Akathisia: overlooked at a cost
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1506 (Published 22 June 2002) Cite this as: BMJ 2002;324:1506All rapid responses
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Akathisia is often mistaken for anxiety, and can even present as
insomnia. To confirm the diagnosis, if the putatively offending drug can't
be ceased, giving oral benztropine 2mg will settle the matter - whereas
use of a benzodiazepine would only confuse it.
Mental and physical symptoms shade into one another in akathisia, in
a way foreign to normal experience, (though present in other movement
disorders like Parkinson's Disease). The characteristic restlessness
("ants in the pants") is often accompanied by mental distress; while a
terrible sense of dread may be felt as abdominal discomfort.
To experience this for the first time, unaware that this is a readily
corrected drug side effect, is frightening. Depressed or psychotic
patients can consider suicide, mistaking akathisia for further
deterioration.
Accordingly it is good practice to demonstrate akathisia to patients,
whenever an antipsychotic drug is prescribed. Patients who have been told
that akathisia is harmless will usually not reject their medication then,
if it does occur.
It is often when a second potentiating drug is added that akathisia
ensues. At such times akathisia should always be demonstrated to the
patient. Perhaps the commonest scenarios are: antipsychotic and
antidepressant medication; and antidepressant and antinausea medication.
Competing interests: No competing interests
Dear sir,
I found this article on akathisia very interesting.
Even though it can occur in medical settings, it can also occur as an
adverse effect of antipsychotic and antidepressant medications in
Psychiatric settings both on the Psychiatric wards and out-patient
clinics.
Clinical features:
The basic feature is the urge to move, patients would often pace with
inability to sit still. Occassionally they may complain of dysphoria.
It is usually mistaken for Psychotic agitation which can be clinically
distinguished by increasing the dose of antipsychotic,which improves the
agitation but akathisia is made worse.
The Prevalence of akathisia is 21% ( Ayd 1961 ) and 32% (Kennedy et
al, 1971 ) depending on the drug potency, dose and rate of increment. It
is commonly caused by high potency antipsychotic like Haloperidol.
Pathophysiology: It is speculated due to the blockade of mesocortical
dopaminergic neurotransmission.
Treatment:
The first and foremost step is to reduce the dose of antipsychotic
medication.
If this is ineffective, to switch to a low potency antipsychotics like
Chlorpromazine or Sulpiride or an atypical antipsychotic like Olanzapine,
Amisulpiride or Risperidone.
Antimuscurinic drugs like Benztropine in the dose of 2 to 6 mg / day may
be useful in patients who also have parkinsonian symptoms.
Benzodiazepines are useful particularly due to their anxiolytic activity
and they act by fascilitating GABAergic transmission ( Clonazepam 0.2 to
0.8 mg / day )
There are also useful results with Propranalol in the dose of 20 to 60
mg/day ( to be avoided in patients with Bronchial Asthma as this can get
worse )
Competing interests: No competing interests
In publishing their case reports of drug-induced akathisia, Akagi and
Kumar focused a needed educational spot-light on this oft overlooked and
misunderstood disorder.1 Each of their three patients developed dysphoric
restlessness after serial doses of known akathisia-inducing medication.
Repeat drug dosing, however, is not necessary for the development of this
psychomotor reaction, for akathisia may develop subsequent to even a
single dose of an inciting drug.2 To understand this phenomenon in the
emergency setting, we undertook a series of studies on the prevention and
treatment of acute drug-induced akathisia.3-5 Using explicit diagnostic
criteria that required a combination of objective signs in addition to
subjective complaints, we observed the induction of akathisia within one
hour of receiving intravenous prochlorperazine (10 mg) in over one-third
of patients.3 If clinicians are not vigilant in pursuing the diagnosis,
mild cases may be misinterpreted as anxiety or go unnoticed altogether.
For some emergency patients with acute drug-induced akathisia, their
compulsion to get up and move is expressed as an insistence on prompt
discharge from the department. The unwary treating physician, eager to
optimize efficiency and department through-put, may misinterpret this
request as an indication of completion of care. For these reasons, a
heightened index of suspicion is required. Accordingly, physicians
providing parenteral drugs known to cause akathisia1 should make it their
habit to look for the signs (i.e., inability to sit or stand still) and to
ask about the characteristic symptoms (i.e., feelings of restlessness or
the urge to move).3,5 This has become more important recently as
parenteral akathisia-inducing drugs (e.g., droperidol, prochlorperazine,
metoclopramide) are assuming greater therapeutic roles in clinical care.
Because acute drug-induced akathisia is common, disturbing to
patients and potentially disruptive to care, we sought to discover an
effective method of prevention. Slowing the rate of infusion of
prochlorperazine from 2 minutes, as recommended by the manufacturer, to 15
minutes was ineffective.4 The co-administration of intravenous
diphenhydramine (50 mg), however, decreased the incidence of akathisia by
60%, though we noted a concomitant increase in sedation.5
In the treatment of acute drug-induced akathisia, we have found
diphenhydramine effective in a majority of patients (unpublished data).
When akathisia persists despite diphenhydramine treatment, beta-adrenergic
receptor antagonists, as recommended by Akagi and Kumar,1 serve as an
established alternative.
1. Akagi H, Kumar TM. Akathisia: overlooked at a cost. BMJ.
2002;324:1506-7.
2. Vinson DR, Drotts DL. Akathisia and prochlorperazine: in reply.
Ann Emerg Med. 2000;36:170-1.
3. Drotts DL, Vinson DR. Prochlorperazine induces akathisia in
emergency patients. Ann Emerg Med. 1999;34:469-75.
4. Vinson DR, Migala AF, Quesenberry CP, Jr. Slow infusion for the
reduction of akathisia induced by prochlorperazine: a randomized
controlled trial. J Emerg Med. 2001;20:113-9.
5. Vinson DR, Drotts DL. Diphenhydramine for the prevention of
akathisia induced by prochlorperazine: a randomized, controlled trial. Ann
Emerg Med. 2001;37:125-31.
Competing interests: No competing interests
Drug-induced akathisia
Akathisia is often seen only as a motor reaction (a movement
disorder) to psychotropic drugs, rather than as a psychomotor phenomenon.
Symptoms of anxiety, dread, dysphoria, agitation or suicidality are often
credited to an exacerbation of illness, rather than to a drug-induced
adverse event. In bipolar disorder, for example, people take several
drugs, most of which can be associated with akathisia. Yet the literature
calls akathisia a movement disorder, and most medical professionals view
it as such. If cognitive and mood symptoms are minimized, and motor
symptoms are emphasized, the diagnosis may be missed. This problem would
be expected to occur in disorders where several drugs are taken
chronically, for example, in bipolar disorder.
Competing interests:
None declared
Competing interests: No competing interests