How to treat akathisia in a patient with a neurocognitive disorder on risperidone (antipsychotic medication) 0.5mg nocte (at night)?

Management of Akathisia in a Patient with Neurocognitive Disorder on Risperidone

The first-line treatment for akathisia in a patient with neurocognitive disorder on risperidone 0.5mg is to reduce or discontinue the risperidone if clinically possible, followed by adding a beta-blocker such as propranolol if needed. 1, 2

Understanding Akathisia in this Context

Akathisia is a common extrapyramidal side effect of antipsychotics like risperidone, characterized by:

• Subjective feelings of inner restlessness 3
• Objective evidence of motoric restlessness 4
• Significant association with subjective cognitive-perceptual deficits that may worsen cognitive symptoms in neurocognitive disorders 3

Risperidone specifically has been documented to cause akathisia in clinical trials, with rates of 10% in adult patients and 8-10% in pediatric patients 2

Treatment Algorithm

Step 1: Evaluate and Reduce/Discontinue Risperidone

• Assess if risperidone is still clinically necessary for the neurocognitive disorder patient 1
• If possible, gradually reduce the dose or discontinue risperidone completely 1
• Be cautious about withdrawal akathisia, which can paradoxically occur when reducing risperidone 5

Step 2: If Risperidone Must Be Continued, Consider Pharmacological Interventions

• First-line pharmacological treatment: Beta-blockers, particularly propranolol (starting at 10mg BID, titrating up to 30-80mg/day as needed) 1
• Second-line options:
  • Anticholinergic medications like benztropine (0.5-2mg BID) 1
  • Benzodiazepines such as lorazepam (0.5-1mg BID) for short-term use 1
  • Consider switching to an antipsychotic with lower risk of akathisia if antipsychotic treatment remains necessary 1

Step 3: Consider Antipsychotic Alternatives if Needed

• If an antipsychotic is still required, consider options with potentially lower akathisia risk:
  • Quetiapine (starting at 25mg at bedtime) 1
  • Olanzapine (starting at 2.5mg at bedtime in elderly/frail patients) 1

Special Considerations for Neurocognitive Disorder Patients

• Anticholinergic medications should be used with extreme caution in patients with neurocognitive disorders as they may worsen cognition 1
• Benzodiazepines carry increased risk of falls, confusion, and paradoxical agitation in elderly patients with neurocognitive disorders 1
• Start with lower doses of all medications and titrate slowly in this population 1
• Monitor closely for sedation and orthostatic hypotension with any medication changes 1

Monitoring and Follow-up

• Regularly assess for improvement in akathisia symptoms using a standardized scale 4
• Monitor for cognitive changes that may occur with medication adjustments 3
• Evaluate for other extrapyramidal symptoms that may co-occur with akathisia 6
• Be vigilant for medication adherence issues, as akathisia significantly impacts compliance 4

Pitfalls to Avoid

• Misdiagnosing akathisia as worsening agitation from the underlying neurocognitive disorder 4
• Adding medications without first considering dose reduction of the causative agent 1
• Using high doses of anticholinergics in elderly patients with neurocognitive disorders 1
• Abrupt discontinuation of risperidone, which may precipitate withdrawal akathisia 5
• Prolonged use of benzodiazepines in elderly patients due to fall risk and dependence potential 1

By following this structured approach, akathisia can be effectively managed while minimizing additional adverse effects in this vulnerable patient population.