medication induced movement disorders jacob alexander july 2012 rural & remote mental health...
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Medication Induced Movement
Disorders
Jacob AlexanderJuly 2012
Rural & Remote Mental Health Service
Extra pyramidal system Anatomical• Neural Network that is part of the
motor system• Reticular formation of the pons and
the medulla• Nigrostriatal pathway• Basal Ganglia• Cerebellum• Cerebral cortex- motor and sensory
areas Functional• Causes involuntary reflexes and
movements• Locomotion• Complex movements • Postural control
Extrapyramidal TractExtrapyramidal Tracts
• The first generation (conventional) antipsychotics may cause significant extrapyramidal side effects, more so than the second generation antipsychotic agents.
• Risperidone and Ziprasidone more likely to cause EPSEs amongst second generation antipsychotic agents
• EPSEs require careful assessment and management
Extrapyramidal Side Effects(EPSEs)
Objectives
• Early Identification
• Encourage and alleviate anxiety for patient and carers
• Be able to explain causes
• Be able to explain treatments
• Draw attention of appropriate health personnel to phenomena
Objectives
• Dystonia
• Parkinsonism
• Akathisia
• Tardive Dyskinesia
• Acetylcholine-Dopamine dysregulation syndromes
Types of EPSEs
• Occurs usually within 48 hours of initiation of the medication
• Involves bizarre and severe muscle contractions
• Can be painful and frightening
• Characterized by odd posturing and strange facial expressions
Dystonia
• Usually occurs after 3 or more weeks of treatment
• Characterized by:– Cogwheeling rigidity– Tremors– Rhythmic oscillations of the extremities– Pill rolling movement of the fingers
Drug-induced Parkinsonism
• Usually occurs after 3 or more weeks of treatment
• Subjectively experienced as desire or need to move
• Described as feeling like jumping out of the skin
• Mild: a vague feeling of apprehension or irritability
• Severe: an inability to sit still, resulting in rocking, running, or agitated dancing
Akathisia
Tardive Dyskinesia
• Usually occurs late in the course of long-term treatment
• Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping)
• Often irreversible
Tardive Dyskinesia
Complications of Tardive Dyskinesia
• Inability to wear dentures
• Impaired respirations
• Weight loss
• Impaired gait
• Impaired posture
Complications of Tardive Dyskinesia
• A rare side effect
• Characterized by hallucinations, dry mouth, blurred vision, decreased absorption of antipsychotics, decreased gastric motility, tachycardia, and urinary retention
• Neuroleptic Malignant Syndrome
Dopamine-Acetylcholine Imbalancein the Extrapyramidal System
• Use rating scales.– AIMS– Simpson Neurological Rating Scale
• Videotape the exam for comparison at a later date
Methods to Improve Assessmentof EPSEs
Treatment
• Titrate dose
• Switch to AP less likely to cause extra-pyramidal side-effects
• Evaluate need for EPSE causing other meds- metaclorpromide, amoxapine, SSRIs
• Anticholinergic agents- benztropine, trihexyphenidyl, benadryl
• Akathisia- benzodiazepines and beta blockers
Treatment of EPSEs
• http://youtu.be/pSXzuCNlI6Q akathisia
• http://youtu.be/2krwEbm5hBo dystonia
• http://youtu.be/_s1lzxHRO4U catatonia
• http://youtu.be/FUr8ltXh1Pc tardive dyskinesia
• http://youtu.be/j86omOwx0Hk parkinsonism