Approach to drug therapy for agitation and restlessness in the last days of life

If agitation or restlessness persists despite general measures and addressing potential causes (see Principles of managing agitation and restlessness in the last days of life), consider adding drug therapy. Initial drug choice is guided by the factors listed in Factors influencing initial drug choice for agitation and restlessness in the last days of life.

Figure 1. Factors influencing initial drug choice for agitation and restlessness in the last days of life. [NB1]

Clinical scenario:

  • if delirium is likely, an antipsychotic is preferred
  • if anxiety is prominent, or alcohol or benzodiazepine withdrawal is likely, a benzodiazepine is preferred.

Urgency of the situation—consider the time to onset of action of the drug.

Comorbidities—in patients with Parkinson disease or ‘Parkinson plus’ disorders (eg Lewy body dementia), use a benzodiazepine or seek expert advice. Haloperidol can aggravate motor features, and should be avoided.

Current treatment (ie whether the patient already takes an antipsychotic or a benzodiazepine).

Note: NB1: Also consider the patient and practical factors (eg drug availability, access) influencing drug choice in the last days of life listed in Principles of drug therapy for symptoms in the last days of life.

If an antipsychotic is indicated for agitation and restlessness, see:

If a benzodiazepine is indicated for agitation and restlessness, see:

Follow the principles of drug therapy for symptoms in the last days of life.

If a patient remains agitated or restless despite reaching the maximum dose of the initial drug, add a drug from the other drug class. For example, if haloperidol (an antipsychotic) was used initially, add midazolam (a benzodiazepine).