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