Medication
Induced Movement
Disorders
Jacob Alexander
July 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 Tracts
Extrapyramidal
Tract
Extrapyramidal Side Effects
(EPSEs)
• 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
Objectives
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
Types of EPSEs
•
•
•
•
•
Dystonia
Parkinsonism
Akathisia
Tardive Dyskinesia
Acetylcholine-Dopamine dysregulation
syndromes
Dystonia
• 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
Drug-induced Parkinsonism
• 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
Akathisia
• 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
Tardive Dyskinesia
Dyskinesia
Tardive
• Usually occurs late in the course of longterm treatment
• Characterized by abnormal involuntary
movements (lip smacking, tongue
protrusion, foot tapping)
• Often irreversible
Complications
of
Tardive
Complications of Tardive Dyskinesia
Dyskinesia
•
•
•
•
•
Inability to wear dentures
Impaired respirations
Weight loss
Impaired gait
Impaired posture
Dopamine-Acetylcholine Imbalance
in the Extrapyramidal System
• 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
Methods to Improve Assessment
of EPSEs
• Use rating scales.
– AIMS
– Simpson Neurological Rating Scale
• Videotape the exam for comparison at a
later date
Treatment
Treatment
of EPSEs
• Titrate dose
• Switch to AP less likely to cause extrapyramidal side-effects
• Evaluate need for EPSE causing other
meds- metaclorpromide, amoxapine,
SSRIs
• Anticholinergic agents- benztropine,
trihexyphenidyl, benadryl
• Akathisia- benzodiazepines and beta
blockers
•
•
•
•
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