How do you differentiate and treat chorea movements versus akathisia?

Differentiating and Treating Chorea Movements versus Akathisia

Chorea and akathisia are distinct movement disorders with different clinical presentations, etiologies, and treatment approaches, requiring careful differential diagnosis to ensure appropriate management.

Clinical Characteristics and Differentiation

Chorea

• Characterized by irregular, rapid, and non-stereotyped movements that flow randomly, giving an appearance of "dance-like" movements during gait 1
• Movements are involuntary, jerky, and can involve any part of the body in random sequence 2
• Often associated with weakness and emotional lability 1
• May occur as a single episode that subsides within days to a few months (55-65% of cases) 2
• Can be associated with antiphospholipid antibodies and/or antiphospholipid syndrome 2
• Distinguished from athetosis, which involves slower and more twisted movements 1

Akathisia

• Characterized by a sense of severe restlessness frequently manifested as pacing or physical agitation 2
• Has both subjective (feeling of inner restlessness and urge to move) and objective components (rocking while standing/sitting, lifting feet as if marching, crossing/uncrossing legs) 3
• Often misinterpreted as psychotic agitation or anxiety 2
• Commonly seen in patients treated with antipsychotics 2
• A common reason for medication noncompliance 2
• Prevalence rates vary widely between 5% and 36.8% in patients on antipsychotics 3

Diagnostic Evaluation

For Chorea

• Brain MRI without contrast is the optimal imaging modality to identify structural causes 1
• Genetic testing is recommended for suspected Huntington's disease 1
• Evaluate for underlying conditions such as systemic lupus erythematosus, antiphospholipid syndrome, or medication side effects 2
• EEG may help diagnose underlying seizure disorders if differential includes epilepsy 2

For Akathisia

• Use standardized assessment scales to track severity and treatment response 4
• Evaluate medication history, particularly antipsychotic use (both conventional and atypical) 3, 5
• Distinguish from tardive dyskinesia, which typically consists of athetoid or choreic movements in the orofacial region 2
• Consider classification based on time of onset: acute, tardive, withdrawal, or chronic akathisia 3

Treatment Approaches

For Chorea

• Dopamine antagonists are usually effective for symptomatic treatment 2
• For chorea associated with systemic lupus erythematosus or other inflammatory conditions, glucocorticoids in combination with immunosuppressive agents (azathioprine, cyclophosphamide) may be used 2
• Antiplatelet and/or anticoagulation therapy is recommended in antiphospholipid-positive patients 2
• Periodic evaluation to detect development of tardive dyskinesia in patients receiving long-term neuroleptic treatment 1

For Akathisia

• First-line approach: If clinically feasible, lower the antipsychotic dose or switch to a lower potency agent 2, 4
• Pharmacological interventions in order of evidence:
  • Propranolol or other lipophilic beta-blockers are the most consistently effective treatment for acute akathisia 3, 4
  • Benzodiazepines may be added if beta-blockers fail, especially if subjective distress persists 3, 4
  • If both approaches fail, consider amantadine or clonidine 3
  • Other agents with limited evidence include anticholinergics, ritanserin, piracetam, valproic acid, and tricyclic antidepressants 3, 4

Common Pitfalls and Caveats

• Akathisia is often underdiagnosed or misdiagnosed, leading to poor medication adherence, exacerbation of psychiatric symptoms, and in some cases, aggression, violence, and suicide 5
• Chorea may be mistaken for other movement disorders such as tics, which are typically briefer in duration 2, 1
• Tardive dyskinesia (which can include choreiform movements) is associated with long-term neuroleptic use and may persist even after medication discontinuation 2
• Withdrawal dyskinesias can occur with gradual or sudden cessation of neuroleptic agents but usually resolve over time 2
• The distinction between psychogenic movement disorders and true chorea or akathisia can be challenging; look for features of distractibility, variability of presentations, and suggestibility in psychogenic disorders 2

Special Considerations

• Children and adolescents may be at higher risk for extrapyramidal side effects including akathisia than adults 2
• Secondary causes of chorea should be ruled out, including demyelinating diseases, cerebrovascular diseases, traumatic brain injury, or metabolic abnormalities 2
• Iron status may play a role in the pathophysiology of akathisia, though the clinical significance remains unclear 4
• Prophylactic antiparkinsonian agents may be considered for patients at high risk for acute extrapyramidal symptoms, especially those with compliance concerns 2