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
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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
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Extrapyramidal TractExtrapyramidal Tracts
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• 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)
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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
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• Dystonia
• Parkinsonism
• Akathisia
• Tardive Dyskinesia
• Acetylcholine-Dopamine dysregulation syndromes
Types of EPSEs
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• 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
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• 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
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• 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
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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
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Complications of Tardive Dyskinesia
• Inability to wear dentures
• Impaired respirations
• Weight loss
• Impaired gait
• Impaired posture
Complications of Tardive Dyskinesia
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• 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
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• Use rating scales.– AIMS– Simpson Neurological Rating Scale
• Videotape the exam for comparison at a later date
Methods to Improve Assessmentof EPSEs
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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
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• 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