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Antipsychotic Induced

Movement Disorders

Presented by Nicole Cannon

Antipsychotic Induced Movement Disorders

Antipsychotics

Introduction

  • The drug of choice for many different mental health conditions
  • Work by blocking dopaming receptors
  • Dopamine is the pleasure neurotransmitter

Side Effects

Side Effects

First Generation

  • Orthostatic Hypotension
  • Anticolinergic effects
  • Negative symptom induction
  • Extrapyramidal symptoms
  • Hyperprolactinemia

Third Generation

  • Akathesia
  • Dizziness
  • Extrapyramidal symptoms
  • Tongue numbness
  • Somnolence
  • Weight gain

Second Generation

  • Metabolic syndrome
  • Increased prolactin
  • Weight gain
  • Dyslipidemia
  • Diabetes Mellitus
  • QT Prolongation
  • Agranulocytosis

Examples

Antipsychotic Medications

Third Generation

  • Aripiprazole

First Generation

  • Haloperidol
  • Loxapine
  • Thiothixene
  • Prochlorperazine

Second Generation

  • Clozapine
  • Olanzapine
  • Risperidone
  • Quetiapine

Akathesia

  • Motor restlessness with feelings of inner tension and discomfort

Types of Movements

Types of Movements

  • Lower limb movements
  • Rocking foot-to-foot
  • Shuffling of legs
  • Trunk rolling
  • Fidgeting of the upper limbs
  • Severe cases
  • Pacing
  • Uncomfortable in any position for more than a few minutes

Treatment Options

Treatment Options

Rating Scales

  • Barnes Akathisia Rating Scale
  • Abnormal Involuntary Rating Scale (AIMS)
  • Hillside Akathisia Rating Scale
  • Prince Henry Hosptial Akathesia Scale

Acute Dystonia

  • Characterized by intermittent or sustanied muscle action
  • Can occur in 25-40% of people receiving conventional antipsychotics
  • Often effects the muscles of the head and neck

Types of Movements

Types of

Movements

Glossopharyngeal spasms

Respiratory stridor/cyanosis

Torticollis (muscle stiffness of the neck)

Trismus (jaw spasms)

Dystonia of the trunk and limbs

Blepharospasm

Oculogyric crisis (eyes rolled into the head

Treatment Options

  • Respond well to anti-parkinsonian agents
  • IM benztropine or diphenhydramine can result in complete resolution of symptoms in 20-30 minutes. Can repeat in 30 minutes if needed
  • Oral anticolinergics can be used in milder cases

Tardative Dystonia

  • A more severely disabling condition
  • Symptoms are more sustained than the acute
  • Prevalence of 1.5-4%
  • Manifesting symptoms are similar to acute dystonia but dintiguished by duration

Treatment Options

Treatment Options

  • No specific treatment options
  • Some patients respond to trihexyphenidyl (an antiparkinsonian agent)
  • Tetrabenzine (Monoamine depletor which depletes dopamine, serotonin, and norepinephrine)
  • Reserpine (Antihypertensive)
  • Large doses of clozapine, baclefen, or benzodiazepines have mixed results
  • Deep brain stimulation

Parkinsonism

  • Develop within days of starting treatment
  • Prevalence rates of 20-40% of patients
  • Continuation of the medication can lead to tolerance and subside

Parkinsonism

Clinical Manifestations

  • Muscle rigidity
  • Tremor
  • Bradykinesia
  • Postural abnormalities
  • Salivation

Rating Scales

  • Targeting Abnormal Kinetic Effects (TAKE)
  • The extrapyramidal scale (EPS)
  • The neurological rating scale for extrapyramidal side efffects (Simpson-Angus scale)

Treatment Options

  • Reduction of the dose or switch to lower potency antipsychotic
  • Anticholinergis medications
  • Maximum therapeutic effect occurs in 3 to 10 days
  • Or longer with more severe symptoms

Tardative Dyskinesia

  • Irregular, repetitive involuntary movements of the face, mouth, and tongue
  • Symptoms usually begin no earlier than 6 months post initiation of treatment
  • Once thought to be irrersible but is contraversial

Risk Factors

Risk Factors

  • Over 50 years of age
  • Female
  • Affective disorders, particularily depression
  • Brain damage or dysfunction
  • Increased duration of treatment
  • Standard antipsychotic medications
  • Use of acute higher doses of antipsychotic medication

Distinguishing Movements

  • Chewing
  • Tongue protrusion
  • Lip smacking
  • Puckering of the lips
  • Rapid eye blinking
  • Abnormal finger movements
  • Trunk and extremity involvement
  • Rare cases: irregular breathing and swallowing leading to belching and grunting noises

Preventative Strategies

Prevention Strategies

  • Avoiding the development of the chronic syndrome
  • Preventative measures include
  • use of atypical antipsychotics
  • lowest possible dose of antipsychotics
  • limit use of PRN medications
  • Close monitoring
  • The earlier the syptoms are recognized the more likely they will resolve if the medication can be changed or discontinued

References

References

Austin, W., & Boyd, M. A. (2015). Psychiatric & mental health nursing for Canadian practice

(3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Bergman H, & Soares-Weiser, K. (2018). Anticholinergic medication for antipsychotic-induced

tardive dyskinesia (review). Cochrane Database of Systematic Reviews, 1, 1-49.

Casey, D. E. (2004). Pathophysiology of antipsychotic drug-induced movement disorders.

Journal of Clinical Psychiatry, 65(9), 25-28.

Johnson, B. G. (2017). Monitoring for drug-induced movement disorders. Nursing2017, 47(5),

56-60.

Mathews, M., Gratz, S., Adetunji, B., George, V., Mathews, M., & Basil, B. (2005).

Antipsychotic-induced movement disorders: evaluation and treatment. Psychiatry, 2(3), 36-41.

Salem, H., Nagpal, C., Pigott, T., & Teixeira, A. L. (2017). Revisiting antipsychotic-induced

akathisia: current issues and prospective challenges. Current Neuropharmacology, 15(1), 789-798.

Sethuram, K. & Gedzior, J. (2014). Akathisia: case presentation and review of newer treatment

agents. Psychiatric Annals, 44(8), 391-396.

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