Can Cogentin (benztropine) be used to treat akathisia?

Cogentin (Benztropine) for Akathisia

Cogentin (benztropine) should NOT be used as a first-line treatment for akathisia, as anticholinergic agents are notably less effective for akathisia compared to other extrapyramidal side effects. 1

Why Benztropine Is Not Recommended for Akathisia

While benztropine is FDA-approved for drug-induced extrapyramidal disorders and can be used at 1-4 mg once or twice daily 2, the evidence specifically for akathisia is poor:

• Anticholinergics are the least effective option among available treatments for akathisia, despite being commonly prescribed 1
• In elderly patients with Alzheimer's disease receiving typical antipsychotics, guidelines explicitly recommend avoiding benztropine (Cogentin) when extrapyramidal symptoms occur 3
• One controlled trial showed benztropine (6 mg/day) did improve akathisia by Day 3-5, but three patients developed confusion or forgetfulness requiring discontinuation 4

Recommended Treatment Algorithm for Akathisia

First-Line Approaches (in order of preference):

1. Lower the antipsychotic dose while remaining in therapeutic range 1
2. Switch to a lower-risk antipsychotic such as quetiapine or olanzapine 1
3. Add propranolol 10-30 mg two to three times daily - this is the most consistently effective pharmacologic treatment 1, 5, 6

Second-Line Options:

• Benzodiazepines (clonazepam) for symptomatic relief, particularly addressing the anxiety component 1
• Mirtazapine has good evidence support 5

Third-Line Options:

• Clonidine 6, 7
• Amantadine (mild dopaminergic agent) 1

Critical Clinical Pitfall

Akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading clinicians to inappropriately increase the antipsychotic dose, which worsens the condition 1. Look for the characteristic objective signs: continual rocking, leg shuffling, pacing, crossing and uncrossing legs while sitting, and marching in place 5, 7.

When Benztropine Might Be Considered

If you must use an anticholinergic (after first-line options have failed or are contraindicated), benztropine can be tried at 1-4 mg once or twice daily 2, but:

• Monitor closely for anticholinergic side effects, especially confusion and memory impairment 3, 4
• Be particularly cautious in elderly patients and children/adolescents 3, 1
• Recognize this is an off-label, evidence-poor choice for akathisia specifically