INTRODUCTION
Family caregivers of cancer patients suffer from physical, psychological, and social distress. With regard to their physical problems, reduced immunity (Kiecolt-Glaser et al., Reference Kiecolt-Glaser, Glaser and Gravenstein1996), heart disease (Shaw et al., Reference Shaw, Patterson and Semple1997), and chronic sleep disorder (Carter, Reference Carter2002) were detected in a survey of the physical condition of family members of cancer patients. Family caregivers may also be cancer patients (Onishi et al., Reference Onishi, Onose and Okuno2005). As for their psychological condition, family caregivers also suffer mental distress once their family member is suspected of having cancer, and they may develop anxiety and/or a depression. The overall prevalence of psychiatric conditions among family members of cancer patients is reportedly 10–50% (Braun et al., Reference Braun, Mikulincer and Rydall2007). The severity of the depressive state of patient's family members is equivalent to that of cancer patients, and the depressive state persists, switching between regression and progression at various phases, such as examination, diagnosis, and recurrence (Northouse et al., Reference Northouse, Mood and Templin2000). In a survey of caregiving family members of terminal-stage cancer patients, depression was noted in approximately one-third within one month after the patient's death (Prigerson et al., Reference Prigerson, Shear and Frank1997). As for the social problems of caregivers, caring for cancer patients often requires family members to abandon their social lives and to suffer an economic burden (Covinsky et al., Reference Covinsky, Goldman and Cook1994). Therefore, families are increasingly recognized as requiring treatment and care and are regarded as second order patients (Lederberg, Reference Lederberg1998).
Confronting the mortality of loved ones is the most stressful event in life (Holmes & Rahe, Reference Holmes and Rahe1967). However, preparing for a loved one's death is important because bereaved caregivers who perceived that could not prepare for their family member's death demonstrated more depression, anxiety, and complicated grief (Hebert et al., Reference Hebert, Schulz and Copeland2009). In addition, one survey reported that 90% of caregivers stated that the key elements of quality end-of-life care were completing things, resolving conflicts, and saying goodbye (Heyland et al., Reference Heyland, Dodek and Rocker2006). Therefore, it is recommended that clinicians intervene early to help caregivers, facilitate appropriate management of each problem, and make time for caregivers to prepare for their loved one's death (Hebert et al., Reference Hebert, Schulz and Copeland2009).
Akathisia is a common adverse effect of antipsychotics and, less commonly, antidepressants (Khawam et al., Reference Khawam, Laurencic and Malone2006). The clinical symptoms of akathisia include subjective complaints of restlessness accompanied by observable restless movements (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, or the inability to sit or stand still) developing within a few weeks of starting or raising the dose of antipsychotics and/or antidepressants (American Psychiatric Association, 2000). The reported prevalence of akathisia varies between 20 and 75%. Its onset is within a few days of the initiation of medication, but it can also occur later in the treatment course (Hsin-Tung & Simpson, Reference Hsin-Tung, Simpson, Sadock and Sadock2000).
Akathisia can cause great discomfort and even agitation and is often described by the patient as the most distressing sensation, and suicide is also a reported complication (Shear et al., Reference Shear, Frances and Weiden1983; Cem Atbasoglu et al., Reference Cem Atbasoglu, Schultz and Andreasen2001). However, the condition is often underdiagnosed or misdiagnosed as anxiety, agitation, or violent behavior (Siris, Reference Siris1985; Rodgers, Reference Rodgers1992; Hirose, Reference Hirose2003). The reasons for underdiagnosis are considered to be related to both the patient's symptoms and the clinician's attitude toward akathisia. Patient-related factors include a mild degree of akathisia; a lack of apparent motor restlessness; and a lack of clear communication about subjective sensations of restlessness, restlessness in body areas other than the legs, and other clinical signs. Clinician-related factors include an overemphasis on objective restlessness, a failure to consider akathisia during antipsychotic therapy, and a failure to fully implement anti-akathisia treatments in ambiguous cases (Hirose, Reference Hirose2003).
Several studies of akathisia in cancer patients have been reported (Fleishman et al., Reference Fleishman, Lavin and Sattler1994; Kawanishi et al., Reference Kawanishi, Onishi and Kato2007; Onishi et al., Reference Onishi, Yamamoto and Wada2007); however, akathisia has not been reported as a cause of distress in family members caring for cancer patients.
In this article, we report a case of akathisia in a spouse caregiver of a terminally ill cancer patient. Initially, family members of the spouse caregiver thought that she was unable to visit the hospital where her husband was being treated because of her depression and the grief she was suffering about the impending loss of her husband. However, careful clinical examination revealed that she had akathisia. After treatment for the akathisia and subsequent palliation of her akathisia symptoms, the spouse caregiver was able to visit the hospital and take part in the care of her terminally ill husband.
