An 80-year-old woman is brought to the office by her husband due to behavioral disturbances. The patient has a history of Alzheimer disease. For the past month, she has been wandering the house at night, looking for a pet cat that died 10 years ago. The patient has also been excessively agitated and hits her husband when he tries to assist her. She has had no other symptoms. Environmental and behavioral interventions have been unsuccessful. Medical history also includes hypertension. Medications include amlodipine and donepezil. There have been no recent changes in medications. Vital signs are within normal limits, and physical examination shows no new abnormalities. Blood cell counts, serum electrolytes, and urinalysis are normal. Caregiver education is provided, and nightly risperidone is started after discussing medication options. A week later, the husband reports that the patient is less aggressive, but her restlessness and wandering have worsened. Now, she cannot sit still, even for a few minutes. Which of the following is the most appropriate next step in management of this patient?

Question

An 80-year-old woman is brought to the office by her husband due to behavioral disturbances.  The patient has a history of Alzheimer disease.  For the past month, she has been wandering the house at night, looking for a pet cat that died 10 years ago.  The patient has also been excessively agitated and hits her husband when he tries to assist her.  She has had no other symptoms.  Environmental and behavioral interventions have been unsuccessful.  Medical history also includes hypertension.  Medications include amlodipine and donepezil.  There have been no recent changes in medications.  Vital signs are within normal limits, and physical examination shows no new abnormalities.  Blood cell counts, serum electrolytes, and urinalysis are normal.  Caregiver education is provided, and nightly risperidone is started after discussing medication options.  A week later, the husband reports that the patient is less aggressive, but her restlessness and wandering have worsened.  Now, she cannot sit still, even for a few minutes.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's worsening restlessness, wandering, and inability to sit still that developed a week after starting the antipsychotic medication risperidone is suggestive of akathisia, a common extrapyramidal symptom. Patients with akathisia experience a sense of inner restlessness and an urge to move, which often present as an inability to sit still and frequent pacing. This, in turn, may contribute to agitation, especially in patients with dementia, who have limited verbal communication ability. Akathisia is more common with high-potency antipsychotics (eg, risperidone, haloperidol), but it can also occur with some lower-potency antipsychotics. The first step in management of akathisia would be a dose-reduction trial or, if clinical benefit is not significant, discontinuation of the antipsychotic entirely. The beta blocker propranolol or a benzodiazepine may be used for symptomatic management of akathisia if antipsychotic discontinuation is not an option. If this patient's aggressive behavior reoccurs following discontinuation of risperidone, a trial of a different antipsychotic medication (eg, quetiapine) with less potential to cause extrapyramidal symptoms could be considered. (Choice A) Memantine, an NMDA receptor antagonist, is used to treat moderate to severe dementia, but there is no evidence to support use for the treatment of akathisia. (Choice B) It is premature to advise nursing home placement without first addressing a potentially treatable cause of worsening behavioral symptoms and considering alternate medications, particularly given the timeline of symptoms worsening following risperidone initiation. (Choice D) Akathisia is a dose-dependent extrapyramidal symptom. Increasing the dose of risperidone would likely worsen akathisia. (Choice E) Benzodiazepines (eg, lorazepam) generally do not have a role in the treatment of dementia-related neuropsychiatric symptoms due to their significant potential for adverse effects (eg, worsening gait/falls, physical dependence, paradoxical disinhibited agitation). Although benzodiazepines are sometimes used to symptomatically treat symptoms of akathisia, this approach is reserved for cases in which dose reduction or discontinuation has failed. Educational objective: Antipsychotics used to treat behavioral disturbances in dementia may cause akathisia, a type of extrapyramidal symptom characterized by an inability to sit still. Initial management consists of a dose-reduction trial or discontinuation of the antipsychotic medication, if feasible. References: The clinical challenges of akathisia. (http://www.ncbi.nlm.nih.gov/pubmed/26683525)

An 80-Year-Old Woman Is Brought to the Office by Her