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0 Extra pyramidal side effects & NMS in older patients Prepared by Bryan McMinn Clinical Nurse Consultant Mental Health Nursing of Older People 31 January 2016
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PERICYAZINE “Neulactil”Mid potency HALOPERIDOL “Serenace”High potency (EPSE) OLANZAPINE “Zyprexa”First Line. (Sedation, wt. Gain) RISPERIDONE “Risperdal”First Line. (EPSE, post hypotension) QUETIAPINE“Seroquel”First Line (Sedation, HT dose related ) ZIPRAZIDONE” Zeldox”Newer (QT interval) (Depots/ Clozapine/ Amisulpride/ Aripiprazole not normally used for older people) Common Anti-Psychotics for Older Patients
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Clozapine Olanzapine Haloperidol Risperidone H1 2 1 Musc 5-HT2C 5-HT2A D4 D2 Quetiapine D1 Binding profile of atypical antipsychotic agents Bymaster et al., Neuropsychopharmacology 14:87-96, 1996 Schotte et al., Psychopharmacology 124:57-73, 1996 Strong EPSE Post. Hypotension Sedation Anti-psychotic effect
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Tardive Dyskinesia Parkinsonism Akathisia Acute Dystonia Neuroleptic Malignant Syndrome
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Ageing effects Parkinsonism and TD greater incidence with age Akathisia – no age effect Dystonia rare in older: young (1:15) Caliguiri, M. et al.(2000)
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Tardive dyskinesia Oral-facial dyskinesias, choreo-athetoid movements (rapid, jerky, slow sinuous) Risk: after months or years, can be earlier in older patients. (Can be spontaneous in dementia) Risk factors Age Cumulative dosage Acute parkinsonism Potency Risp. 6% v. Halo. 32% Gender? Ethnicity?
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No reliable treatment Stop all ACh. Drugs Reduce AP (worsens after stopping, ↑ with age) Switch AP Benzo’s? Vit E? Tardive dyskinesia
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S’s same as PD Rigidity, cog-wheeling, mask like face, laryngeal spasm, drooling Shuffling gait, stooped posture Coarse tremor Psychomotor retardation Parkinsonism
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Risk 5-30 days May resolve (months) Prevalence 50-75% Incidence 32% (corrected for spontaneous PD) Risp. 0.5mg/day 6.7% 2mg 21% Parkinsonism
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Parkinsonism: managing Dose reduction Switch to low potency drugs? Anti-parkinsonian & anti-cholinergics contraindicated
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Akathisia Unrelated to age But may be risk of becoming persistent/ chronic
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Akathisia: symptoms Risk 5-60 days Dysphoria, apprehension, anxiety Inner discomfort, restlessness Unable to remain still, compelled to move
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Troubled facial expression Shifting weight, leg crossing, fidgeting Writhing movements “Body caressing” Rocking, walking on spot, pacing Akathisia: signs
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Akathisia: v. “restless legs” Aka.RL Body parts AllLegs only Sensory S’s in calves AbsentPresent Myoclonic jerks RareUsual Fluctuation IntensityWorse at night Sleep disturbance RareUsual
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Dose reduction, switching Beta blockers (low dose to avoid hypotension, may be ineffective) Benzodiazepines (no studies) Anti-cholinergic: mixed results, not recommended Akathisia: managing
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Acute Dystonia Rare in older patients Risk 1-5 days Painful muscle spasms, head, neck, larynx, torso Lasts minutes to hours Occur suddenly, frightening
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IM (IV) Benztropine Great caution! Tachycardia Mydriasis Urine retention Constipation Confusion Acute Dystonia: managing
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Switching? Ziprazidone 5% Quetipaine 1% Botox!! (idiopathic, tardive, localised, intractable) Dystonia: managing
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Neuroleptic Malignant Syndrome Risk: weeks Rare, 10% mortality, can persist week after medication ceased, immediate medical intervention Coarse tremor & catatonia resembles severe Parkinsonism, fluctuating Muscle rigidity, myoglobinaemia Autonomic instability: labile pulse & BP, hyperthermia, profuse sweating Clouding of consciousness Elevated serum CK
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NMS: Risk factors Pre-NMS Psychomotor agitation, dehydration Related to treatment High potency Neuroleptic drug Neuroleptic dose in first 24 hrs> 600mg chlorpromazine (equivalent) Maximum dose in any 24 hr >600mg chlorpromazine Associated Past ECT (J.Bryant. CMH 2008)
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NMS Management High risk patients Monitor temp/ BP tds/ hydration Record episodes of profuse sweating On suspicion Assess for other medical illness FBC, MBA, CK, serum iron On diagnosis withdraw all dopamine blocking drugs
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Specific treatment of NMS Bromocriptine/ Dantrolene IV fluids Supportive intensive care (esp. renal) Cooling blankets Anti-pyretics
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NMS v. Serotonin Syndrome NMSSS Onset Days –weeksMinutes-hours Hyperthermia 90%50% Muscle tone RigidityHyperreflexia Autonomic MoreLess Resolution 5-10days24hrs Similar Muscle tone, agitation, delirium, hypertension, tachycardia, sweating
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