Chapter 13: Antiparkinsonian DrugsParkinsons Disease & Extrapyramidal Side Effects Extrapyramidal side effects: serious and dangerous complications of treatment with psychotropic drugs These are the result of biochemical changes similar to Parkinsons The four cardinal symptoms of Parkinsons: Tremors Bradykinesia Rigidity Postural instability Parkinsons is related to degeneration of substantia nigra at beginning of dopamine tracts Extrapyramidal side effects are caused by the blockade of dopamine receptorsSpecific Extrapyramidal Side Effects Akathisia: subjective feeling of restlessness, jittery feelings, and nervous energy; most common; responds poorly to treatment Akinesia and bradykinesia: absence of movement or slowed movement; weakness, fatigue, painful muscles; often responds to anticholinergics Dystonias: abnormal postures caused by involuntary muscle spasm; sustained, twisted, and contracted positioning Torticollis: contracted position of the neck Oculogyritic crisis: contracted position of the eyes upward Laryngeal: pharyngeal constriction; potentially life-threatening Drug-induced parkinsonism: tremor, rigidity, bradykinesia, and postural instability Tardive dyskinesia: (tardive = late appearing); tongue writhing, tongue protrusion, teeth grinding, lip smacking Neuroleptic malignant syndrome: potentially lethal; hyperthermia, rigidity, and autonomic dysfunction Treated with muscle relaxants Pisa syndrome: patient leaning to one side; older adults more vulnerablePeople at Risk for EPSEs Women Patients with first episode of schizophrenia Older adults Patients with affective symptoms

Anticholinergics To Treat Extrapyramidal Side Effects Schizophrenia excessive dopamine Antipspycotic drugs block dopamine Block dopamine receptors extrapyramidal side effects Antiparkinsonian drugs to fix the side effects Schizoprenia might worsen due to increased dopamine Anticholinergics given to restore Ach-dopamine balanceSide Effects of Anticholinergics CNS: confusion, agitation, dizziness, drowsiness, cognitive impoverishment Cognitive decline is a major symptom of schizophrenia so giving anticholinergics to them worsens mental abilities PNS: dry mouth, blurred vision, nausea, nervousnessPeripheral Side Effects and Interventions Dry mouth: sugarless hard candy and sugarless gum; frequent rinses; take meds before meals Nasal congestion: OTC nasal decongestants Urinary hesitation: running water, warm water over perineum Urinary retention: catheterize; encourage frequent voiding Blurred vision: sunglasses, caution with driving, pilocarpine eye drops Constipation: laxative, high fiber diet, increased fluid intake Mydriasis: if eye pain develops, may be narrow-angle glaucoma; immediate attention needed Decreased sweating: take temp, reduce body temp if there is a fever (sponge baths) Fever: limit strenuous activity; wear appropriate clothingAnticholinergic Effects on Cranial Nerves III: dilates pupils; blurred vision; impaired accommodation VII: dry mouth, decreased tearing, dry nasal passage IX: dry mouth, dry nasal passage X: tachycardia, constipation, urinary hesitancy and retentionRisks Associated with Anticholinergic Use Might be lethal in overdose Induce dependence Exacerbate tardive dyskinesia Induce psychosis Erectile dysfunction Paralytic ileus

Anticholinergics in Older People: More Pronounced Reaction Slower metabolism and elimination Deficits in cholinergic transmission Difficulties in older men with prostate enlargement can be exacerbated Cognitive impairment results Interactions with Anticholinergics Intensifies sedative effects when combined with CNS depressants Decreased absorption with antacids and antidiarrheals Teaching Patients about Anticholinergics Avoid discontinuing abruptly; taper over a 1 week period Avoid driving until tolerance develops Avoid OTC meds with anticholinergic or antihistamine properties; avoid alcohol and antacidsAnticholinergic Drugs Benztropine (Cogentin): used to treat all parkinsonian-like disorders Most frequently prescribed anticholinergic Usually given orally, but can be given IM for nonadherant psychotic patients or for acute dystonia Diphenhydramine (Benadryl): effective for most parkinsonian-like disorders; less potent that benztropine Trihexyphenidyl (Artane): first anticholinergic used for EPSEs; not available parenteral formOther Treatment Options for EPSEs Dopamine agonist: amantadine (symmetrel) Beta blocker: propranolol (Inderal) Benzodiazepines: diazepam (valium); lorazepam (Ativan); clonazepam (Klonopin) Vitamins E and B6: diminish symptoms associated with tardive dyskinesiaPrevention Establish if patient is high-risk group Obtain baseline info about EPSEs Chose antipsychotic with lower probability of causing EPSEs High-risk: haldol, prolixin, other traditional Lower risk: clozaril, seroquel, other atypicals Monitor pt regularly Consider switching to atypical drug or lower dose or changing to a new atypical drug; add antiparkinsonian agent