Descriptors of End Stage Restlessness

Physical Movement

• agitation
• fidgeting
• tossing and turning
• pacing
• myoclonic jerks
• seizures
• twitching
• plucking
• fumbling
• muscle-spasm and twitching progressing to seizure
• involuntary spontaneous muscle-contractions
• purposeless yet coordinated movement

Verbalizations

• moaning
• crying out
• repetitive vocalizations

Cognitive Impairment

• impaired consciousness
• hallucinations
• paranoia
• disorientation
• confusion
• inattention
• Psychoemotional Disorder
• irritability
• anxiety
• worry
• unease

Psychoemotional Disorder

• irritability
• anxiety
• worry
• unease

Causes

• Medication side effects and interactions
• Psychological
• Post Traumatic Stress Disorder (PSTD)
• Withdrawal
• Constipation
• Urinary retention
• Infection
• Pain
• Brain metastasis
• Electrolyte imbalance
• Low blood sugar

DELIRIUM:

D Drugs

E Electrolytes

L Liver failure

I Infection/hypoxia

R Renal failure

I Impaction

U Urinary infection or retention

M Mets to brain

I WATCH DEATH:

I Infections (Pneumonia, Urinary Tract Infections)

W Withdrawal (Ethanol, opiate)

A Acute Metabolic (acidosis, renal failure, imbalances)

T Trauma (acute to severe pain)

C Central nervous system pathology (epilepsy, cerebral hemorrhage)

H Hypoxia

D Deficiencies (vitamin B12, thiamine)

E Endocriopathies (thyroid, parathyroid, hypopituitarism, hyper/hypoglycemia,

Cushing’s)

A Acute vascular (Stroke, MI, PE, heart failure)

T Toxins/drugs

H Heavy metals

Assessment

History

• Onset
• Precipitating/relieving factors
• Timing or pattern to restlessness
• What diseases/illness does this person have that may
  o cause the restlessness
• Medications
• Reactions to medications, interventions
• Associated symptoms (anxiety, sleep disturbances,
  o irritability, altered perception, disorganized thinking,
  o incoherent speech, disorientation to person, place &
  o time, change in LOC, memory impairment)
• Sleep disturbances
• Psychosocial concerns
• Spiritual concerns
• Caregiver concerns
• Quality of life

Physical Exam

• Appearance of patient
• Assess for reversible factors contributing to restlessness
• Cardiopulmonary system
• GI/GU system
• Signs of infection

Non Pharmacological Interventions

• Patient/family education to alleviate fear
• Do not argue with patient
• Safe environment
• Correct visual or hearing deficits (where are the patient’s hearing aids, glasses)
• Quiet, restful, subdued, comforting environment to reduce stimuli
• Encourage use of cognitive/behavioral therapies such as relaxation, visualization, distraction
• Palliative Arts therapy including (but not limited to) massage, music, therapeutic touch
• Pet therapy
• Prayer
• Religious rituals
• Active listening for family
• Role model to family
• Emotional support
• Orange juice with 1 -2 sugar packets
• Consistent caregivers known to patient
• Frequent re-orientation
• Calendar and/or clock in the room
• Familiar pictures
• Familiar environment
• Familiar sounds, smells and textures
• Avoid television and extraneous noises

Pharmacological Interventions

Pharmacological treatment should be based on relieving cause of delirium/restlessness whenever possible. Resolution of underlying factor(s) should be primary goal whenever possible. Utilize team collaboration in assessment,  intervention and education with the patient and family.

• Treat precipitating pain or other symptom appropriately

If no contributing factors can be found/resolved:

• Haldol (Haloperidol) 0.5 – 2 mg po/IM q1hour for acute episodes. Continue until acute episode controlled, then Haldol 0.5 – 2 mg po q 6 h PRN. (MDD = 20 mg/day)

If withdrawal from alcohol or benzodiadzepines are causing the delirium:

• Ativan (Lorazepam) 0.5 – 2 mg po/sl q 6h PRN (MDD = 12 mg/day)

Evaluate and document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve.

Collaborate with psychosocial and spiritual professionals to confirm that symptoms are managed with the most effective combination of non pharmacological and pharmacological interventions

References

Breibart W, Chochinov HM & Passik SD. Psychiatric symptoms in palliative medicine. In: Doyle D, Hanks G, Cherny N, Calman K eds Oxford Textbook Palliative Medicine. 3rd ed. pp. 748 -750, Oxford University, 2005.

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed. Kendall/Hunt publishing Co.

Kuebler KK, Davis MP & Moore CD. (2005). Palliative Practices: An Interdisciplinary Approach. Elsevier/Mosby: Missouri.

Kuebler KK, Heidrich DE, Vena C & English N. Delirium, Confusion and Agitation. In: Ferrell B & Coyle N, eds Textbook of Palliative Nursing 2nd ed, pp 404 – 420. Oxford University Press, 2006.

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