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Confusion and delirium in advanced illness are common and the cause is often multifactorial. They are particularly common in elderly patients moved from a familiar environment. Severe agitation, anguish or aggression with risk to self or others is fortunately rare.
Clinicians must comply with the Mental Capacity Act 2005 when providing care for those patients who lack capacity as a result of confusion and delirium.
Consider and appropriately treat reversible causes, which may include:
Drugs should only be prescribed if necessary. Reassurance, helping to orientate the patient and alleviate their fear may be all that is required.
Sedation should only be necessary if the patient is very distressed and not amenable to reassurance, or is a danger to themselves or others.
Antipsychotics are the drugs of choice for delirium.
For patients with mild to moderate distress:
For patients with severe distress and/or an immediate danger to self and others:
Patients may require the administration of their haloperidol via a continuous subcutaneous infusion (CSCI):
The maintenance dose is usually based on the initial cumulative dose needed to settle the patient. This is usually 5mg or less over 24 hours.
Continue to review the dose needed, particularly if the underlying cause can be resolved.
Levomepromazine is more sedating than haloperidol
The use of atypical antipsychotics may be appropriate in those patients intolerant of haloperidol or levomepromazine. Please seek specialist advice.
Although antipsychotics are first-line treatment for delirium, in patients with advanced cancer agitation and restlessness may represent an anxiety state. In these cases, benzodiazepines may be more appropriate and effective.
In cases of extreme distress, where urgent control of symptoms is needed, diazepam or midazolam can be given as a titrated, slow intravenous injection.
Benzodiazepines used alone carry an increased risk of paradoxical agitation, especially in the elderly.
Occasionally the combination of an antipsychotic and benzodiazepine is more successful than either alone: