Anxiety, delirium and agitation + noisy respiration secretions

What should be considered for treating anxiety, delirium and agitation?

Cause of anxiety e.g., pain, breathlessness, consider non-drug methods e.g., CBT and drug therapy

What should be used to treat anxiety lasting less than 4 weeks?

Benzodiazepine e.g., diazepam, midazolam, lorazepam

What should be used to treat anxiety lasting longer than 4 weeks in palliative care?

SSRI with/out benzodiazepine initially

What benzodiazepine can be used to provide sedative effects which may be useful for patients with anxiety in palliative care?

Midazolam

What should be used first line for agitation in palliative care?

Non-pharmacological and look for cause first

What should be used to treat short term agitation with anxiety?

Benzodiazepine e.g., midazolam

What should be used for agitation with delirium in palliative care?

Antipsychotic e.g., haloperidol

When should specialist advice be sought for agitation?

If diagnosis is uncertain, not responding to treatment or if treatment causes unwanted sedation

What is the term to describe the rattle like sound of fluid in the lungs occurring 24-48 hours before a patient dies, causing them no pain or discomfort?

Death rattle

What can be a cause of breathlessness related to secretions?

Excessive respiratory secretions

What is first line for excessive respiratory secretions?

Hyoscine butylbromide or hydrobromide

What is the MHRA warning for hyoscine butylbromide?

Risk of serious ADRs in patients with underlying cardiac disease - can cause tachycardia, hypotension or anaphylaxis, monitor patients with heart disease and have resuscitation facilities available

What is second line for noisy respiratory secretions?

Glycopyrronium

What are the properties of hyoscine and glycopyronnium that can cause adverse effects such as dry mouth, urinary retention, delirium, agitation and sedation?

Anticholinergic side effects

What anticholinergic used for noisy respiratory secretions is less likely to cause central effects as it doesn’t cross the blood brain barrier?

Glycopyrronium bromide - hyoscine does cross

What drugs can be used for excessive secretions?

Hyoscine hydrobromide or butylbromide subcutaneously, Glycopyrronium, atropine