PART 3 / CH 58
Extrapyramidal Symptoms (EPS)
Amy Gagliardi
A. Overview
Neuroleptic blockade of the D2 receptors in the basal ganglia may cause a variety of unpleasant, frightening and sometimes life-threatening side effects commonly referred to as EPS. While more common with typical neuroleptics, they may also occur with newer agents.
B. General approach
1. Go see the patient: identify the onset, time course and symptoms.
2. Do a targeted physical exam with a focus on the motor system.
3. Perform a brief mental status exam.
4. Treat the symptoms quickly.
C. Acute Dystonia
· Characterized by brief or prolonged muscle contractures, usually of the head, neck, and tongue, resulting in abnormal movements.
· Laryngeal or pharyngeal dystonias, which present with hoarse voice or a choking sensation, are a medical emergency.
· Other presentations include oculogyric crisis (one or both eyes turned upward), tongue protrusion, and torticollis.
· Prevalence = 10%
D. Parkinsonism
· The same triad as idiopathic parkinsonism:
1. resting tremor (rhythmic, 3-6 cycles/second)
2. rigidity (lead pipe continuous or cogwheel)
3. bradykinesia (masklike facies, difficulty initiating movement,
shuffling gait with propulsion and retropulsion, decreased arm
swing while walking, decreased spontaneous movements).
· If there is rigidity and disorientation, this is likely not parkinsonism and NMS should be ruled out.
· Prevalence = 50%
E. Akathisia
· An objective or subjective feeling of restlessness, characterized by pacing, rocking, or rapid alteration of sitting and standing.
· Patients often describe a sense of "I can't stay still" or "I'm jumping out of my skin."
· Often misdiagnosed as anxiety, agitation, psychosis
· Prevalence ³10% of all patients on neuroleptics
F. Extrapyramidal symptoms: diagnosis
| onset | risk factors | ddx | |
|---|---|---|---|
| acute dystonia | rapid - often hours after 1st dose up to 5 days out | male under 40 high potency meds | seizures tetanus |
| parkinsonism | 2-6 weeks or immed. after dose increase | female elderly previous hx of parkinsonism other neurologic illness | Parkinson’s disease catatonia negative sxs of schizophrenia psychomotor retardation tardive dyskinesia |
| akathisia | 1-4 weeks or immed. after dose increase | female middle-aged | almost anything: anxiety, agitation, psychosis, "acting out" |
G. Extrapyramidal symptoms: treatment
| symptom | treatment recommendations |
|---|---|
| acute dystonia | If laryngeal dystonia with airway compromise, cogentin 4 mg IV/IM then ativan 2 mg IV/IM slowly if needed otherwise, 1) cogentin 2 mg IM/IV or 2) benadryl 50 mg IM/IV If no response in 20 minutes, repeat above. If no response after two trials, ativan 1 mg IM/IV. After treatment, neuroleptic can be continued with standing dose of anticholinergic coadministered for two weeks. If symptoms return, change to lower potency neuroleptic. |
| parkinsonism | 1) dose antipsychotic as low as possible, or switch to low potency antipsychotic, and 2) cogentin 0.5-2 mg po bid and/or 3) benadryl 25-50 mg po bid and/or 4) amantadine 100 mg po bid or tid note: anticholinergics should be stopped after 14 days if asymptomatic because long-term use can increase the risk of tardive dyskinesia |
| akathisia | If no other EPS: 1st choice: propanolol 10 to 30 mg po tid 2nd choice: lorazepam 1 mg po tid 3rd choice: cogentin 1 mg po bid If other EPS present: 1st choice: cogentin 2 mg po bid 2nd choice: cogentin with propanolol as above 3rd choice: cogentin with lorazepam as above After treatment, neuroleptic may be continued with benzo or beta-blocker indefinitely; anticholinergics should be weaned after two weeks if possible. |
source: Hyman SE, Tesar GE (1994). Manual of Psychiatric Emergencies. Little, Brown.