual first-line
antipsychotic medication for delirium in patients with advanced
disease because of its efficacy, relative safety, and versatility
(eg, few anticholinergic effects, minimal cardiovascular adverse
effects, lack of active metabolites, and availability in different
routes of administration; Table 11-3).47 However,
only 0.5% to 2% of hospitalized cancer patients
receive haloperidol for symptoms of delirium,47,68 and
only 17% of terminally ill patients receive any antipsychotic
drugs for agitation or delirium.29,47,68 The American
Psychiatric Association practice guidelines provide directions for
the use of antipsychotics for treatment of delirium,47 and
growing evidence supports their use.12,69-88 In
general, doses of haloperidol need not exceed 20 mg in a 24-hour
period; however, some clinicians advocate higher doses in selected
cases.89 The FDA has issued a warning about the
risk of QTc prolongation and torsades de pointes on electrocardiogram
with intravenous haloperidol; in nonterminal patients, QTc intervals
should be monitored regularly.90 In severe agitation
related to delirium, clinicians may add lorazepam to haloperidol.
This combination may be more effective in rapidly sedating the agitated,
delirious patient and may help minimize any extrapyramidal adverse
effects of haloperidol.91..."
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