Akathisia: Care Staff Guide to Medicine-Induced Restlessness

"I can't sit still. I feel like I'm going to crawl out of my skin." Akathisia is a distressing side effect of antipsychotic medicines, and it is often mistaken for anxiety, agitation or a worsening of the illness the medicine is meant to treat. The risk is that the response to akathisia, for example giving more of the same medicine, can make it worse. Care staff see people throughout the day and are in a strong position to notice the pattern and speak up. This guide draws on a clinical review published in the Canadian Journal of Psychiatry and explains what akathisia is and how to respond.

What is akathisia?

A 2018 review by Pringsheim and colleagues in the Canadian Journal of Psychiatry describes akathisia as a neuropsychiatric syndrome caused by antipsychotics. The word comes from the Greek for "inability to sit". It has two parts: a subjective experience of inner restlessness, tension and unease, and objective, visible restlessness of the body. The review notes that it can sometimes drive impulsive behaviour.

What it looks like

The subjective feeling is a mounting sense of tension and unease, particularly when a person is expected to stay still, for example when waiting in a queue, sitting through a meal or lying in bed. The objective signs, as described in the review, include trouble sitting, standing or lying still. When seated, people may swing, cross or jiggle their legs. When standing, they may shift their weight from foot to foot or pace. Many people cannot describe the feeling in words and may simply say they feel awful, anxious or unable to settle.

When does it start?

The review says akathisia usually appears early, often within hours or days of starting an antipsychotic or increasing the dose. Chronic akathisia is defined as signs lasting more than three months. It can also follow a reduction or stopping of the medicine, known as withdrawal akathisia. A related picture, pseudoakathisia, has visible signs without the inner feeling.

Who is at risk?

The review reports that people who have not taken antipsychotics before, and those whose dose is increased quickly, are at higher risk. Taking more than one antipsychotic is also a risk factor. In a community sample of 372 people with schizophrenia described in the review, the overall prevalence of akathisia was 18.5%, and it was higher in people taking two antipsychotics than in those on a single second-generation drug. This shows how common the problem can be in routine practice.

Why it is missed

The review stresses that akathisia is under-recognised and is often mistaken for psychotic agitation, restless legs syndrome, anxiety, intoxication or withdrawal from substances, or tardive dyskinesia. Staff may see a person who cannot settle and assume their mental health is worsening. That matters because the response could be a higher dose of the medicine that is causing the restlessness.

Akathisia is also not the same as restless legs syndrome, which tends to be worse in the evening and when resting, with an urge to move the legs that is relieved by movement. Our guide to restless legs syndrome explains the differences. Nor is it the same as tardive dyskinesia, which our guide to tardive dyskinesia covers.

Risks: distress, aggression and suicide

Akathisia is deeply unpleasant. The review says it is uncertain whether it is a direct risk factor for suicide, but it has been associated with suicidal thoughts in first-episode psychosis and with violent or aggressive behaviour. For this reason, unexplained distress after a medicine change should be taken seriously. Our guide to suicide and self-harm awareness explains how to respond to expressed distress and risk. Treat any statement of hopelessness, however it arises, according to your service's risk procedures.

What care staff should do

• Ask and listen. Ask the person whether they feel restless inside, and listen to how they describe it. Do not dismiss it as nerves.
• Link it to the timeline. Note when restlessness began and whether it followed a new antipsychotic, a dose increase or a dose reduction.
• Report promptly to the prescriber, GP or mental health team, and say clearly that you are worried about a possible medicine side effect.
• Do not give extra doses of antipsychotic or as-required sedation for restlessness unless the prescriber has advised it.
• Do not stop the medicine yourself, as sudden changes can cause relapse and further problems.
• Keep the person safe and comfortable. Provide space to walk, a calm environment and reassurance that the feeling is a recognised effect and can be treated.
• Record observations in neutral language and share them at handover.

How it is managed

According to the review, management starts with assessment, ideally using a validated tool such as the Barnes Akathisia Rating Scale, before an antipsychotic is started and while the dose is being raised. First steps may include reducing the dose, stopping extra antipsychotics, or switching to a medicine less likely to cause akathisia, such as clozapine, olanzapine or quetiapine, balancing this against the risk of the underlying illness getting worse.

If another medicine is added, the review identifies propranolol as the most studied and the first choice, with checks for contraindications and monitoring of blood pressure and pulse, and at least five days to judge benefit. Mirtazapine may be considered if propranolol is unsuitable, ineffective or not tolerated. The review says medicines that block acetylcholine, such as benztropine and biperiden, should not be routinely used because of cognitive and anticholinergic side effects, and that a benzodiazepine such as clonazepam may be used short term and then tapered because of the risks of tolerance and dependence. Vitamin B6 may be considered short term in people who do not respond to other approaches, though very high doses taken for a long time can damage nerves. The authors conclude that treatment should be individualised and that adjunct medicines should be prescribed cautiously because the evidence is limited. All of this is for the prescriber to decide.

Supporting someone with akathisia

• Offer regular opportunities to move, walk and stretch, and avoid expecting the person to sit through long activities.
• Reduce caffeine if it appears to worsen restlessness, and make sure sleep is protected.
• Reassure them that you believe them and are acting on it.
• Involve family or advocates, who often notice that the person "is not themselves".
• Make sure the side effect is recorded in the person's notes so it is recognised in future.

Antipsychotic medicines are used in the care of people with conditions such as schizophrenia, and good care means looking at the whole picture of treatment, side effects and support.

Frequently asked questions

Is akathisia just anxiety?

No, although it is often mistaken for it. The Pringsheim review says akathisia is frequently misdiagnosed as anxiety, psychotic agitation or restless legs syndrome.

Can it start after a dose is reduced?

Yes. The review describes withdrawal akathisia following a reduction or stopping of an antipsychotic.

Does it go away?

Many people improve once the prescriber changes the treatment, but the review notes chronic akathisia can last more than three months, so early reporting matters.

Keep building your knowledge

Noticing and reporting side effects early prevents unnecessary suffering. Explore the health and social care learning available through Learnsignal CPD to keep your knowledge current.

This article is general information for care staff, based on published clinical guidance and NHS information, and does not replace the advice of a person's own prescriber or clinicians. Never stop, start or change a medicine without clinical advice.