Anxiety/Agitation/Delirium

Presentation: Anxiety, agitation, and delirium can often present together and be difficult to differentiate. At the end-of-life, management is often similar and outlined below. 

  • Anxiety: A common sensation among children with life-threatening illness that can be difficult to separate from physical symptoms and can cause exacerbation of physical symptoms (pain, dyspnea, etc.). 

  • Agitation: Unpleasant state of arousal that can manifest as loud speech, crying, increased motor activity, inability to relax, or increased autonomic arousal. Can be very distressing to patients and families. 

  • Delirium: An acute-onset disturbance of consciousness that fluctuates throughout the day. 

Non-pharmacologic management:

  • Meditation, diaphragmatic breathing, biofeedback 

  • Massage

  • Calm environment, comfort objects, and people

  • Limit people and interventions

  • Unless behavior is dangerous, do not attempt to redirect or correct agitation

Pharmacologic management: 

  • Treat underlying cause (pain, dyspnea, sleep disturbance, electrolyte imbalance, etc.)

  • Antipsychotics for delirium and agitation (avoid benzodiazepines)

  • Anxiolytics for anxiety

Drug Dosing
Lorazepam*

0.02 - 0.05mg/kg q6h prn

PO/SL/IV/SC

(max 1-2mg)
Clonazepam*

0.005 - 0.01mg/kg PO q8-12h

Can increase every 3 days up to 0.05 - 0.1mg/kg PO q8-12h

(max 0.2mg/kg/day)
Haloperidol

0.01 - 0.02mg/kg PO q8h prn (max 0.5-1mg)

Acute agitation: 0.025mg/kg PO and can repeat in 1 hour as needed
Risperidone

0.25 - 0.5mg PO qPM or divided

(max 3mg/day)
Olanzapine

1.2 - 2.5mg PO daily

Increase wekly as needed

(max 5mg/day)
Quetiapine

25mg q12h PO

Increase daily by 25mg/dose

(max 100-200mg q12h)

*Avoid benzodiazepines in delirium, this can exacerbate symptoms