Neuropsychiatric Conditions

Anxiety

Delirium

Depression

Fatigue

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ANXIETY

F41.0-3/ F41.8-9+ (Z51.5)

DESCRIPTION

• Anxiety is defined as the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension.
• Anxiety is characterised by excessive feelings of fear apprehension and worry.
• Anxiety may be associated with symptoms of depression, poor concentration, insomnia, irritability, panic attacks, sweating, tremor and nausea.
• It is a common symptom in palliative care and the complex multi-causative nature of anxiety in patients with life threatening illnesses always require a multimodal approach.

GENERAL MEASURES

• Address any contributing factors such as pain and dyspnoea.
• Consider other underlying conditions that may mimic anxiety e.g. electrolyte imbalance, hyperthyroidism, hypoxia, arrhythmias and many medicine side effects.
• Access for depression or any other previous psychiatric illness.
• Include the caregivers.
• Ensure the patient and caregivers have received the desired amount of information around the nature of the disease, treatment, side-effects and outcomes.
• A multi-disciplinary team approach is recommended (including a spiritual carer).

MEDICINE TREATMENT

Acute management of anxiety:

For an acute episode or intense prolonged anxiety:

• Benzodiazepine, e.g.:
• Diazepam, oral, 2.5–5 mg as a single dose.
  • Repeat if required up to 12 hourly.
    LoE:IIb^xii
  • Avoid if liver function impaired.
    LoE:IVb^xiii

OR

• Lorazepam, oral, 0.5–1 mg, immediately.
  • Repeat as necessary to control symptoms.
    LoE:IVb^xiv
  • Tablets may be crushed and administered sublingually.
    LoE:IIIb^xv

CAUTION Benzodiazepines, especially diazepam IV, can cause respiratory depression. Patients with liver dysfunction require lower doses. Monitor patients closely.  LoE:IVbxvi In the short-term, benzodiazepines can aggravate delirium.

• In frail and elderly patients or where respiratory depression is a concern, reduce the dose by half.  
  LoE:IVb^xvii
• The safest route of administration is oral with the IV route having the highest risk of respiratory depression and arrest.
• Monitor vital signs closely during and after administration.
• Use haloperidol instead of benzodiazepines in patients with respiratory insufficiency.
• To avoid inappropriate repeat dosing allow at least 15-30 minutes for the medication to take effect. Repeated IM doses of benzodiazepines may result in toxicity owing to accumulation.

Patient unable to take oral medication/ terminal sedation required: See section: Sedation in palliative care.

Long-term treatment:

• SSRI e.g.: 
• Fluoxetine, oral o Initiate at 20 mg every alternate day for 2 weeks

LoE:IIb^xviii

• Increase to 20 mg daily after 2–4 weeks
• Delay dosage increase if increased agitation/panicked feelings occur.

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Note

Fluoxetine is contraindicated if eGFR < 10mL/min
LoE:IIb^xix

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OR

• Citalopram, oral.
  • Initiate at 10 mg daily for 2 weeks.
  • Then increase to 20 mg daily.

LoE:IVb^xx

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Note

Effect of SSRIs are only apparent after 2-3 weeks of treatment, so they should be reserved for patients where end-of-life is not imminent.

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REFERRAL

• Poor response to treatment.

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DELIRIUM

F05.0-1/F05.8-9 + (Z51.5)

DESCRIPTION

• Delirium (confusion) is very common in the terminal stages of advanced disease and is associated with a short prognosis.
• When treatment of the underlying cause(s) of delirium is not possible or unsuccessful, pharmacological management is necessary.
• Causal treatment may not be indicated in patients with limited prognosis and pharmacological symptomatic therapy has to be initiated without delay.
• See Adult Hospital Level chapter: Emergencies and Injuries: Delirium

GENERAL MEASURES

• Assess for underlying causes e.g. infection or electrolyte imbalance.
• Remove factors that can agitate the patient (e.g. full bladder, thirst, pain, constipation, medicines such as opioids, steroids, benzodiazepines, withdrawal of medicines, dehydration, liver or renal impairment and cerebral tumour).
• Reduce polypharmacy.
• Where appropriate, ensure adequate fluid and nutritional intake (not indicated in the pre-terminal stage).
• Mobilise early when appropriate.
• Monitor for sensory deficits and manage accordingly e.g. using hearing aids.
• Keep the family involved and informed.
• Provide tools of care such as how to orientate and reassure the patient.

