How to manage akathisia in a patient with Parkinsonism?

Management of Akathisia in Parkinsonism

The first-line approach is to reduce or discontinue the offending antipsychotic medication if clinically feasible, followed by β-blockers (propranolol) or benzodiazepines for symptomatic relief, while avoiding anticholinergic agents in patients with underlying Parkinson's disease. 1, 2

Critical Distinction: Drug-Induced vs. Parkinson's Disease-Related Akathisia

The management strategy fundamentally differs based on whether akathisia is:

• Antipsychotic-induced in a patient with Parkinsonism (most common scenario)
• Nocturnal akathisia as a manifestation of Parkinson's disease itself

This distinction is crucial because anticholinergic agents—commonly used for drug-induced parkinsonism—are not consistently helpful for akathisia and may worsen the underlying condition. 1

Stepwise Management Algorithm

Step 1: Medication Adjustment (First Priority)

Reduce or discontinue the causative antipsychotic if clinically possible. 1, 2, 3

• This is the most reliable treatment for acute akathisia 3
• Acute akathisia commonly resolves upon treatment discontinuation 2
• Balance this against risk of psychiatric decompensation 3

If antipsychotic continuation is necessary:

• Switch to lower-risk atypical antipsychotics (quetiapine, clozapine) 4
• However, be aware that even these agents can occasionally cause akathisia 2, 5

Step 2: Pharmacological Symptomatic Treatment

For patients WITHOUT underlying Parkinson's disease symptoms:

β-Blockers (First-Line):

• Propranolol is the most thoroughly studied intervention 2, 3
• Provides symptomatic relief for drug-induced akathisia 1, 6

Benzodiazepines (Alternative First-Line):

• Effective for symptomatic management 1, 2, 3
• Particularly useful when β-blockers are contraindicated 6

For patients WITH Parkinson's disease symptoms:

Avoid anticholinergic agents as they are not consistently helpful for akathisia specifically 1

Consider:

• Low-dose mirtazapine (serotonin 2A antagonist): thoroughly studied for akathisia 2, 3
• Gabapentin or pregabalin (voltage-gated calcium channel blockers) 2
• Clozapine for nocturnal akathisia in Parkinson's disease: mean dose 26.4 mg at bedtime showed excellent results in all patients studied, with additional benefits for tremor and confusion 7

Step 3: Resistant Cases

For chronic or tardive akathisia that persists after drug withdrawal:

• Rotation between different pharmacological strategies may be optimal 2
• Consider sequential trials of: β-blockers → mirtazapine → benzodiazepines → gabapentinoids 2
• Opioids may be effective in refractory cases 2

Common Pitfalls to Avoid

Misdiagnosis: Akathisia is frequently misinterpreted as psychotic agitation, anxiety, or worsening of the underlying psychiatric illness, leading to inappropriate dose escalation of the causative agent. 1, 4

Inappropriate use of anticholinergics: While anticholinergics treat drug-induced parkinsonism effectively, they are not consistently helpful for akathisia and should not be the primary intervention. 1

Overlooking high-risk medications: High-potency typical antipsychotics (haloperidol) and antiemetics (metoclopramide) pose the greatest risk for drug-induced parkinsonism and akathisia. 4

Assuming atypical antipsychotics are risk-free: Even drugs with minimal extrapyramidal side effects (clozapine, quetiapine, aripiprazole) can induce akathisia. 2, 5

Special Considerations

Prophylaxis: Prophylactic antiparkinsonian agents should not be routinely prescribed except in high-risk patients (young males on high-potency agents with history of dystonic reactions). 1, 4

Monitoring: Maintain high index of suspicion in patients with motor disabilities, drug-induced parkinsonism, or those under mechanical restraint. 2

Medication noncompliance: Akathisia is a common reason for treatment discontinuation, making prompt recognition and management essential for maintaining therapeutic adherence. 1