II. Definitions
- Akathisia
- Motor restlessness or psychomotor aggitation typically as a medication-related Extrapyramidal Side Effect
- May present as inability to sit still, pacing or wringing hands
III. Pathophysiology
- Decreased Dopaminergic activity in the mesocortical pathway
- Mesocortical Pathway originates in the ventral tegmental area
- Mesocortical Pathway projects to the Limbic System and prefrontal cortex
- Mesocortical pathway typically inhibits motor function
- When this pathway is inihibited, unwanted involuntary movement occurs
- Other effects
- Decreased Dopaminergic activity in ventral tegmental area may increases Serotonin and Norepinephrine activity
IV. Symptoms
- Tense and ucomfortable Sensation
- Timing
- Onset may be abrupt with rapid infusion of IV medications (e.g. Compazine, Metoclopramide)
V. Signs
- Leg fidgety movement
- Pacing
- Inability to sit still
- Rocking from foot to foot, shifting weight while standing
VI. Causes: Medication-Induced Acute Akathisia
- Antipsychotics
- Antidepressants
- Antiemetics
- Antihypertensives
- Antibiotics
- Neurologic Agents
VII. Differential Diagnosis
VIII. Management
- Reduce medication dose or switch to alternative medication
- Acute symptomatic management
- Beta Blockers
- Propranolol 40-80 mg orally daily
- Serotonin Antagonists (5HT-2A)
- Mirtazapine 15 mg orally daily
- Cyproheptadine (Periactin) 8-16 mg orally daily
- Benzodiazepines
- Clonazepam 0.5 to 1 mg daily to twice daily
- Diazepam 5-15 mg orally daily
- Anticholinergics
- Benztropine (Cogentin) 1-4 mg orally daily
- Other agents
- Amantadine 100 mg orally daily
- Clonidine 0.1 mg orally daily to twice daily
- Beta Blockers
IX. Prevention
- Infuse Compazine or Metoclopramide over 30 minutes in a bag (e.g. D5W) instead of a bolus over minutes