A 52-year-old man with schizophrenia is brought to the emergency department by his group home staff due to agitation. Staff report that for the past 2 weeks, the patient has been leaving the group home in the mornings and walking all day in the neighborhood. Today, he became very angry and started shouting when asked to remain in the home. A month ago, his antipsychotic was switched from quetiapine to risperidone for increasing auditory hallucinations. Although the intensity of his voices significantly improved after 2 weeks, the patient has since become increasingly agitated, and dosage escalations to target his agitation do not appear to be calming him. On mental status examination, he is cooperative but seems on edge, getting up to pace. No localized abnormal movements are seen. The patient makes limited eye contact and fidgets with his clothes. He is oriented to time, place, person, and circumstance. He does not have auditory hallucinations. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

Question

A 52-year-old man with schizophrenia is brought to the emergency department by his group home staff due to agitation.  Staff report that for the past 2 weeks, the patient has been leaving the group home in the mornings and walking all day in the neighborhood.  Today, he became very angry and started shouting when asked to remain in the home.  A month ago, his antipsychotic was switched from quetiapine to risperidone for increasing auditory hallucinations.  Although the intensity of his voices significantly improved after 2 weeks, the patient has since become increasingly agitated, and dosage escalations to target his agitation do not appear to be calming him.  On mental status examination, he is cooperative but seems on edge, getting up to pace.  No localized abnormal movements are seen.  The patient makes limited eye contact and fidgets with his clothes.  He is oriented to time, place, person, and circumstance.  He does not have auditory hallucinations.  Which of the following is the most appropriate next step in pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d7fa_afea_bc81_e13bf796e464_MD0003_00 This patient's increasing agitation despite improvement in his psychotic symptoms is consistent with akathisia, the most common extrapyramidal symptom association with antipsychotic medication. Patients with akathisia describe a subjective sense of inner restlessness that may manifest as pacing or an inability to sit still (eg, walking all day in the neighborhood). In severe cases, patients may become extremely distressed, resulting in increased agitation and overall global worsening. Clinicians must differentiate akathisia from worsening psychotic agitation because akathisia is dose dependent. An increase in antipsychotic dosage would make akathisia worse, as seen in this patient in whom efforts to target restlessness and agitation by increasing the antipsychotic dose were ineffective (Choices D and E). Akathisia is more common with high-potency, first-generation antipsychotics but can also occur with some second-generation antipsychotics, such as risperidone, as in this patient. The first steps in management of akathisia include the following: Cautiously reducing the antipsychotic dosage Changing to an antipsychotic with less potential to cause extrapyramidal symptoms Adding a beta blocker (eg, propranolol), an anticholinergic (eg, benztropine), or, less commonly, a benzodiazepine (eg, lorazepam) Propranolol is a common initial choice; it may work by blocking noradrenergic and serotonergic inputs on dopamine pathways. (Choice B) Switching to the first-generation antipsychotic haloperidol would not be indicated because it has a higher risk of causing extrapyramidal symptoms, including akathisia. (Choice C) The patient's auditory hallucinations have responded well to risperidone. Discontinuing the antipsychotic puts the patient at risk of decompensation. In addition, the use of benzodiazepines, such as lorazepam, in patients with schizophrenia is associated with increased mortality and is not a preferred option for long-term treatment for akathisia unless other measures such as dosage reduction, antipsychotic change, or propranolol have failed. Educational objective: Akathisia should be considered if a patient becomes agitated or restless when an antipsychotic is changed or the dosage is increased. Treatment options include reducing the dose, changing to an antipsychotic with less potential to cause extrapyramidal symptoms, and/or starting treatment with propranolol, benztropine, or a benzodiazepine. References: The clinical challenges of akathisia. (http://www.ncbi.nlm.nih.gov/pubmed/26683525)

A 52-Year-Old Man with Schizophrenia Is Brought to the Emergency