What are alternative treatments for akathisia in an 83-year-old male with dementia, who has not responded to Depakote (valproate)?

From the Guidelines

For an 83-year-old male with dementia who appears to have akathisia and is attempting to get up from his wheelchair despite Depakote being ineffective, non-pharmacological approaches should be tried first, including regular repositioning, comfort assessment, scheduled toileting, and providing appropriate activities to reduce restlessness, as recommended by the most recent guidelines 1.

Alternative Treatments for Akathisia

Several alternative treatments can be considered for akathisia in this patient population.

• Low-dose quetiapine (25-50mg) or olanzapine (2.5-5mg) may help reduce restlessness while having a lower risk of extrapyramidal side effects than typical antipsychotics.
• Benzodiazepines like lorazepam (0.5mg) can be used short-term for acute episodes.
• Beta-blockers such as propranolol (10-20mg twice daily) specifically target akathisia symptoms.

Prioritizing Non-Pharmacological Interventions

Before medication changes, it's essential to rule out physical discomfort from pressure sores, constipation, pain, or urinary retention, as recommended by the American Psychiatric Association practice guideline 1. Non-pharmacological interventions, such as cognitive training, music or art therapy, physical exercise, and diet, may have a positive impact on cognition and physical function, and should be prioritized over pharmacotherapy interventions, as stated in the Japanese guidelines 1.

Medication Management

Any medication should be started at the lowest possible dose with careful monitoring for side effects, particularly in elderly patients with dementia who are more susceptible to adverse reactions, including increased fall risk and cognitive decline, as highlighted in the assessment and management of frailty in individuals living with dementia 1. The most recent guidelines recommend providing individualized and appropriate treatments for depression or other mood disorders, considering the risk of adverse effects, comorbidities, and the presence of behavioral and psychological symptoms associated with these mental health disorders 1.

From the Research

Alternative Treatments for Akathisia

The patient in question is an 83-year-old male with dementia who has not responded to Depakote (valproate) for akathisia. Considering the available evidence:

• The study 2 suggests that propranolol or other lipophilic beta-blockers are the most consistently effective treatment for acute akathisia.
• If beta-blockers fail, the addition of benzodiazepines may be a sensible next choice, especially if subjective distress persists 2.
• Other agents that have been investigated for the treatment of akathisia include amantadine, clonidine, ritanserin, piracetam, and tricyclic antidepressants 2.
• Valproate has been used in the treatment of various psychiatric disorders, including bipolar disorder and schizophrenia, but its efficacy in treating akathisia is not well established 3.
• In the context of dementia, divalproex sodium has been used to treat behavioral disturbances, and it may be effective in some patients 4.

Considerations for Treatment

When considering alternative treatments for akathisia in this patient:

• The patient's age and dementia diagnosis should be taken into account when selecting a treatment, as some medications may have adverse effects or interact with other medications.
• The study 4 found that divalproex was well tolerated in patients with dementia, except for reversible sedation and transient worsening of gait and confusion in some cases.
• Valproic acid has been proposed as a potential treatment for hyperactive or mixed delirium, but its use in akathisia is not well established 5.
• Further research is needed to determine the efficacy and safety of various treatments for akathisia in patients with dementia.

Potential Treatment Options

Based on the available evidence, potential treatment options for this patient may include:

• Propranolol or other lipophilic beta-blockers
• Benzodiazepines
• Amantadine or clonidine
• Other agents such as ritanserin, piracetam, or tricyclic antidepressants
• Divalproex sodium, although its efficacy in treating akathisia is not well established.