Management of Combative Behavior in Hospice Patients

Introduction to Combative Behavior Management

The American Academy of Family Physicians recommends that risperidone can be used cautiously at very low doses (starting 0.25 mg daily at bedtime, maximum 2-3 mg/day) for severe combativeness in hospice patients, but recent high-quality evidence suggests that supportive care and treatment of underlying delirium causes may be superior 1

Identify and treat reversible causes of delirium first, including metabolic disturbances, hypoxia, bowel obstruction, infection, CNS events, bladder obstruction, and medication effects (particularly opioids, benzodiazepines, anticholinergics), as recommended by the National Comprehensive Cancer Network 2
For patients with weeks to days of life expectancy, haloperidol 0.5-1 mg every 1-4 hours PRN remains a guideline-recommended option for severe delirium with agitation, with alternative agents including risperidone 0.5-1 mg twice daily, olanzapine 2.5-15 mg daily, or quetiapine 50-100 mg twice daily, according to the National Comprehensive Cancer Network 2
If agitation is refractory to high doses of neuroleptics, consider adding lorazepam 0.5-2 mg every 4-6 hours rather than escalating antipsychotic doses, as suggested by the National Comprehensive Cancer Network 2

Start risperidone at 0.25 mg daily at bedtime in hospice/palliative care patients, as this population is particularly vulnerable to adverse effects, according to the American Academy of Family Physicians 1
Titrate risperidone slowly to maximum 2-3 mg/day (usually divided twice daily), with current research supporting use of low dosages, as recommended by the American Academy of Family Physicians 1
Extrapyramidal symptoms may occur at doses ≥2 mg/day, so consider dose reduction rather than adding anticholinergic medications if these develop, according to the American Academy of Family Physicians 1
Atypical antipsychotics have diminished but not eliminated risk of extrapyramidal symptoms and tardive dyskinesia compared to typical agents, as noted by the American Academy of Family Physicians 1

Assess and treat reversible delirium causes (metabolic, infection, medications, constipation, urinary retention), as recommended by the National Comprehensive Cancer Network 2
Implement supportive care measures (family presence, orientation, environmental modifications), according to the National Comprehensive Cancer Network 2
If severe combativeness persists and poses safety risk, consider risperidone 0.25 mg at bedtime, as suggested by the American Academy of Family Physicians 1
Titrate slowly over days to effect (maximum 2-3 mg/day divided), according to the American Academy of Family Physicians 1
Monitor closely for extrapyramidal symptoms, hypotension, and sedation, as recommended by the American Academy of Family Physicians 1
If refractory agitation, add lorazepam rather than escalating antipsychotic, as suggested by the National Comprehensive Cancer Network 2