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Terminal agitation due to antimuscarinic-induced urinary retention in dementia with Lewy bodies — SCE Geriatri

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HardPalliative CareTerminal agitation due to antimuscarinic-induced urinary retention in dementia with Lewy bodiesSCE Geriatric Medicine

An 89-year-old woman with dementia with Lewy bodies is dying from aspiration pneumonia. She can no longer swallow and her agreed goal is comfort. Hyoscine hydrobromide was started subcutaneously 8 hours ago for noisy respiratory secretions that were distressing her daughter. The secretions have diminished, but she has since become intermittently restless and plucks at the bedclothes, although she settles with reassurance. She has passed no urine for 10 hours, and bladder scanning shows 650 mL. There is no grimacing, respiratory distress or faecal loading. Subcutaneous haloperidol and midazolam are available as anticipatory medicines. Which is the most appropriate immediate management?

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Correct answer: A — Stop hyoscine hydrobromide, catheterise the bladder, and reassess without administering haloperidol.

The temporal relationship to hyoscine hydrobromide, new urinary retention and restlessness indicates an antimuscarinic adverse effect with a reversible bodily cause for the agitation. NICE recommends actively seeking causes such as a full bladder, treating reversible causes before escalating symptom medication, and changing or stopping antisecretory medicines when urinary retention, delirium or agitation occurs. The bladder should therefore be decompressed, hyoscine stopped and the response reassessed. Haloperidol should not be administered: dementia with Lewy bodies is specifically associated with potentially severe antipsychotic sensitivity, and haloperidol is contraindicated in this condition. Thus A and B fail despite haloperidol being a conventional treatment for terminal delirium in patients without this contraindication. D addresses retention and avoids haloperidol but continues the likely causative medicine despite clinically significant adverse effects. E correctly stops hyoscine and relieves retention, but immediate midazolam is premature because the agitation is mild, settles with reassurance and may resolve after bladder decompression. A benzodiazepine could be considered if distressing agitation persists after reversible causes have been addressed. If noisy secretions recur and remain distressing, non-pharmacological measures and an individually selected alternative antisecretory strategy can then be reviewed.

Reference: Care of dying adults in the last days of life: Recommendations (Published 16 December 2015; checked 26 August 2026) — https://www.nice.org.uk/guidance/ng31/chapter/Recommendations Dementia: assessment, management and support for people living with dementia and their carers (Published 2018; checked 26 August 2026) — https://www.nice.org.uk/guidance/ng97/chapter/Recommendations HALDOL 2 mg/ml oral solution: Summary of Product Characteristics (Text revised 22 September 2023; checked 26 August 2026) — https://www.medicines.org.uk/emc/product/15252/smpc