Severe restlessness কী?

Severe restlessness মানে রোগী ভিতরে অস্থিরতা অনুভব করে এবং স্থির বসে/শুয়ে থাকতে পারে না—বারবার হাঁটা, পা নাড়ানো, উঠা-বসা, irritability, panic বা agitation দেখা যায়। Antipsychotic/antiemetic drug-এর কারণে হলে এটাকে akathisia বলা হয়; DSM-5 অনুযায়ী subjective restlessness + excessive movement থাকে।

Common causes

1. Medical emergency: hypoxia, hypoglycaemia, sepsis, fever, pain, head injury, stroke, seizure/post-ictal state।
2. Metabolic: Na/Ca imbalance, renal/hepatic failure, thyroid storm, dehydration।
3. Drug/substance: alcohol withdrawal, benzodiazepine withdrawal, amphetamine/cocaine intoxication, caffeine excess।
4. Medication-induced akathisia: haloperidol, risperidone, metoclopramide, prochlorperazine, antidepressant dose change।
5. Psychiatric: panic attack, acute psychosis, mania, severe anxiety।
6. Delirium: acute confusion + fluctuating consciousness; NICE delirium risk factors include age ≥65, cognitive impairment/dementia, hip fracture, severe illness।

Symptoms

• স্থির বসতে না পারা, pacing, rocking, পা নাড়ানো
• ভেতরে “অসহ্য অস্থিরতা”
• irritability, aggression, shouting
• insomnia
• anxiety/panic
• confusion, disorientation হলে delirium ভাববেন
• suicidal thought থাকলে akathisia emergency

Clinical diagnosis

History: onset, drug history, antipsychotic/antiemetic শুরু বা dose বাড়ানো, substance use/withdrawal, fever/pain/trauma।
Examination: vitals, SpO₂, GCS/mental status, hydration, neuro exam, pupil, tremor, rigidity, signs of infection।
Scale: Akathisia suspected হলে Barnes Akathisia Rating Scale। Delirium হলে 4AT/CAM।

Specific investigations

Bedside first: RBS, SpO₂, BP, pulse, temperature, ECG।
Blood: CBC, CRP, electrolytes Na/K/Ca/Mg, renal function, LFT, TSH if indicated, ABG/VBG if hypoxia/acidosis, serum alcohol/toxicology if suspected।
Urine: urine R/M/E, culture if UTI suspected, urine drug screen, pregnancy test in reproductive-age female।
Imaging: CT brain if trauma, focal neuro sign, seizure, sudden confusion, anticoagulant use।
Others: CXR, blood culture, LP only if meningitis/encephalitis suspected.

Treatment management

First steps

• ABCDE, low-stimulation room, remove hazards, verbal de-escalation।
• Cause treat করুন: hypoglycaemia → dextrose; hypoxia → oxygen; pain → analgesia; sepsis → antibiotics/fluids; withdrawal → benzodiazepine protocol।
• Project BETA/ACLP principle: drug choice should follow underlying cause; aim is rapid calming, not deep sleep।

Pharmacological drugs — point আকারে:-

1. Lorazepam

Tablet 1.Lozicum 1mg AS A  Lorazepam AS A  Benzodiazepine hypnotics, Benzodiazepine sedatives.

• Dose: 1–2 mg PO/IM/IV; repeat cautiously after 30–60 min if needed.
• Duration: acute episode; withdrawal হলে protocol অনুযায়ী কয়েক দিন।
• Used why: alcohol/benzodiazepine withdrawal, stimulant intoxication, severe anxiety-related agitation। ACLP recommends lorazepam 1–2 mg for EtOH/BZD withdrawal or CNS stimulant intoxication.
• Side effects: sedation, respiratory depression, hypotension, falls, paradoxical agitation।
• Interactions: alcohol/opioid/other sedatives → respiratory depression ↑; avoid in severe COPD/OSA unless monitored।
• Haloperidol

Tablet 2.Halopid 5mg AS A Haloperidol AS A Butyrophenone drugs, Drugs used in tremor, tics & related disorder.

• Dose: 2–5 mg PO/IM; severe acute agitationে 5 mg IM; elderly/deliriumে lower dose.
• Duration: shortest possible; deliriumে usually ≤1 week। NICE notes short-term use, usually 1 week or less, and ECG monitoring especially with cardiac risk.
• Used why: psychosis/mania, delirium with risk to self/others when de-escalation fails।
• Side effects: EPS, acute dystonia, akathisia, QT prolongation, NMS, sedation।
• Interactions: QT-prolonging drugs macrolide/fluoroquinolone/amiodarone; levodopa effect কমায়; CNS depressants sedation বাড়ায়।
• Olanzapine

Tablet 3.Deprex 5 mg AS A  Olanzapine AS A Atypical neuroleptic drugs.

