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What causes sleeplessness and restlessness while on Mirtazapine?

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Posted on Mon, 18 Jul 2016
Question: My 88 year old mother with dementia had her Mirtazapine increased from 15 mg to 30 mg three weeks ago. It has made her agitation and sleeplessness worse. So she was started on Olanzapine 2.5 mg last night. I stayed the night in the nursing home to keep an eye on her and it was a horror night. She could not keep any part of her body still - extreme restlessness and some 'jerks' which persisted even when she had some brief sleep from 2.30 to 5 am. She was up and down out of bed about 40 times. Hyperventilating, panicky (she often has those anyway). Asking strange questions bordering on delirium (hasn't had these before). My question is will these side effects go away or does it mean the drug is not suited to her/not suited to her in combination with that dosage of Mirtazapine? I'm not sure I can stand another night like that and it's very upsetting for her too - should we push through it? It's a long weekend over here so can't ask her doctor. Would like your advice but won't use it when talking to her doctor of course. Her calcium serum levels are up around 2.8 due to parathyroid adenoma but her Sensipar is going to be increased to deal with that.
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Answered by Dr. Ronald Schubert (1 hour later)
Brief Answer:
Mirtazapine side effects

Detailed Answer:
Thank you for contacting HCM with your health care concerns

I am sorry to hear that your mother is having such side effects from her medication. The increased restlessness is all due to the mirtazapine. Instead of increasing the dose they should be decreasing it. Higher doses are activating and the lower doses are more sedating. It is due to the changes in the brain with higher doses. i would highly recommend refusing to take the olanzipine and asking to reduce the mirtazapine to 7.5mg. That may help more than adding a medication to counter side effects from a medication. There are significant risks with olanzapine I don't think your mother should have to continue this medication. If your doctor refuses you do have the right to refuse their treatment plan. you need to e your mothers advocate here and not give in to pressure from the doctor. you have the right to question and refuse treatment.

If her behaviors still are a problem then lorazapem can help but this should only be used as needed and sparingly.

I hope I answered your question. Please contact us again if you have any additional questions
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Ronald Schubert (30 hours later)
Dear Dr Schubert,

Many thanks for your response. Unfortunately with benzodiazapines she gets more panicky when the 'vagueness' and confusion they cause sets in - she also gets more unsteady on her feet and has had a fall with them.

We do need to find something for her very bad generalised anxiety disorder and disturbed sleep - any other suggestions? Would a different anti-psychotic have the same effect?

Many thanks.....
doctor
Answered by Dr. Ronald Schubert (34 hours later)
Brief Answer:
Anitpsychotics

Detailed Answer:
I am sorry to say that any of the antipsychotic medications will all have the same side effects. Has your mother been tried on Trazodone? This is a antidepressant that has sedative side effects and may also help with anxiety.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Ronald Schubert (6 hours later)
Dear Dr XXXXXXX Schubert,

Thank you for that suggestion - I can try asking the psycho-geriatrician about it, although I think he is fed up with my questions....

My brother is angry with me, thinking I made a mountain out of a molehill with the akathesia. He thinks that because it stopped the next day (ie whe wasn't walking around or twitching or restless) she probably would have been ok to take the Olanzapine again and give it a fair trial. Maybe he's right. Can the akathesia reduce over time? If it didn't continue during the day is that a sign that it probably wasn't anything to worry about and she would have been ok to continue taking it?

Many thanks
doctor
Answered by Dr. Ronald Schubert (20 minutes later)
Brief Answer:
restless leg side effect

Detailed Answer:
The side effect from all anti-psychotics is called extra pyramidal and manifests as restless legs or tremor. It can also be lip smacking or facial grimacing. These side effects don't usually lessen with time. They actually can get worse and may even become permanent if on the medication of a long time. So I would agree with you to not use the medication for fear of the restlessness and also from an increase in diabetes and stroke with the anti-psychotics.

I recommend perhaps one more trial but if she goes through the same thing stop immediately.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Ronald Schubert (3 days later)
Dear Dr Schubert,

Thank you for your reply.

I slept on the floor at the nursing home on Wednesday night and noticed she was getting the restless legs, unable to stay still and unable to sleep. I thought it was strange - maybe she's like that without the medication. But at 2 am I found out they had given her the Olanzapine by mistake. She got just over two hours sleep that night and was very distressed. However... her restlessness wasn't as bad as the previous time (maybe because I was unaware she had had something or maybe because I'd had a sleeping tablet).

The issue is, the second day after each dose of Olanzapine, her anxiety does seem to be better and she is more content. So we are starting to think it does have a good effect. But how could we get around the sleeplessness/restlessness at night - is that likely to decrease?

Many thanks
doctor
Answered by Dr. Ronald Schubert (12 hours later)
Brief Answer:
restless leg side effect

Detailed Answer:
You may want to ask to try benadryl at night. Sometimes it may help with the restless legs. We can use benadryl for Parkinson's disease so this may give her some relief and allow for better sleeo
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Ronald Schubert

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What causes sleeplessness and restlessness while on Mirtazapine?

Brief Answer: Mirtazapine side effects Detailed Answer: Thank you for contacting HCM with your health care concerns I am sorry to hear that your mother is having such side effects from her medication. The increased restlessness is all due to the mirtazapine. Instead of increasing the dose they should be decreasing it. Higher doses are activating and the lower doses are more sedating. It is due to the changes in the brain with higher doses. i would highly recommend refusing to take the olanzipine and asking to reduce the mirtazapine to 7.5mg. That may help more than adding a medication to counter side effects from a medication. There are significant risks with olanzapine I don't think your mother should have to continue this medication. If your doctor refuses you do have the right to refuse their treatment plan. you need to e your mothers advocate here and not give in to pressure from the doctor. you have the right to question and refuse treatment. If her behaviors still are a problem then lorazapem can help but this should only be used as needed and sparingly. I hope I answered your question. Please contact us again if you have any additional questions