1. 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

2. 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

3. 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

4.  Tardive Dyskinesia  Parkinsonism  Akathisia  Acute Dystonia  Neuroleptic Malignant Syndrome

5. 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)

6. 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?

7.  No reliable treatment  Stop all ACh. Drugs  Reduce AP (worsens after stopping, ↑ with age)  Switch AP  Benzo’s?  Vit E? Tardive dyskinesia

8.  S’s same as PD  Rigidity, cog-wheeling, mask like face, laryngeal spasm, drooling  Shuffling gait, stooped posture  Coarse tremor  Psychomotor retardation Parkinsonism

9.  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

10. Parkinsonism: managing  Dose reduction  Switch to low potency  drugs?  Anti-parkinsonian & anti-cholinergics contraindicated

11. Akathisia  Unrelated to age  But may be risk of becoming persistent/ chronic

12. Akathisia: symptoms  Risk 5-60 days  Dysphoria, apprehension, anxiety  Inner discomfort, restlessness  Unable to remain still, compelled to move

13.  Troubled facial expression  Shifting weight, leg crossing, fidgeting  Writhing movements  “Body caressing”  Rocking, walking on spot, pacing Akathisia: signs

14. 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

15.  Dose reduction, switching  Beta blockers (low dose to avoid hypotension, may be ineffective)  Benzodiazepines (no studies)  Anti-cholinergic: mixed results, not recommended Akathisia: managing

16. Acute Dystonia  Rare in older patients  Risk 1-5 days  Painful muscle spasms, head, neck, larynx, torso  Lasts minutes to hours  Occur suddenly, frightening

17.  IM (IV) Benztropine  Great caution!  Tachycardia  Mydriasis  Urine retention  Constipation  Confusion Acute Dystonia: managing

18.  Switching?  Ziprazidone 5%  Quetipaine 1%  Botox!! (idiopathic, tardive, localised, intractable) Dystonia: managing

19. 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

20. 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)

21. 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

22. Specific treatment of NMS  Bromocriptine/ Dantrolene  IV fluids  Supportive intensive care (esp. renal)  Cooling blankets  Anti-pyretics

23. 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