Search for in
Terminal restlessness


Table of Contents


Terminal Restlessness





Terminal restlessness is a syndrome observed in patients in their last days of life. It is a variant of delirium and refers to a spectrum of signs of central nervous system irritability that may include restlessness, agitation, distressed vocalising, twitching, myoclonic jerking or recurrent fitting.

Causes


There are obviously multiple causes of terminal restlessness in the palliative care setting.



1. Uncontrolled pain and other symptoms


Uncontrolled pain can be a major contributor to restlessness and it is important to explore all avenues of dealing with pain, particularly the more difficult to manage neuropathic pain and pain due to anguish. Other symptoms such as dyspnoea, retained secretions and urinary retention also need to be addressed.
Top of Page


2. Drugs


Many drugs cause cognitive decline, agitation, hallucinations and abnormal behaviour. Polypharmacy is common in palliative care and great care is needed to rationalise drug treatment particularly in the elderly and frail patients. Metabolism of drugs also needs to be taken into consideration with liver and renal failure so often seen in the deteriorating patient. Morphine doses can often be reduced, particularly if there is renal failure and/or dehydration. Drug interaction and side effects so often develop in a dehydrated patient with multisystem failure. Stopping drugs is vitally important in terminal care but care is also needed to continue with judicious use of analgesics, and other drugs essential for pain and symptom control.



3. Metabolic


Uraemia, hypercalcaemia, hyponatraemia, hypoxia from anaemia or respiratory disease may be treatable but obviously should only be treated with comfort goals in mind. Invasive and detailed investigations and active treatment with unrealistic goals should be avoided.



4. Infections


Treating UTIs and respiratory infection may be helpful in reducing terminal restlessness in certain instances.



5. Constipation


This difficult problem in palliative care is worth treating diligently and may improve the mental state of some patients, but expectations should relate realistically to intake of food.



6. Cerebral causes


Primary or secondary tumour can cause severe mental confusion and drowsiness which usually responds well to dexamethasone 4mgm qid. which can be given either by the oral or subcutaneous route (mgm for mgm). Sometimes other sedatives are needed as described below.



7. Post ictal


Anticonvulsants may improve the mental state for some patients with recurring fits.


8. Anxiety


Terminal restlessness can be caused by unresolved family conflict, denial, fear, spiritual dilemmas etc. and counselling and support can be helpful in this situation.



9. Withdrawal


Withdrawal of alcohol, narcotics or even nicotine in heavy users can cause restlessness in terminal patients. Simple measures such as nicotine patches can help.
Top of Page


Treatment


Supportive treatment


In addition to addressing the above causes, providing an appropriate physical environment and emotional support is helpful. Familiar surroundings and faces, family and nursing support are always helpful.



Sedation


If, as if often the case, all the above has been attended to and there is still a need for sedation, the following medication is recommended.



The Benzodiazepines


This group of drugs is very helpful for terminal restlessness, sedation, fitting, myclonic jerking etc. They are also useful for minor procedures (eg. faecal disimpaction), and for catastrophic events such as severe haemorrhage (because of their amnesic effects). See table below.



NOTES:

1. If a rapid response is needed, use short acting midazolam or lorazapam. NB. Midazolam is expensive (nearly 5 x cost of clonazepam!) - use sparingly and NOT long term.

2. All the benzos have an anticonvulsant effect if this is needed. Clonazepam has more anticonvulsant action than midazolam.

3. Clonazepam helps with neuropathic pain if that is an associated problem.

4. Use low doses in the elderly or frail patient particularly if there is liver and renal failure, low serum albumin or respiratory insufficiency.

5. Care is needed to prevent falls and fractures in the frail and elderly on benzos.

6. Beware of the problems of abrupt withdrawal of long term benzos, particularly if short acting - fits, confusion, tremors etc.

7. Benzos have NO analgesic effect and concurrent analgesics need to be continued even in a semicomatose or comatose patient.


Drug Dose & Formulation Half Life Dose Frequency Route of Administration
diazepam (Valium) 2.5-10mg injection, tablet 20-48hrs 1-2 x daily oral, rectal, sublingual
clonazepam (Rivotril) 0.5-2.5mg oral drops, tablet, injection;22-54 hrs 2 x daily oral, sublingual, sc
lorazepam (Ativan) 0.5-2.5mg tablet 12-16 hrs 2-3 x daily oral, ublingual
midazolam (Hypnovel) 2.5-10mg injection 1-3 hrs 3 hrly or by infusion sc, IV (used rarely in emergencies)

Top of Page

Neuroleptics


For the more severely disturbed and confused patient neuroleptics are often needed, sometimes in conjunction with benzos. Also if there is an adverse reaction to benzos neuroleptics may be needed. The following table shows the most commonly used neuroleptics.

Haloperidol is usually effective in targeting agitation, paranoia and fear. The intravenous route is often more effective and quicker acting than the S.C. route. Haloperidol is also an excellent antiemetic if that is required. However it has more anticholinergic side effects than thioidazine. If more sedation is needed thioidazine or chlorpromazine may be more effective but these agents have more hypotensive side effects. Chlorpromazine can be given by deep IM injection but is irritating to tissues and this may be a particular problem in an emaciated patient.



Barbiturates


For the patient with mental disturbance not responding to the above, phenobarbitone may be useful and can be given by the S.C. route in doses 50 - 100mgm 4 - 8 hourly. It can also be given as an infusion of up to 800mgm per day. It should be stressed that injectable phenobarbitone is not compatible with morphine and it should be infused through a different butterfly line.This can also be a useful drug if there is a paradoxical hyperexcitability resulting from benzo usage.

It needs to be emphasised that medications are only indicated if appropriate supportive care has not succeeded in settling the patient. Measures to help reduce anxiety by providing a well lit room that is quiet and contains familiar objects and family is often all that is required.


Generic Name Approx daily dose Route
haloperidol (Serenace) 0.5-5mg, 2-12 hrly po, iv, sc
thioridazine (Melleril) 10-75 mg, 4 - 8 hrly po
chlorpromazine (Largactil) 12.5 - 50mg, 4-8 hrly po, iv
or 100-200mgm, 8 hrly suppos

Top of Page

Dr Andrew Binns

 Previous Index 1
The use of morphine in nursing homes
Palliative Care
Index		 Next
Strontium in Prostate Cancer
© 2007 Northern Rivers General Practice Network
16 Carrington Street (PO Box 519), Lismore, NSW 2480, Australia.
Ph: +61 (0)2 6622 4453 Fax: +61 (0)2 6622 3185
Email: Webmaster Email: Feedback
Disclaimer and Privacy Statement