• Dose: 5–10 mg PO/ODT; 5–10 mg IM acute agitation।
• Duration: acute control; psychiatric illness হলে specialist plan অনুযায়ী।
• Used why: psychosis/mania-related agitation; deliriumে oral atypical option হিসেবে used। ACLP lists olanzapine 5–10 mg PO or 10 mg IM.
• Side effects: sedation, weight gain, hyperglycaemia, orthostatic hypotension।
• Interactions: IM olanzapine + benzodiazepine close timing avoid—respiratory/CNS depression risk; smoking lowers level।
• Risperidone

Tablet 4.Frenia 4 Mg AS A Risperidone AS A Atypical neuroleptic drugs.

• Dose: 0.5–2 mg PO; acute agitationে commonly 1–2 mg।
• Duration: cause-based; deliriumে short course, psychosisে longer specialist plan।
• Used why: oral antipsychotic for psychosis/mania or delirium-related agitation। ACLP lists risperidone 2 mg as oral option.
• Side effects: EPS/akathisia, hyperprolactinaemia, QT prolongation, sedation।
• Interactions: fluoxetine/paroxetine level বাড়ায়; levodopa effect কমায়।
• Propranolol — akathisia হলে

          Tablet 5.Indever 10 mg AS A Propranolol Hydrochloride AS A Beta-adrenoceptor blocking drugs, Beta-blockers.

• Dose: 10–20 mg PO BD/TDS; titrate 30–120 mg/day if tolerated।
• Duration: usually 5–14 days then reassess; causative drug adjust না করলে relapse হতে পারে।
• Used why: antipsychotic-induced akathisia; first adjust causative antipsychotic, then propranolol often first-choice।
• Side effects: bradycardia, hypotension, fatigue, bronchospasm, depression।
• Interactions/avoid: asthma/COPD, heart block, bradycardia; verapamil/diltiazem/digoxin → bradycardia ↑।
• Mirtazapine — akathisia alternative

          Tablet 6.Mirapro 15 mg AS A Mirtazapine AS A Atypical anti-depressant drugs.

• Dose: 7.5–15 mg PO at night।
• Duration: 5–14 days then reassess।
• Used why: propranolol contraindicated/ineffective হলে akathisia; JAMA 2024 network meta-analysisে mirtazapine 15 mg/day effective found.
• Side effects: sedation, increased appetite, weight gain, dry mouth।
• Interactions: other serotonergic drugs → serotonin syndrome rare; alcohol/sedatives → sedation ↑।
• Benztropine / Trihexyphenidyl

বাংলাদেশে Benztropine খুব commonly marketed না

বাংলাদেশে practicalভাবে psychiatrists অনেক সময় Benztropine-এর বদলে নিচের alternative বেশি ব্যবহার করেন:

• Procyclidine
• Tablet 7.Cyclid 5mg AS A Procyclidine Hydrochloride AS A Antiparkinson drugs.

      OR

       7.Tablet 7.Tridyl 2 mg AS A  Trihexyphenidyl Hydrochloride  AS A Antiparkinson drugs.

• Dose: Benztropine 1–2 mg PO/IM; Trihexyphenidyl 2 mg BD/TDS।
• Duration: short-term; reassess frequently।
• Used why: EPS/parkinsonism/dystonia prominent হলে; pure akathisiaতে benefit limited।
• Side effects: dry mouth, constipation, urinary retention, blurred vision, confusion।
• Avoid/interactions: elderly delirium, glaucoma, BPH; other anticholinergic drugs toxicity বাড়ায়।

Prevention

• Antipsychotic/antiemetic lowest effective dose ব্যবহার।
• Rapid dose escalation ও antipsychotic polypharmacy avoid—AIA preventionে recommended।
• New antipsychotic/metoclopramide শুরু করলে restlessness actively ask করুন।
• Sleep, hydration, pain control, infection treatment, oxygenation maintain।
• Alcohol/benzodiazepine dependent patientে abrupt stop নয়।
• Delirium prevention: orientation, glasses/hearing aid, mobilization, sleep hygiene, constipation/urinary retention treat।

Overview / Summary

Severe restlessness একটি symptom, diagnosis নয়। প্রধান জরুরি কারণ: hypoxia, hypoglycaemia, sepsis, delirium, intoxication/withdrawal, psychosis/mania, এবং drug-induced akathisia।

Actionable Plan / Steps

1. Vitals + RBS + SpO₂ + ECG immediately.
2. Drug/substance history নিন।
3. Delirium বনাম akathisia আলাদা করুন।
4. Cause treat করুন।
5. Danger থাকলে monitored setting-এ lorazepam/antipsychotic cause-based use করুন।
6. Akathisia হলে causative drug reduce/switch + propranolol বা mirtazapine consider।

Reference List

• NICE CG103: Delirium prevention, diagnosis and management.
• Wilson MP et al. Project BETA Psychopharmacology of Agitation. West J Emerg Med. 2012;13(1):26–34.
• Gerolymos C et al. Drug efficacy in antipsychotic-induced akathisia. JAMA Network Open. 2024;7(3):e241527. doi:10.1001/jamanetworkopen.2024.1527
• Harrison’s Principles of Internal Medicine, latest ed.: Delirium and acute confusional states.
• Kaplan & Sadock’s Synopsis of Psychiatry: Akathisia/EPS and agitation management.

Md.Rafiqul Islam Lipu. Date:-21-05-2026 Thursday Time:-2-39-56 Pm