MEDICINE TREATMENT

For agitated and acutely disturbed patient:

• Olanzapine, oral dispersible tablet or IM, 2.5–5 mg.
  • This can be repeated in 30–60 minutes, if required and then 6 hourly to a maximum dose of 20 mg within 24 hours.
  • Monitor vital signs and beware of oversedation, neuroleptic malignant syndrome, and acute dystonia.

In hyperactive delirium or severe agitation or where there is no response or resistance to olanzapine:

ADD

• Lorazepam, oral, 0.5–1 mg 2–4 hourly as required.
  • Tablets may be crushed and administered sublingually.

LoE:IIIb^xxi, LoE:IVb^xxii

OR

Patients unable to swallow:

• Midazolam, SC/IV, 0.5–5 mg immediately.
  • Titrate up slowly.
  • Lower doses are indicated for patients with liver dysfunction.

LoE:IVb^xxiii

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DEPRESSION

F32.0-3/F32.8-.9/F33.0-3/F33.8-9/F34.1 + (Z51.5)

DESCRIPTION

• Depression is characterised by persistent feelings of extreme sadness and low mood associated with loss of interest in activities and inability to experience pleasure.
• These are often associated biological features of significant changes in appetite and weight, disturbed sleep, fatigue and poor concentration.
• Diagnosis of major depression in a terminally ill patient often relies more on the psychological or cognitive symptoms (worthlessness, hopelessness, excessive guilt and suicidal ideation) than the physical/somatic signs (weight loss and sleep disturbance) described in depression in patients who are not terminally ill.
• The key indicators of depression in the terminally ill are persistent feelings of hopelessness and worthlessness and/or suicidal ideation.
• Demoralisation is a phenomenon where hope and meaning is lost and where patients wish to hasten their death because they cannot foresee any future pleasure.

GENERAL MEASURES

• Exclude physical reversible causes e.g. hypothyroidism, hyperthyroidism, or hypercalcaemia.

MEDICINE TREATMENT

• SSRI, e.g.:
• Fluoxetine, oral
  • Initiate at 20 mg every alternate day for 2 weeks
  • Increase to 20 mg daily after 2–4 weeks
  • Delay dosage increase if increased agitation/panicked feelings occur.

LoE:IIb^xxiv

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Note

Fluoxetine is contraindicated if eGFR < 10mL/min
LoE:IIb^xxv

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OR

• Citalopram, oral.
  • Initiate at 10 mg daily for 2 weeks.
  • Then increase to 20 mg daily.

LoE:IVb^xxvi

OR

If sedation is required: 

• Amitriptyline, oral, at bedtime.
  • Start with: 25 mg, increase by 25 mg/day at 3-4 day intervals.
  • Dose range: 75-150 mg daily.

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Note

Effect of SSRIs are only apparent after 2-3 weeks of treatment, so they should be reserved for patients where end-of-life is not imminent.

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FATIGUE

R53 + (Z51.5)

DESCRIPTION

• Fatigue is defined as a subjective feeling of tiredness, weakness or lack of energy.
• The pathophysiology is not fully understood but will be multifactorial in most palliative care patients, including disease- and treatment-related causes.
• Fatigue may be severe, distressing and persistent, regardless of adequate amounts of sleep and rest.

GENERAL MEASURES

• Treat underlying causes such as anaemia, depression, and infections.
• Encourage aerobic exercises, where appropriate.
• Ensure that the multidisciplinary team assists with activity pacing, assisted devices where indicated, and diet.

MEDICINE TREATMENT

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Note

Because of limited evidence, consideration of steroids in palliative care should be restricted to use in the terminally ill with fatigue and a specific short-term treatment goal.

Fatigue can also protect patients at the end of life from physical and emotional distress.

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• Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 0.5 mg/kg (e.g.: 15-30 mg) daily, for 1 week.

LoE:IIb^xxvii

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_07 November 2024

Chapter 24: Medicines used in Palliative Care_24.2 Neuropsychiatric Conditions