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Extrapyramidal Symptoms

Manifestations

Acute Dystonia

  • Severe spasm of muscles of tongue, face, neck and back
  • Horse voice, pharyngeal or laryngeal spasms
  • Stiff or thick tongue
  • Oculogyric crisis
  • Opisthotonus

Treatment: Anticholinergic medication (benztropine, diphenhydramine)

Akathisia

  • Anxious behavior, inability to remain calm
  • Pacing and squirming
  • Profound restlessness - pacing, marching, shuffling, foot tapping, rocking motion, etc
  • Disturbed sleep patterns
  • Impaired concentration

Parkinsonism

**not to be confused with exacerbation of psychosis or anxiety - increase in antipsychotic dosage will make akathisia more intense

Treatment: beta blockers, benzodiazepines and anticholinergic drugs

Acute dystonia

Parkinsonism

Akathisia

Tardive dyskinesia

  • Bradykinesia, slow pill-rolling tremors
  • Mask-like facies
  • Drooling
  • Tremor
  • Rigidity
  • Shuffling gait
  • Cogwheeling
  • Stiff, stooped posture

Nursing Interventions

Treatment: anticholinergic drugs (benztropine, diphenhydramine) and amantadine (Symmetrel)

Tardive Dyskinesia

Defined

  • Involuntary choreoatoid movements of the tongue and face
  • Lip-smacking, grimacing, frowning, sucking/kissing motions
  • Slow, worm-like tongue movements
  • Involuntary movements of the limbs, toes, fingers, and trunk
  • Irregular and rapid or slow serpentine movements
  • Trunk may rock, twist, jerk or thrust forward

Medications

Treatment: no reliable management, irreversible.

Short term increase in antipsychotic dosage.

*Prevention: use lowest effective dose for shortest time required. Reassess need after 12 months. Neurological evaluation every 3 months

  • Alert medical staff
  • Stay with patient
  • Administer medications - Anticholinergic agents
  • These symptoms can be uncomfortable, disturbing and dangerous to patients. Monitor for effects and respond to patient needs

EPS are movement disorders resulting from effects of antipsychotic drugs on the extrapyramidal motor system.

Extrapyramidal system is the neuronal network that helps regulate movement and reflexes. Dopamine is used in the basal ganglia to maintain proper muscle tone and motor stability.

  • Conventional neuroleptics (First generation antipsychotic agents)
  • Atypical antipsychotics (Second generation antipsychotic agents) - lower incidence
  • Antiemetics
  • Antidepressents (SSRIs)
  • Anticonvulsives
  • Antibiotics and Antifungals
  • Antivirals

Pathophysiology

D2 antagonists initiate the blockage of dopamine receptors in the basal ganglia, reducing of dopamine responses to the brain.

This generates alteration in a person's movement and functioning.

Fluctuations in other neurotransmitters such as serotonin, norepinephrine, and acetylcholine may also contribute to the symptoms.

Antiemetics

Conventional Neuroleptics

Dopamine antagonists include:

  • metoclopramide (Reglan) - vertigo/dizziness, acid reflux, appetite stimulant

Classified as conventional neuroleptics:

  • prochlorperazine (Compazine)
  • neuroleptic
  • haloperidol (Haldol) and droperidol (Inapsine) - conventional neuroleptics

Classified as atypical antipsychotic:

  • olanzapine (Zyprexa) - atypical
  • **haloperidol (Haldol)
  • **trifluoperazine (Stelazine)
  • *fluphenazine
  • loxapine (Loxitane)
  • perphenazine
  • chlorpromazine (Thorazine)
  • thioridazine (Mellaril)
  • chlorprothixene (Taractan)
  • levomepromazine (Levoprome)
  • molindone (Moban)
  • thiothixene (Navane)
  • droperidol (Inapsine) - also used as antiemetic
  • fluphenazine (Permitil)
  • pimozide (Orap)
  • prochlorperazine (Compro)

Anticonvulsives

Used to treat seizure activity.

Sometimes used as mood stabilizers in patients with epilepsy, bipolar disease, posttraumatic stress disorder, and chronic migraine.

  • valproic acid (Depakene)
  • valproic acid and valproate sodium (Depakote)

Atypical antipsychotics

Also used to treat autism spectrum disorders, nausea and vomiting. Include:

  • clozapine (Clozaril)
  • quetiapine (Seroquel)
  • olanzapine (Zyprexa)
  • risperidone (Risperdal)
  • aripiprazole (Abilfy)
  • ziprasidone (Geodon)
  • paliperidone (Invega)
  • asenapine (Saphris)
  • iloperidone (Fanapt/Fanapta)
  • lurasidone (Latuda)
  • *donepezil (Aricept) - Ach inhibitor used for Alzheimer disease

Antidepressants

Antibiotics & Antifungals

  • trimethorprim (Primsol/Proloprim)
  • sulfamethoxazole (Bactrim and Septra)
  • Aminoglycosides
  • streptomycin
  • gentamicin
  • neomycin
  • kanamycin
  • tobramycin
  • amphotericin B (Fungizone)

SSRIs

  • fluoxetine (Prozac)
  • citalopram (Celexa)
  • fluvoxamine (Luvox)
  • escitalopram (Lexapro)
  • paroxetine (Paxil)
  • sertraline (Zoloft)

Antivirals

  • acyclovir (Zovirax)
  • vidarabine (Vira-A)
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