To standardize physicians' judgment, Francis' criteria (Francis et al., Reference Francis, Martin and Kapoor1990) were proposed for the diagnosis of akathisia. These criteria are based on a combination of a clinical assessment and a medical chart review, and the potential cause was categorized as 1) definite: if it was temporally related, there was laboratory confirmation, the patient improved with treatment or cessation of the offending agent, and there was no other cause present; or 2) probable: if all the previous criteria were met but another possible cause was present or laboratory confirmation was not achieved.
CASE REPORT
Medical History of the Cancer Patient – Husband
The patient was a 77-year-old man with a stage IV bladder carcinoma. At the initial operation, because of the presence of peritoneal dissemination and rectum stenosis, only colostomy was performed. He received chemotherapy and completed three courses. However, when he was admitted to the hospital for the fourth course of chemotherapy, his chemotherapy was discontinued because pulmonary embolism developed. After that, pain, nausea, and vomiting developed, and he received medication to control his symptoms. His general condition gradually deteriorated, and his life expectancy ranged from several days to weeks.
Medical History of the Spouse Caregiver – Wife
The patient's wife was a 74-year-old. She had lost her appetite and was diagnosed with major depressive disorder at another mental clinic after her husband started the second chemotherapy course. She received 75 mg sulpiride, 10mg clotiazepam, and 0.25 mg triazolam, and her appetite improved a month later. However, she lost her appetite again when her husband was hospitalized for his fourth chemotherapy course. After that, the administered sulpiride dose was gradually increased from 75 mg to 150 mg, and 5 mg paroxetine was added over 2 weeks. However, her emotional condition did not improve, and she could scarcely go out or visit her hospitalized husband for a month — she met her husband just one time, but she left after 5 minutes because of restlessness. The daughters, who were living with the wife, also reported that she was wandering around the house. In addition, the daughters thought that their mother's depressive symptoms would worsen as she was confronted with the expected loss of her husband. Therefore, they brought her to our outpatient service so that we could provide her with mental support.
At the initial visit, she was depressed, but not frustrated. We found that both her legs were moving a little. She mentioned that she felt a sense of inner restlessness in both legs while she was sitting, which was relieved by walking around the room, and that these symptoms had developed when the dose of sulpiride was increased. Her symptoms fulfilled the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision criteria for drug-induced akathisia. We directed her to stop taking sulpiride. After 2 days, one daughter reported that the distress of their mother was reduced compared with on the day of the medical examination. Three days and five days after the discontinuation of sulpiride, the patient visited her husband was able to take care of him calmly at the hospital. Six days later, her husband died.
DISCUSSION
We reported a spouse caregiver of a cancer patient who had akathisia. This is the first case of akathisia in the caregiver of a cancer patient.
Initially, we thought that the symptoms of the spouse caregiver were caused by the exacerbation of her major depressive disorder and her grief about losing her husband, because we had not met the wife before and believed the information from the daughters that she was under treatment for major depressive disorder. However, careful examination of the spouse caregiver revealed that her symptoms of restlessness had developed after the dose of sulpiride that she was being administered had been increased, and that she was suffering from akathisia in addition to her grief. Her distress was palliated after the sulpiride treatment was discontinued, and she visited her husband three times and was also able to take care of him before he died. Sulpiride is an antidepressant that can also cause akathisia (Jimenez-Jimenez et al., Reference Jimenez-Jimenez, Garcia-Ruiz and Molina1997; Janno et al., Reference Janno, Holi and Tuisku2004); therefore, based on Francis' criteria, we identified sulpiride to be the offending drug in this case.
We consider that the caregiver's grief became stronger as her husband's condition got worse, but that this was misdiagnosed as depression; therefore, the dose of sulpiride was increased, and akathisia developed. There were several aspects of the spouse caregiver's akathisia that were underdiagnosed for 2 weeks or that were difficult to diagnose. First, the doctor of the mental clinic did not have a chance to examine the wife directly because her symptoms prevented her from leaving the house. Therefore, the doctor of the mental clinic could not recognize her grief and akathisia. Second, the daughters believed that their mother was grieving about losing her husband and thought that her distress was a normal psychogenic reaction. Third, the akathisia was mild, and the symptom of motor restlessness was unremarkable, and therefore it was difficult for the family members to properly recognize the symptoms. Finally, we had a bias toward a diagnosis of major depressive disorder because we had received information from a psychiatrist at the mental clinic and the statements of the family members.
The detection and treatment of the wife's akathisia resulted in the improvement of her distress-related symptoms, and she was able to take care of her terminally ill husband. This might have reduced any potential regret about her caregiving role. This case suggests that drug-induced akathisia is a cause of distress in spouse caregivers who are taking certain drugs. It is therefore important for clinicians to realize that family caregivers might suffer from not only socioeconomic, physical, and psychological problems but also from side effects of medication.
