Akathisia: overlooked at a cost
August 29th, 2009 by Wyverns Rose
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1123446
Akathisia has been well documented as a common and distressing side effect of antipsychotic drugs and an important cause of poor drug compliance. However, even in psychiatric settings, it is not recognised readily. In one study of movement disorders induced by neuroleptics, akathisia was diagnosed in only 26% of patients who had it.
Akathisia is common in general medical settings, especially when patients are taking antiemetics. In cancer patients undergoing chemotherapy, 50% of patients met the diagnostic threshold of akathisia,
yet 75% stated they would not have reported the symptoms of akathisia. Therefore, diagnosis can easily be missed if it relies on patients? reports.
Antidepressants are another group of drugs known to cause akathisia but are not as well recognised. The list of drugs reported to cause akathisia has been growing (box) and the disturbance of the serotonin or dopamine system has been postulated in the aetiology of the disorder.
Non-neuroleptic drugs reported to cause akathisia
Antiemetics: Metoclopramide, prochlorperazine, [domperidone]
Antidepressants: Tricyclics, selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline), venlafaxine, [nefazodone]
Calcium channel blockers: Cinnarizine, flunarizine (also H1 antagonists), [diltiazem]
Others: Methyldopa, levodopa and dopamine agonists, [lithium carbonate], [buspirone], [anticonvulsants], [pethidine], [interferon alfa], [sumatriptan]
[ ]=anecdotal or not well established
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As our cases illustrate, akathisia may manifest in various ways and is not necessarily easily recognisable as restlessness. The distress associated with the unpleasant symptoms of akathisia may lead to behavioural disturbance on the ward and to the use of neuroleptic drugs, which will exacerbate the condition rather than ameliorate it.
Compliance with treatment may be affected, as in cases 1 and 2. Refusal of surgery after use of preoperative antiemetics has been reported, and akathisia is thought to contribute appreciably to drug non-compliance in psychiatric settings. Suicidal ideation or suicide attempts have been reported with fluoxetine, droperidol, and metoclopramide, attributed to the distress and unpleasantness of severe akathisia. Therefore, prompt diagnosis and management are crucial in minimising patients? distress and disruption of medical or surgical treatments.
Patients often find it difficult to explain the inner restlessness or mental unease, and the condition may easily be interpreted as acute anxiety or depression. Therefore diagnosis relies on a high index of suspicion on the part of the clinician. Thus when patients present with acute symptoms of agitation and restlessness, their medication should first be checked for a recent introduction or increase in the dose of drugs associated with akathisia. There may be a history of previous similar episodes, as in all our cases, which will help in the diagnosis. Such individual susceptibility may indicate a genetic predisposition.
9 The diagnosis can be confirmed retrospectively when the symptoms abate rapidly with the withdrawal of the offending drug.
On diagnosis, the offending or suspected drug should be withdrawn or the dose reduced if possible. Where this is not possible, propranolol or other lipophilic ? blockers are considered to be the most effective. Benzodiazepines can be considered as additional treatment. Patients should be made aware of the diagnosis so that they can report the symptoms early if they experience similar problems in the future.
Wyverns