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 Tract Extrapyramidal 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 Imbalance in the Extrapyramidal System

Use rating scales. –AIMS –Simpson Neurological Rating Scale Videotape the exam for comparison at a later date Methods to Improve Assessment of 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

akathisiahttp://youtu.be/pSXzuCNlI6Q dystoniahttp://youtu.be/2krwEbm5hBo catatoniahttp://youtu.be/_s1lzxHRO4U tardive dyskinesiahttp://youtu.be/FUr8ltXh1Pc parkinsonismhttp://youtu.be/j86omOwx0Hk