General Management of Restlessness and Agitation

Midazolam*

SC stat: 2.5mg–5 mg

SC 24-hour Syringe Driver/pump*: 5mg–30 mg**

Especially if anxiety/restlessness predominates.

Levomepromazine**

Oral PRN: 6.25mg-25mg

SC stat: 5mg–25mg

SC 24-hour Syringe Driver/pump: 5–75mg**

Especially if features of paranoia or psychosis are present.
Also useful as an antiemetic. Very sedative at higher doses.
Smaller doses in elderly

Haloperidol**

Oral PRN: 1.5mg–2.5 mg

SC stat: 1.5mg–2.5 mg

SC 24-hour Syringe Driver/pump: 1.5mg–5mg

Especially if features of paranoia or psychosis are present.
Also useful as an antiemetic. Smaller doses in the elderly eg 0.5mg

*Midazolam may cause disinhibition and paradoxical agitation, particularly at high doses.

**Start at lowest dose in the range especially in frail elderly patients; review dose every 24 hours and increase if necessary by 30%–50% according to additional ‘as required’ doses. Higher doses than this are occasionally necessary – seek Specialist Palliative Care Team advice.

  • Patients who are dying with severe agitation may be very resistant to the effects of sedatives and may need repeat doses at 30–60 minute intervals until settled.
  • Occasionally the combined administration of an anti-psychotic and benzodiazepine is required.
  • For patients requiring rapidly escalating doses of sedatives, contact the Specialist Palliative Care Team for advice.

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.