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Recognition of Movement Disorders: Extrapyramidal Side Effects and Tardive Dyskinesia

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Recognition of Movement Disorders: Extrapyramidal Side Effects and Tardive Dyskinesia A SPECIAL ARTICLE Recognition of Movement Disorders: Extrapyramidal Side Effects and Tardive Dyskinesia. Would You Recognize Them If You See Them? Elizabeth Pulsifer Anderson Edward B. Freeman Anti-emetic, anti-spasmodic and prokinetic medications commonly used in gastroen- terology are neuroleptics, a class of drugs which includes anti-psychotics used for schiz- ophrenia. These medications are capable of causing serious and potentially permanent side effects. The manifestation of neuroleptic drug side effects may range from dra- matic and debilitating to very subtle. It has been demonstrated repeatedly that these side effects often go unrecognized. Doctors prescribing prokinetics, anti-emetics and anti-spasmodics need to be able to recognize these side effects. A full description of the most common movement side effects and the corresponding medical term is included as a resource list for professionals and patients. BACKGROUND who are being treated for psychiatric disorders such as ny drug capable of causing Extra Pyramidal schizophrenia are at risk for neuroleptic side effects, Side effects (EPS) and Tardive Dyskinesia (TD) yet several gastroenterology drugs have the same side A is by definition a neuroleptic, Latin for “seize effect profile as Thorazine. Patients taking these med- the neuron.” It is widely assumed that only patients ications need to be monitored carefully to prevent potentially irreversible side effects. Psychiatrists have long been trained to recognize Elizabeth Pulsifer Anderson, Director, Pediatric Ado- the signs and symptoms of EPS and TD and a great lescent Gastroesphageal Reflux Association, Inc. deal of physician education has been aimed at them, (PAGER). Edward B. Freeman, M.D., Psychiatrist, Private Practice, Killeen, Texas. (continued on page 16) 14 PRACTICAL GASTROENTEROLOGY • MAY 2004 Recognition of Movement Disorders A SPECIAL ARTICLE (continued from page 14) any of the body’s voluntary muscles including those of Because it is impossible to predict which patients may develop symptoms, familiarity with the the vocal cords. The movements of dystonias can appear numerous GI drugs capable of causing very bizarre and deliberate but are involuntary. neuroleptic reactions is essential. Dyskinesias are involuntary, often hyperkinetic movements of various types that have no purpose and EPS and TD are documented with the use of are not fully controllable by the patient. Some are ran- metaclopramide, domperidone, cisapride, promethazine, prochlorperazine, perphenazine, dom, some rhythmic, most are very odd looking and hycosamine sulfate and other belladonna alkaloids, socially stigmatizing. They can affect the ability to ini- ranitidine, chlorpromazine, thiethylperazine maleate, tiate or stop a movement as in Parkinson’s. They can trimethobenzamide, ondansetron hydrochloride, affect the smooth movement of a joint resulting in a phenothaizines, baclofen and rabeprazole. jerky articulation. Abrupt and seemingly violent Symptoms suggestive of EPS or isolated reports movements of a limb are common as are gyrations of of movement disorders are associated with any body part. Tics and involuntary vocalizations are scopolamine, olsalazine, mesalamine and related to dyskinesias. balsalazide disodium, cimetidine, esomeprazole, Extrapryramidal Side Effects (EPS) describes omeprazole and pantoprazole. movement side effects that begin during the early phases of treatment with a neuroleptic drug. Early yet it has been well documented that they often miss onset symptoms tend to resolve quickly and com- the symptoms. In some studies, experts in the field pletely when the patient is weaned from the offending pick up twice as many cases of tardive as newly medication(s). The word refers to symptoms originat- trained psychiatrists. ing in a specific part of the brain that refines and mod- Most other physicians have never been trained to ulates movement. recognize the many different manifestations of EPS and Tardive Dyskinesia/Dystonia (TD) simply means TD. These conditions can be particularly difficult to rec- late onset of the same EPS movement side effects. ognize in children, even for those with specific training. They can appear after months of trouble free treat- The relationship between neuroleptic medications ment, or they can begin to appear as the dose is low- and movement disorders is extremely complex and ered or the drug is withdrawn. Symptoms generally confusing. A neuroleptic may cause movement symp- appear shortly after drug withdrawal although they can toms in a patient, but the same drug can also tem- appear months later. The previous cut off of three porarily suppress the symptoms or delay the onset of months post withdrawal is now being questioned. Tar- symptoms for the same patient. Symptoms often first dive reactions may resolve quickly, but these late reac- appear during withdrawal of the medication. Move- tions are more likely to be persistent or permanent. ment symptoms can occur spontaneously, but they are