Akathisia

Question 1

Assessment

Answer 1

While there are a range of standardised tools for assessing extrapyramidal side effects the most common tool for assessing akathisia is the Barnes Akathisia Rating Scale (BARS).
Instructions: Patient should be observed while they are seated, and then standing while engaged in neutral conversation (for a minimum of two minutes in each position). Symptoms observed in other situations, for example while engaged in activity on the ward, may also be rated. Subsequently, the subjective phenomena should be elicited by direct questioning.

Question 2

Treatment

Answer 2

On diagnosis, the antipsychotic dose should be reduced until the akathisia disappears, or an alternative antipsychotic (usually an SGA – lower doses of Quetiapine/Olanzapine or Clozapine if treatment resistant) should be trialled. For short-term measure, consider propranolol or benzodiazepines. Propranolol should be avoided in patients with asthma or severe peripheral vascular disease and some patients with heart failure. It should be used cautiously in patients with diabetes.
A number of other drugs, including anticholinergic drugs are less effective (may be effective where other parkinsonian symptoms are present). Cyproheptadine, mirtazapine and clonidine have been used with mixed results. Other possible treatments for acute akathisia include Vitamin B6, diphenhydramine, trazadone and zolmitriptan (weak evidence). Parenteral midazolam has been successfully used to prevent akathisia associated with IV metoclopramide.
Only a small proportion of patients respond favourably to any of the above drugs and dose reduction or change of antipsychotic are better options.