Microsoft word - confused and aggressive patients.doc

Guideline: Care of Confused and Aggressive Patients (Some of these features are present in terminal agitation, see the Integrated Confusion is common in patients with advanced cancer. Up to 20% of hospitalised cancer patients have organic mental disorders. More than 75% of terminally ill cancer patients become confused at some stage. Aggression may be a feature of confusion in any patient, however out of character. It may also be encountered in distressed carers and relatives, particularly when exposed to alcohol. ¾ Most cases of confusion are multi-factorial ¾ In about 50% of cases, the cause remains undefined. ¾ Infection ¾ Dehydration ¾ Polypharmacy – especially opioids and anticholinergics ¾ Alcohol withdrawal ¾ Drug withdrawal ¾ Biochemical disturbance ¾ Hypoxia ¾ Hypercapnia ¾ Pain fatigue ¾ Hypoglycaemia ¾ Vitamin deficiency ¾ Pain ¾ Fatigue ¾ Trauma ¾ Cerebrovascular accident ¾ Fear ¾ Frustration ¾ Humiliation ¾ Inappropriate assertiveness ¾ Vulnerability ¾ Threats (self defence) ¾ Feeling of oppression. Communication:
Explanation is important:
¾ Calmly explain everything to the patient, family and carers.
The environment needs to be quiet and reassuring, with:
¾ Subdued lighting
¾ Familiar faces
¾ A small number of (familiar) staff involved in care
¾ Safety
Use Of Medication In Confused And Aggressive Patients Iatrogenic problems:
Always check that drugs are not the major cause of cognitive dysfunction. Recent
prescription of opiates, antidepressants, anticholinergics etc. may be implicated,
especially in a patient with co-existing metabolic derangements.
Choice of psychotropic drugs:
HALOPERIDOL is the drug of choice in palliative care. It has less cardiovascular
side effects. It has a long half life, and gives smooth effective antipsychotic control for
a sustained period. It can be given oral y or subcutaneously. For rapid onset of
action, high dose intravenous medication gives immediate effective plasma levels.
LEVOMEPROMAZINE Has a broadly similar use to haloperidol, however is more
BENZODIAZEPINE DRUGS reduce the element of anxiety and panic which often
accompanies confusion and agitation. However, they have no antipsychotic effect,
and may even precipitate heightened aggression and agitation in an already confused
patient because of the disinhibiting effect. For this reason, benzodiazepines should
not be used in a psychotic patient without the addition of haloperidol. The rapid onset
of sedation with SC midazolam is sometimes a helpful adjunct to the use of SC/IV
haloperidol in controlling a highly agitated patient.
¾ In patients with psychotic features only haloperidol should be used.
¾ Midazolam has a theoretical advantage in that it doesn’t decrease the seizure

HALOPERIDOL 3mg to 6mg orally
HALOPERIDOL 5mg SC, repeated up to 30mg per 24 hours
HALOPERIDOL 5-10mg SC supplemented by

MIDAZOLAM 5mg SC for rapid sedation (repeated within one hour if ineffective)

Wherever possible, distress should be anticipated by careful team assessment. Early
intervention with low dose psychotropic drugs on a regular basis will prevent a
potentially dangerous and distressing emergency. Signs of developing confusion,
paranoia or aggression should be reviewed on a daily basis, with dose adjustments as
Recommended regime:
HALOPERIDOL 3mg – 6mg orally/SC in the evening
or at night

Side effects of antipsychotics:
Typical antipsychotics
(haloperidol and levomepromazine) have more
extrapyramidal side effects than atypical antipsychotics (olanzapine and
Haloperidol is nevertheless the drug of first choice in palliative medicine because of
its flexibility. It has less cardiovascular side effects than the phenothiazines. It is
available in parenteral form. Common side effects:
extrapyramidal effects (especially acute dystonia, akathisia), hypothermia, sedation,
hypotension, endocrine effects, blood disorders, alterations in liver function,
neuroleptic malignant syndrome. Haloperidol has no antimuscarinic effects.
Levomepromazine (methotrimeprazine, Nozinan) is a useful alternative because of
its analgesic effect and greater anti-emetic effect. Its combined profile can be useful
in the terminal stage when a higher level of sedation is acceptable. Common side
effects: sedation (particularly with doses >25mg/24hr), dose-dependent postural
hypotension, antimuscarinic effects.
Olanzapine and risperidone are atypical antipsychotics which have also been used
in palliative care because of their better side-effect profile. They are not available in
parenteral form, so are less useful for the management of acute agitation and not
useful for the treatment of behavioural features.


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