7 Managing anxiety, delirium and agitation

7 Managing anxiety, delirium and agitation

We will review and update these recommendations on a regular basis.

7.1 Address reversible causes of anxiety, delirium and agitation first by:

  • exploring the patient's concerns and anxieties

  • ensuring effective communication and orientation (for example explaining where the patient is, who they are, and what your role is)

  • ensuring adequate lighting

  • explaining to those providing care how they can help.

7.2 Treat reversible causes of anxiety or delirium, with or without agitation, for example hypoxia, urinary retention and constipation.

7.3 Consider trying a benzodiazepine to manage anxiety or agitation (see table 6 for treatments for managing anxiety, delirium and agitation).

At the time of publication (April 2020), midazolam and levomepromazine did not have a UK marketing authorisation for this indication or route of administration (see General Medical Council's guidance on prescribing unlicensed medicines for further information).

Table 6 Treatments for managing anxiety, delirium and agitation in patients aged 18 years and over

Treatment

Dosage
Higher doses may be needed for symptom relief in patients with COVID-19. Lower doses may be needed because of the patient's size or frailty

The doses are based on the BNF and the Palliative care formulary

Anxiety or agitation and able to swallow: lorazepam tablets

Lorazepam 0.5 mg to 1 mg 4 times a day as required (maximum 4 mg in 24 hours)

Reduce the dose to 0.25 mg to 0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours)

Oral tablets can be used sublingually (off-label use)

Anxiety or agitation and unable to swallow: midazolam injection

Midazolam 2.5 mg to 5 mg subcutaneously every 2 to 4 hours as required

If needed frequently (more than twice daily), a subcutaneous infusion via a syringe driver may be considered (if available) starting with midazolam 10 mg over 24 hours

Reduce dose to 5 mg over 24 hours if estimated glomerular filtration rate is less than 30 ml per minute

Delirium and able to swallow: haloperidol orally

Haloperidol 0.5 mg to 1 mg at night and every 2 hours when required. Increase dose in 0.5‑mg to 1‑mg increments as required (maximum 10 mg daily, or 5 mg daily in elderly patients)

The same dose of haloperidol may be administered subcutaneously as required rather than orally, or a subcutaneous infusion of 2.5 mg to 10 mg over 24 hours

Consider a higher starting dose (1.5 mg to 3 mg) if the patient is severely distressed or causing immediate danger to others

Consider adding a benzodiazepine such as lorazepam or midazolam if the patient remains agitated (see dosages above)

Delirium and unable to swallow: levomepromazine injection

Levomepromazine 12.5 mg to 25 mg subcutaneously as a starting dose and then hourly as required (use 6.25 mg to 12.5 mg in the elderly)

Maintain with subcutaneous infusion of 50 mg to 200 mg over 24 hours, increased according to response (doses greater than 100 mg over 24 hours should be given under specialist supervision)

Consider midazolam alone or in combination with levomepromazine if the patient also has anxiety (see dosages above)

Special considerations

Seek specialist advice for patients under 18 years old

Notes: At the time of publication (April 2020), midazolam and levomepromazine did not have a UK marketing authorisation for this indication or route of administration (see General Medical Council's guidance on prescribing unlicensed medicines for further information).

See BNF and MHRA advice for appropriate use and dosing in specific populations.

[amended 22 April 2020]