Symptoms that persist for six to twelve months are often clearly induced by medication. The best way to considered to be permanent although they may dimin- avoid permanent movement disorders is to use neu- ish slightly over the course of several years. roleptics very cautiously and to monitor patients Masking is the term used to describe the ability of closely for emerging symptoms. the drug to cover the toxic symptoms it is producing. TERMINOLOGY EPIDEMIOLOGY There are two major classifications of movement dis- Studies of movement symptoms in patients taking neu- orders, dystonias and dyskinesias. There are also two roleptics for schizophrenia show prevalence rates time frames used to classify the onset of symptoms. ranging from .5% to nearly 70%. Studies examining D y s t o n i a s are spasms of individual muscles or this wide range of published prevalence rates show the groups of muscles. They can be sustained or intermit- discrepancies are most likely due to the skill of the tent, sudden or slow, painful or painless. They can aff e c t (continued on page 18) 16 PRACTICAL GASTROENTEROLOGY • MAY 2004 Recognition of Movement Disorders A SPECIAL ARTICLE (continued from page 16) observer. Movement disorders caused by motility and Movement symptoms are generally not present dur- antispasmodic medications in the treatment of gas- ing sleep, can worsen with stress, and patients can often trointestinal diseases are widely believed to be rare. suppress these symptoms for a short period of time This assumption is probably dangerous and inaccurate. through intense concentration. Movement symptoms Small studies of metaclopramide in particular show may be present uniformly throughout the day, or they EPS and TD in up to 30% of patients. Given the dev- may have a diurnal pattern. Some specific movement astating and potentially permanent nature of TD, symptoms are more troublesome during resting and extreme care should be taken to use neuroleptic drugs abate during voluntary movement. Other specific symp- only when absolutely necessary and in the lowest toms are only problematic during voluntary movement. doses possible. Movement symptoms can wax and wane over time and deliberate provocation may be necessary to elicit the symptom in a clinical setting. This is typically RISK FACTORS done by distracting the patient with conversation or Most risk assessment studies on EPS and TD have asking them to perform a mental task, such as math, been conducted in patients with schizophrenia. In that requires intense concentration. Tongue and facial these patients, TD is associated with older age, higher symptoms are often the first to appear and a thorough medication doses and longer treatment periods; i.e. neurological exam involves careful observation of the total exposure. Females also appear to be a higher risk. tongue in the mouth and sticking out. Concomitant treatment with any additional drugs EPS and TD can mimic disorders such as Parkin- capable of causing neuroleptic side effects is likely to s o n ’s Disease, To u r e t t e ’s Syndrome, Huntington’s increase the risk of EPS and TD. This includes both Chorea, tics, cerebral palsy, stroke and hyperactivity. traditional antipsychotics and the newer, “atypical” They are often mistaken for psychiatric disturbances antipsychotics which still carry some risk. Substances and patients may be shunned. as common as alcohol and cold medications have some During episodes of dystonia, opposing muscles risk of TD and EPS. Caution is needed as well with that should relax contract. This can result in a limb that patients taking anticonvulsants, antihistamines, barbit- appears distorted. One of the most common manifesta- uates or antidepressants as some drugs in these cate- tions is an ankle that twists and won’t bear weight. In gories have a high risk of EPS and TD. some cases, muscle groups that should be uninvolved Underlying “soft neurological” factors or mental in the activity being attempted will get involved. The retardation are significant risk factors in the develop- result can be shoulders that swing violently during ment of TD. walking or an entire arm and shoulder that cramp and Many experts caution that tapering down to drug contort while the hand is holding a pen. In some free periods a few times a year is necessary to ascer- instances, the opposing hand/arm/shoulder may also tain whether a patient has “covert” symptoms that are contort in a perverse sympathy. being masked by the continuing use of the drug. Other Some patients find quirky tricks that can short cir- experts believe that this cycling on and off for “drug cuit a dystonia or dyskinesia. For example, a few holidays” can provoke a tardive reaction and is an patients with torticollis find that stroking their jaw or additional risk factor. touching the back of the head can stop the muscle spasms. A case report describes one patient with a severe gait disturbance who found that tossing a small RECOGNIZING SIDE EFFECTS OF NEUROLEPTICS object from hand to hand allowed him to walk more Movement symptoms may be so subtle that a psychia- normally. For this reason, patients should be asked trist or neurologist who specializes in movement dis- about any odd mannerisms.
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